Eyeworld

EW FEATURE 48 MIGS roundup • July 2017 AT A GLANCE • The CyPass Micro-Stent can be used in conjunction with cataract surgery to lower IOP in patients with mild to moderate glaucoma. • The CyPass should be avoided in patients with advanced glaucoma, inflammatory glaucoma, and in complex cases. • Surgical pearls include tilting the patient's head slightly less than you would for angle surgery and getting comfortable with gonioscopy. • Possible complications include a larger-than-planned cleft, bleeding, and a lower IOP, although these are uncommon. • There is a learning curve with CyPass, but it's manageable for cataract surgeons. by Vanessa Caceres EyeWorld Contributing Writer with inflammatory or neovascular glaucoma. "I would avoid doing the CyPass in 'train wreck' scenarios. Keep it to people controlled on med- ications first," recommended Steven Sarkisian, MD, clinical professor and glaucoma fellowship director, Dean McGee Eye Institute, Universi- ty of Oklahoma, Oklahoma City. He added that the micro-stent has not yet been tested in pediatric glauco- ma. A nanophthalmic patient would also give Dr. Flowers some pause. Surgical pearls There are a few ways you can better manage CyPass implantation, ac- cording to surgeons who are familiar with the device through its clinical trials. "You have to be comfortable with intraoperative gonioscopy and have a clear view of the angle anato- my and know the surgical landmark of the angle," said Quang Nguyen, MD, associate head, Division of Ophthalmology, and director of the glaucoma service, Scripps Clinic, La Jolla, California. "When inserting, the height of the elbow seems to predicate the an- gle of approach. You need the tip to 'glide' along the sclera. It's better to underinsert and then tap into place. If it hangs up, stop," Dr. Craven ad- vised. "The angle of insertion needs to be adjusted. This is usually where you want the elbow up." "Avoiding 3 and 9 o'clock is also helpful because the ciliary plexus is there, and the patient may feel the implant as it goes in if under topical anesthesia," Dr. Sarkisian said. Dr. Flowers advocates tilting the patient's head less than you do for angle surgery. "People doing angle surgery are used to rotating the head by 45 degrees. But with this, since you're trying to implant perpendic- ular to the iris, you don't want the head rotated as much—probably 10 to 15 degrees less," he said. He also recommends implant- ing the device slightly deeper versus superficially. "You could get some corneal changes with superficial implantation," Dr. Flowers said. Planning on IOP reduction, avoiding complications The CyPass is able to offer greater IOP reduction than phacoemulsifi- Glaucoma surgeons familiar with the MIGS device share surgery and patient selection pearls F or cataract surgery in mild to moderate glauco- ma patients, the CyPass Micro-Stent (Alcon, Fort Worth, Texas) now offers another treatment option. The CyPass was approved in the U.S. last summer by the U.S. Food and Drug Administration. The device was approved specifi- cally for mild to moderate glaucoma, and that's a description that sur- geons familiar with CyPass support as well. "It's for patients with open angles who have an IOP in the 20s [and who are] on one or two med- ications," said E. Randy Craven, MD, Wilmer Eye Institute, Johns Hopkins University, Baltimore. "Since you're taking the cataract out at the time of the procedure, the person's angles will be open, so there's no worry about narrow angles," said Brian Flowers, MD, Fort Worth, Texas. "I do find that it works even in patients on multiple medications." Patients who would not do as well with the CyPass are those with an uncontrolled high IOP who are on multiple medications and those Laying the groundwork for CyPass use CyPass shown in the eye Source: Quang Nguyen, MD cation alone, Dr. Nguyen said. "The COMPASS trial revealed unequivocal scientific data that demonstrates the additive effect of CyPass to phaco surgery to provide excellent control long term," he said. "You can expect a 20% to 40% drop in IOP, depending on the preoperative IOP and number of meds," Dr. Sarkisian said. "This has been proven to be superior to phaco alone in the U.S. pivotal trial and as effective as a standalone procedure in patients outside the U.S." Although there is still nothing as effective as trabeculectomy at lowering IOP, Dr. Sarkisian said, complications from trabeculectomy prompt him to avoid it unless all other options have failed. One other factor tracked by surgeons is reduction in medica- tion use. In the COMPASS trial, mean medication use decreased from 1.4 to 0.2 in the micro-stent group compared with 1.3 to 0.7 in the group having cataract surgery alone. 1 "Mean 24-month medication use was 67% lower in microstent subjects (P<0.001); 59% of control versus 85% of microstent subjects were medication free," according to investigators. The complications associated with CyPass are self-limiting with no long-term effects, Dr. Nguyen said. One complication that he has seen is a larger-than-expected cleft, due to surgeon error from not entering straight at the time of implantation. "Although I have yet to expe- rience it, one can postulate that if you make lateral movements, you can cause a cleft," Dr. Sarkisian agreed. "The CyPass has an intuitive implantation technique, but it is not easy, and you have to be trained properly to implant the device."

• Blank Page
• Blank Page (1)