Eyeworld

World view Exponential progress on the horizon W ith the Xen Gel Stent and CyPass Micro-Stent joining the iStent as FDA-approved MIGS devices, we now have MIGS options that can address all degrees of glaucoma damage. Remarkably, all three devices have dif- ferent mechanisms of action. The iStent achieves trabecular bypass, the CyPass directs fluid to the suprachoroidal space, and the Xen drains aqueous to a subconjunctival bleb. Glaucoma surgeons and patients now have unprecedented alternatives for surgical management. New devices bring new opportunities but also the need to learn new techniques and figure out where the options fit into our current treatment of glaucoma. This month's feature articles review the newer surgical options for glaucoma. Richard Lewis, MD, John Berdahl, MD, and Michael Greenwood, MD, share their views on the range of trabecular bypass devices and procedures. The CyPass is discussed by Bri- an Flowers, MD, Steven Sarkisian, MD, Quang Nguyen, MD, and E. Randy Craven, MD. Next, Paul Palmberg, MD, Arsham Sheybani, MD, Nathan Radcliffe, MD, and Joseph Panarelli, MD, review their experience with the Xen Gel Stent. Finally, Davinder Grover, MD, and Kateki Vinod, MD, show how they position the Xen procedure as an alternative to a conventional tube shunt or a trabeculectomy. In the past, I have been critical about the lack of innovation in glaucoma surgery. One example that I have cited is a popular glaucoma textbook that used the same diagram of a trabeculectomy in its 2005 edition that was used in the 1985 edition. The chapter on surgery was also recycled through mul- tiple editions. But now we have almost the opposite issue—an explosion of glaucoma surgical technology. We now can choose among the iStent, CyPass, Xen, Trab360, GATT, Kahook Dual Blade, ABiC, Trabectome, and endocy- clophotocoagulation before we get to a trabeculectomy or tube shunt. And that's not all. The Hydrus, InnFocus MicroShunt, iStent Inject, and iStent Supra are all expected to receive FDA approval in the next year or so. This array of options should allow surgeons to select an appropriate technology for every glaucoma patient. Dr. Palmberg makes a bold prediction that the Xen and the InnFocus MicroShunt will not only replace trabs and tubes but will also capture the MIGS market and even be an alternative to medical therapy. His optimism is based on the efficacy of the full-thickness approach that creates a bleb. He is confident that safety will be far closer to the MIGS competitors than tradi- tional trabeculectomy. However, these operations require mitomycin-C and bleb management. Bleb issues raise all the old questions about hypotony, infection, scarring, and leaks, but hopefully the answers with these devices will be new and not as discouraging. A triumph of full-thickness micro-tubes over "classical" MIGS technology will be a return to the future since blebs are one of the main problems that MIGS procedures are trying to avoid. We may be entering a "post-MIGS" era, where the broadening of the definition has rendered the term less meaningful. The MIGS description— first used by Ike Ahmed, MD—helped encapsulate a sea-change in thinking about glaucoma surgery. But maybe whether a bleb takes a technology out of the MIGS zone may not be so important. The key is efficiency combined with outcomes, and if bleb operations work well and safely, we should all cheer. The iStent and other non-device technologies have shown us that MIGS procedures lower pressure. Because of this efficacy, MIGS options are be- coming increasingly popular with surgeons, and industry is also on board with more than $3 billion invested. We have always had the unmet need of glaucoma patients becoming blind with suboptimal treatments, but now for the first time, we have both significant investments and many competing technologies. This is a recipe for success. My expectation is that progress will be exponential. EW Reay Brown, MD, Glaucoma co-editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S July 2017 Vol. 22 • No. 7 Publisher Donald Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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