Eyeworld

53 EW FEATURE July 2017 • MIGS roundup Contact information Palmberg: ppalmberg@med.miami.edu Panarelli: jpanarelli@NYEE.EDU Radcliffe: drradcliffe@gmail.com Sheybani: sheybaniar@wustl.edu especially when the stent becomes "capped," resulting in a flat-appear- ing bleb. Another complication could be bleb leaks—though Dr. Panarelli called them uncommon—which should only result if there is perfora- tion of the conjunctiva. Though he has yet to encounter it, Dr. Panarelli said his biggest concern is erosion, which would more likely occur when the device fails and comes in close contact with the eyelid. He hasn't had any cases of early or late onset hypotony, but Allergan does mention this as a possibility. The small luminal diameter of the stent provides sufficient resistance to mostly avoid these issues, he said. The XEN, like other MIGS pro- cedures, leaves open the possibility of trabeculectomy and tube shunts, if needed, by the patient later. Be- cause the XEN bleb tends to be more nasal, Dr. Radcliffe said a trabeculec- tomy could still be done at 12:00, and as many tube shunts as needed could be performed. Dr. Panarelli said reimbursement has been a challenge thus far. While it's likely to change in the future, he has found that prior authorization is required by many insurance plans, or the patient pays out of pocket. Dr. Radcliffe also said that while he's found some insurance plans cover the XEN, it's important to have a policy where patients understand they will pay out of pocket and be reimbursed by insurance, if covered. "I don't hesitate to ask patients to pay out of pocket, reminding them that if the insurance reimburs- es, they'll be reimbursed. But this is the case where if patients pay several thousand dollars for a stent, they're going to see excellent intraocular pressures, they're going to have their glaucoma problems resolved, they're going to be very thankful and happy that they made this investment in their vision," Dr. Radcliffe said, adding that he's optimistic about the future of XEN insurance reimburse- ment moving forward. Dr. Sheybani doesn't implant the XEN without prior insurance ap- proval, not wanting patients to pay out of pocket when there are other options covered by insurance. "These operations may replace trabeculectomy and tube-reservoir shunts in primary glaucoma sur- gery if the clinical trials show equal efficacy and greater safety. They will likely replace MIGS because of greater effectiveness and comparable safety, and will conceivably compete with medical therapy as initial treat- ment for glaucoma," Dr. Palmberg said. EW References 1. Batlle JF, et al. Three-year follow-up of a novel aqueous humor microshunt. J Glauco- ma. 2016;25:e58–65. 2. Ahmed IK, et al. Use of a 45 μm ab-interno subconjunctival gel-stent with adjunctive mitomycin-C for the treatment of uncontrolled open angle glaucoma. 2015 AGS Annual Meeting. 3. Musch DC, et al. Visual field improvement in the collaborative initial glaucoma treatment study. Am J Ophthalmol. 2014;158:96–104. Editors' note: Drs. Panarelli, Radcliffe, and Sheybani have financial interests with Allergan. Dr. Palmberg has finan- cial interests with Allergan and Santen. Join the largest subspecialty society representing the fields of cornea and external disease. Member Benefits • Cornea: The Journal of Cornea and External Disease • Annual Meetings: Select discounted registration at membership events and educational programs • VideoEd: A weekly broadcast of clinical videos recorded live at national and international cornea meetings • Kera-net: The online forum for the exchange of clinical and scientific information • Cornea Society News: Quarterly newsletter sent to all Society members CorneaSociety.org Save the Date July 8-9, 2020 World Cornea Congress VIII Singapore2020 corneacongress.org/2020

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