Eyeworld

131 March 2017 EW MEETING REPORTER val MIGS—XEN (Allergan, Dublin, Ireland). The suprachoroidal approach facilitates outflow through the uveo- scleral pathway. It involves ab inter- no insertion through a self-sealing clear corneal incision. As such, there is no scleral penetration and the integrity of the trabecular meshwork is preserved. With CyPass, Dr. Lewis said there is a sweet spot to hit for insertion: it needs to be placed deep enough so that it's not occluded by the iris, but not so far that it is lost all together. The procedure itself, however, he called straightforward. In the COMPASS study, there was a two-point difference in IOP lowering with CyPass compared to cataract surgery alone, and the effect was maintained for 2 years. The biggest thing to watch for with suprachoroidal devices, Dr. Lewis said, is hypotony with clinical side effects. If the patient is experi- encing persistent decreased vision, he said the pressure needs to be raised to avoid permanent effects on the macula. As for XEN—a hydrophilic porcine gelatin that's hard when dry but soft and flexible, like a noodle, when hydrated—Dr. Lewis said it works like a trabeculectomy but with a more posterior bleb. XEN is FDA approved for moderate to advanced glaucoma and does not have to be performed in conjunction with cata- ract surgery. Garry Condon, MD, Pittsburgh, discussed MIGS in the pipeline, focusing much of his discussion on the Hydrus Microstent (Ivantis, Irvine, California), an 8 mm, flexible scaffold designed to target multiple collector channels. Currently in clinical trials, Dr. Condon described his experience with Hydrus, calling it "the easiest canal procedure I've ever done in my life." Hydrus has a spade-like tip that is nestled into the trabecular meshwork. When the scaffold exits the device, Dr. Condon said it seems to dive nicely and naturally into the canal. He noted several studies that have found more IOP lowering with Hydrus compared to cataract surgery alone. He also said there had been no reduction in visual acuity outcomes vs. cataract surgery alone with the device. An attendee asked whether placing one iStent (Glaukos)—the on-label usage combined with cataract surgery—is a "waste" of his and his patient's time when research has shown placing two or three iStents results in more IOP lowering. Dr. Condon said placing two or three iStents would certainly be more effective than one, but he said it's not a waste of time by any stretch to just perform the on-label procedure. Even if the IOP lowering is not ideal, Dr. Condon said the surgeon is practicing his or her canal surgical technique, which is valuable regardless. Editors' note: Dr. Lewis has financial interests with Advanced Vision Science (Goleta, California), Aerie Pharmaceu- ticals (Irvine, California), Alcon, Aller- gan, CenterVue (Fremont, California), Glaukos, and Ivantis. Dr. Condon has financial interests with Alcon, Allergan, and Ivantis. Dr. Crandall does not have any financial interests related to his comments. Five pearls for phaco with glaucoma Dr. Lewis provided his top five pearls for performing cataract surgery in glaucoma patients. Pearl 1: Does the patient really have glaucoma? While Dr. Lewis said every surgeon checks pressure, he emphasized the importance of visual field screening, fundus exams or OCT, and gonioscopy. "It takes 2 minutes and it's remarkable the kind of pathology we find on visual field screening," Dr. Lewis said. Pearl 2: Glaucoma patients want to see well after cataract sur- gery too. "It's surprising when I take a survey of a glaucoma audience… how few [surgeons] will put in a to- ric lens," Dr. Lewis said, noting that his one exception for toric lenses in glaucoma patients are those with pseudoexfoliation. He also noted that he would advise against multifocal IOLs for glaucoma patients, opting for mono- vision instead. Pearl 3: Glaucoma patients want off their drops. While cata- ract surgery itself is certainly not a cure for glaucoma, Dr. Lewis noted research that shows a 20% decrease in IOP just from phaco surgery. "I feel cataract surgery in a glau- coma patient is a chance to clean the slate, stop drops, and see what happens," he said. "IOP reduction is greatest in patients with ocular hypertension, early glaucoma, or narrow or closed angles." Further, the expanding role of MIGS in cataract surgery makes it an exciting time in glaucoma, Dr. Lewis said. Pearl 4: Avoid complications. Though it might seem obvious, Dr. Lewis reminded surgeons to be pre- pared for pupil problems. If needed, he suggested the use of pharmaco- logic agents, devices like Malyugin rings (MicroSurgical Technology, Redmond, Washington) or iris hooks, and managing zonules with capsular tension rings. Pearl 5: Be prepared for postop pressure rise. Glaucoma patients are more prone to postop pressure rise and it should be expected. This pres- sure can be managed with miotics and burping the wound to release viscoelastic. Dr. Lewis warned phy- sicians against jumping too quickly to blame steroids. Steroid-induced glaucoma doesn't happen in one night, he said, noting that pressure rise related to steroids would devel- op later. "Don't stop steroids on day one because pressure is up; treat the pri- mary problem," Dr. Lewis said. Editors' note: Dr. Lewis has financial interests with Advanced Vision Science, Aerie Pharmaceuticals, Alcon, Allergan, CenterVue, Glaukos, and Ivantis. Taking on cataract blindness During the Thursday morning session, Alan Crandall, MD, Salt Lake City, gave the inaugural Alan Crandall Lecture. Dr. Crandall's lecture, "Taking on Cataract Blindness," featured a mixture of both science and histo- ry, as he went through his time in ophthalmology and discussed some of the many advancements in tech- niques and technologies. He discussed his training from 1973 to 1977 and the conversion to extracapsular cataract extraction (ECCE). Dr. Crandall also mentioned the transition to some of the early phaco techniques and the introduc- tion of femto, new phaco machines, and IOLs. He also highlighted evolu- tion in glaucoma procedures. Dr. Crandall then went on to discuss his work abroad in devel- oping countries. He stressed the importance of this work in trying to teach a new set of teachers and provide ophthalmic care at all levels. This also involves trying to provide training for ophthalmic assistants and residents, as well as trying to create a center of excellence where all ophthalmology procedures can be done. Dr. Crandall said that 51% of all worldwide blindness is due to cataracts, and 9 out of 10 blind peo- ple live in the developing world. The World Health Organization (WHO) estimates 1.4 million children are blind from avoidable or treatable causes, Dr. Crandall said. continued on page 132

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