EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/831102
87 June 2017 EW MEETING REPORTER phacoemulsification, Dr. Brown's ideas and designs might not have been immediately accepted but laid the groundwork for many of the microinvasive glaucoma surgery (MIGS) options on the market today. Dr. Brown said he felt he really should share this honor with his wife, Mary Lynch, MD, Atlanta, who has worked with him on this front. The couple shares more than two dozen patents for glaucoma and cataract surgery devices and instru- ments. "We're seeing exponential growth in glaucoma surgery driven by MIGS," Dr. Brown said. "I have been attempting to innovate in glaucoma surgery for more than three decades … most products are unfortunately on the flat part of the curve, but I have contributed to the growth," he added, pointing toward an exponential growth curve chart tracking the evolution of MIGS. At the time when he was tout- ing the possibility of glaucoma as a surgical disease, it was a contrarian opinion, Dr. Brown said. Glaucoma was thought of as a medical disease and surgery too risky. But the hard reality, he said, is that medical ther- apy carries the issues of non-com- pliance, side effects, and long-term expense. When you compare eyes on drops to eyes that have had sur- gery, the proof is in the pictures. Dr. Brown first worked with a device, originally designed by anoth- er physician as a vitreous cutter, modified into the glaucoma me- chanical trephine, or "trabecufine." The device allowed for an ab-interno trabeculectomy. However, there were issues with the outcomes—trouble with the hole, scarring—and Dr. Brown said it was abandoned before viscoelastic and mitomycin-C could have helped it along. "What we needed was a device to keep the hole open and control flow. I couldn't accept that blebs were going to be key to glaucoma surgery," Dr. Brown said. Along this vein, Dr. Brown patented a tack, which he called the glaucoma faucet, that could control pressure from the cornea. Looking for support, Dr. Brown pitched the depend on the experience of the surgeon and the individual situation of the patient. For each option, Dr. Price said it's important to look at how reliable the visual recovery is and what the risks and complica- tions are. He said to typically choose the least invasive option, which for him is Descemet's membrane endothelial keratoplasty (DMEK), which is only Descemet's and endothelial cells. It offers the best visual recovery and least risk of rejection, Dr. Price said. "But we still have unpredictable refractive changes." DMEK is becoming more like cataract surgery. Some patients are 20/20 or 20/40 by day 5, he said, noting DMEK accelerates cataract formation a little more than with Descemet's stripping endothelial keratoplasty (DSEK) or penetrating keratoplasty (PK). Dr. Price also described decision- making for cataracts with corneal problems. Make sure the AC depth is deep enough for later phaco, and if it's not, remove the lens during DMEK. "In summary, it's all about deci- sions," he said, adding to remember that the number one thing is patient symptoms. Editors' note: Dr. Price has financial interests with Haag-Streit (Koniz, Switzerland). Innovator's Lecture takes a look at the past, present, and future of surgical glaucoma The Innovators General Session highlighted everything from big data to low-energy phaco surgery to an eye drop to treat presbyopia, and more, but the main event was the Charles D. Kelman Innovator's Lecture, introduced by Dr. Kelman's wife, Ann Kelman, and delivered by Reay Brown, MD, Atlanta. In "Overcoming resistance: Making glaucoma a surgical dis- ease," Dr. Brown detailed his work over the last few decades to improve the surgical treatment of glaucoma. Though this goal is something he's been striving for since the 1980s, like Dr. Kelman's experience with continued on page 88