Eyeworld

EW GLAUCOMA 146 April 2017 beyond its covers. With the pur- chase of this book, readers gain access to a library of online video content demonstrating the surgical techniques for performing most of the procedures described in the text. These are actual surgical videos contributed by the authors and are immensely valuable in helping the surgeon new to MIGS understand and acquire the skills necessary to perform these procedures. Notable videos include those on gonioscopic assisted transluminal trabeculotomy and the XEN gel implant. If there is a criticism to offer, it is that the videos tend to be brief and cover only the key elements of each procedure, and they lack any voiceover narration. This latter omission misses a great opportunity to share pearls of experience and to describe nonvisual sensations that can guide surgery, such as the degree of resistance that should be expected when inserting a device through the angle into the suprachoroidal space. Overall, this text provides—as its title states—a practical guide for learning and incorporating MIGS techniques into clinical practice. The book would be of value to oph- thalmology residents and glaucoma fellows as an adjunct to their formal training, to comprehensive ophthal- mologists considering adding MIGS to their cataract surgical practices, and to glaucoma specialists who may have trained before the MIGS era or who are not currently offering MIGS and wish to be more familiar with the techniques unique to this new and exciting class of glaucoma surgical procedures. EW Contact information Realini: hypotony@gmail.com by Tony Realini, MD, MPH MIGS procedures. These chapters are organized into four distinct sections, addressing procedures designed to enhance trabecular outflow, uve- oscleral outflow, aqueous humor reduction, and transconjunctival flow. This organization echoes the arrangement of chapters in the basic science section for easy reference between the two. Specific chapters cover cataract surgery as a stand- alone procedure, trabeculotomy by various techniques, the iStent (Glau- kos, San Clemente, California) and Hydrus (Ivantis, Irvine, California) implants, excimer laser trabeculosto- my, canaloplasty, VISCO 360 (Sight Sciences, Menlo Park, California), suprachoroidal shunts (SOLX Gold [Solx, Waltham, Massachusetts], Cy- Pass [Alcon, Fort Worth, Texas], and iStent Supra [Glaukos]), endoscop- ic cyclophotocoagulation, as well as the XEN gel implant (Allergan, Dublin, Ireland), and the InnFocus MicroShunt (Miami). The structure of these chapters is standardized. Each begins with a case presentation to illustrate the role of individual procedures in clin- ical glaucoma practice—a novel and helpful feature. Subsequent sections common to all chapters include a description of the procedure and its rationale, optimal patient selection, surgical technique, complications, and how to recognize and man- age them, as well as a summary of clinical trial results to date. High-res- olution, full-color photographs and illustrations depict the devices and highlight surgical techniques. The final chapter describes how to incor- porate MIGS into an existing clinical practice. The content of this textbook is superb, but the most interesting content of this book is what lies many cases on ab interno approaches through the angle that are not part of standard glaucoma surgeries. Peer-to- peer instruction at meetings and workshops is beneficial but limited in that informa- tion and instruction must be absorbed and digested in real time. A new textbook, Minimally Invasive Glau- coma Surgery: A Practical Guide (Thieme, 2017), is a tremendously valuable tool to satisfy the unmet need for comprehensive edu- cation in MIGS techniques. Edited by a trio of MIGS pioneers—Brian Francis, MD, Steven Sarkisian, MD, and James Tan, MD—the text itself is a well-curated collection of 40 chapters on virtually every aspect of MIGS written in many cases by the investigators who played key roles in the clinical development of these devices and procedures. Overall there are 77 contributors from eight countries representing a mix of ex- perts from the worlds of academia, private practice, and industry. The text itself is both com- prehensive and timely, a difficult combination to achieve. The first third of the text addresses the basic anatomy and physiology necessary to understand the concepts and techniques of the various MIGS procedures, including the science of aqueous inflow and outflow as well as subconjunctival filtration path- ways. Notable chapters define the uveoscleral outflow pathway (con- tributed by Alex Huang, MD, and Robert N. Weinreb, MD) and the suprachoroidal space (Don Minck- ler, MD). The remainder of the book is devoted to chapters on each of the Dr. Realini reviews Minimally Invasive Glaucoma Surgery by Brian A. Francis, Steven R. Sarkisian Jr, James C. Tan, eds. New York: Thieme, 2017 T he past decade has seen a dramatic evolution in our approach to glaucoma surgery. While standard filtration techniques such as trabeculectomy and tube-shunt implantation remain the bedrock of surgical glaucoma manage- ment, a new array of devices and procedures—collectively termed microinvasive glaucoma surgery (MIGS)—offers novel approaches to the reduction of IOP in many cases while avoiding the formation of a filtering bleb and all of its attendant risk of sight-threating complications. Incorporating these new pro- cedures into clinical practice can pose a challenge. The techniques are somewhat novel—focusing in Review of Minimally Invasive Glaucoma Surgery: A Practical Guide Book review mm Hg to 15.9 (± 5.2) mm Hg at 12 months postop. The mean number of IOP-lowering medications went from 3.5 to 1.7 medications at 12 months. Some of the adverse events of the trial at 12 months included a best corrected visual acuity loss of 6.2% and 24.6% experiencing hypotony, although with no clini- cally significant consequences and without requiring surgical interven- tion. There was a 21.5% IOP increase from baseline and 32.3% required a needling procedure. Dr. Grover said that surgeons wanting to include XEN implants in their armamentar- ium of glaucoma surgeries need to be comfortable with handling blebs. "It is hard to group the trial patients who had needling together. Every surgeon has a different standard and a different technique for needling. What we need to take away from the study is that the outcomes were not much different in the patients that were needled than in those that were managed medically. Mitomycin improves the success rate and reduc- es the need to do a needle procedure afterward. But I think it is safe to say that if you are going to do this surgery, you should feel relatively comfortable with bleb management and needling," he said. EW Editors' note: Dr. Grover has finan- cial interests with Allergan (Dublin, Ireland) and Reichert Technologies (De- pew, New York). Dr. Lewis has financial interests with Allergan, Alcon, Ivantis (Irvine, California), and Glaukos. Contact information Grover: dgrover@glaucomaassociates.com Lewis: rlewiseyemd@icloud.com Changing continued from page 145 Source: Constance Okeke, MD, MSCE

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