Eyeworld

83 EW GLAUCOMA February 2017 Dr. Brown: The growing popularity of the iStent is threatening the traditional glaucoma treatment paradigm. Histori- cally the preferred therapy for glaucoma has been three or even four different eye drops with surgery considered as a distant last resort. But with the advent of MIGS—and the iStent in particular— the paradigm is changing. This study compares treatment with two iStents to the use of a topical prostaglandin over a 3-year follow-up period. The pres- sure control and side effects were very similar in the two groups, suggesting that surgery with the iStent is a rea- sonable alternative to eye drop therapy. Although it makes intuitive sense that two iStents would lower IOP better than one, the data supporting this conclu- sion is very limited. It would have been interesting to see how a single iStent would have done—especially since in the U.S. we are generally using just one iStent. But the main point is that this study provides further evidence support- ing a change in treatment patterns. The increasing use of the iStent at the time of cataract surgery in glaucoma patients has demonstrated that the iStent can be used as a safe and effective alternative to drop therapy. Prognostic factors for lowering IOP in POAG by combined supraciliary microstenting- phaco cataract surgery: Compass RCT Tsontcho Ianchulev, MD Purpose: To evaluate prognostic fac- tors for reducing IOP by supraciliary stenting (CyPass, Alcon, Fort Worth, Texas) in POAG patients having cataract surgery. Methods: POAG subjects (N=505) having cataract surgery were randomized to phaco (control; n=131) or microstenting + phaco (stent; n=374) groups (1:3 ratio). We assessed IOP and medication use during postoperative 12 months. Results: Control and stent re- spective baseline mean IOPs were 24.5±2.95 and 24.4±2.77 mm Hg, and preop mean medications were 1.3±1.0 and 1.4±0.9. The 12-month IOP reductions were 25.5% and 31.7%, mean medications were 0.7±0.9 and 0.2±0.5, and the propor- tion of patients on no medications were 52.3% and 89.0%, respectively. Therapeutic response did not differ by patient age, gender, or baseline IOP and medications. Conclusion: Supraciliary microstent- ing better reduced IOP and postop medication use in multiple sub- groups vs. phaco controls. Dr. Brown: The CyPass is the second MIGS device to receive FDA approval for use in combination with cataract surgery in patients who have mild to moderate glaucoma. This is the same indication as the iStent. Like the iStent, the CyPass was shown in its pivotal study to lower IOP more than phaco alone. But where the iStent is implanted into Schlemm's canal and lowers IOP by trabecular bypass, the CyPass is implanted into the supraciliary space and lowers IOP by enhancing outflow through the ciliary body. The pivotal study showed CyPass to be very safe, although a small number of patients experienced prolonged iritis, transient hypotony and tube malposition. But most of these issues were resolved successfully with treatment, and visual outcomes were the same between pa- tients receiving phaco alone and those receiving phaco plus the CyPass. There are no studies comparing the iStent and the CyPass. EW Editors' note: Dr. Brown has financial interests with Glaukos and Transcend Medical (Menlo Park, California). Contact information Brown: reaymary@comcast.net Methods: The MIGS Study Group evaluated implantation of two stents (iStent, Glaukos, San Clemente, California) as the sole procedure vs. prostaglandin in 98 qualified phakic eyes with OAG, PEX or OHT naïve to therapy. Inclusion criteria also included IOP 21–40 mm Hg, C/D ratio ≤0.9, and ability to undergo follow-up through 60 months. Ocular hypotensive medication was to be added if postoperative IOP exceeded 21 mm Hg, regardless of treatment group. Efficacy evaluation included IOP and additional medical therapy. Safety parameters includ- ed intraoperative sequelae, optic nerve evaluation, BCVA, slit lamp assessment, and incidence of adverse events through 5 years. Results: Pretreatment mean IOP was 25.7±2.5 mm Hg in the two-stent group and 25.0±4.6 mm Hg in the travoprost group. In the stent group, one subject experienced iridodialysis cleft and one subject had hyphe- ma, both associated with subject movement during surgery and both resolving 1 day later. Mean IOP was ≤15.5 mm Hg in both groups throughout the 3-year follow-up. At 3 years, mean IOP was 14.5 mm Hg in stent eyes and 15.2 mm Hg in the prostaglandin group, with five subjects in the stent group and seven subjects in the prostaglandin group receiving additional medical therapy. Cataract progression was re- ported in seven of the stent subjects and four of the medication subjects; one subject per group had cataract surgery. Conclusion: Data from this study suggests IOP can be managed with either two stents implanted as the sole surgical procedure or topical prostaglandin through 3 years following diagnosis of open-angle glaucoma. Glaucoma View Dr. Noecker's presentation at clinical.ewreplay.org.

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