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Reporting from the Combined Ophthalmic Symposium (COS), August 11–13, Austin, Texas EW MEETING REPORTER 118 September 2017 He mentioned the importance of making sure the reservoir plate is greater than 6 mm posterior to the limbus. Trabs and tubes have an im- portant role in 2017 but are not necessarily first line any longer, he said, noting that the XEN Gel Stent (Allergan, Dublin, Ireland) may be a new way to do trabeculectomy, and the EX-PRESS Glaucoma Filtration Device (Alcon) helps with hypoto- ny in the immediate postoperative period. Editors' note: Dr. Samuelson has no financial interests related to his presen- tation. Dr. Rhee has financial interests with Glaukos (San Clemente, Califor- nia) and Ivantis (Irvine, California). Crosslinking Sumit "Sam" Garg, MD, Irvine, California, discussed crosslinking, noting that ectasia progression is defined by a consistent change in at least two of the following param- eters where the magnitude of the change is above the normal noise of the testing system: progressive steepening of the anterior corne- al surface, progressive steepening of the posterior corneal surface, and progressive thinning and/or an increase in the rate of corneal thickness change from the periphery proach is now possible with both medical and surgical therapy, Dr. Samuelson said. Douglas Rhee, MD, Cleveland, presented on trabs and tubes in 2017. He recognized that there may be an implication that trabeculecto- my and tube shunts don't matter as much anymore, but he argued that they do. Trabeculectomy works for both open- and closed-angle glauco- ma, and it has proven effectiveness with 49 years of experience. There are minimal additional costs, a "mountain" of data on effectiveness, and nothing yet gets IOP as low, he said. Dr. Rhee shared results from a 20-year follow-up study with trab- eculectomy, which showed success rates between 57% and 88%. His treatment algorithm starts with medications followed by laser and then an open menu of pro- cedures. He argued that it's still important to know how to do trab and tubes. In his approach to both open- and closed-angle glaucoma, trabs and tubes were listed in the treatment options. Trab is a good step when other options fail and for those who need low IOP, he said. Dr. Rhee offered tips on trabeculec- tomy technique, including making the scleral flap (using a tunnel), moving the pledget to get a diffuse bleb, and injecting an MMC and lidocaine mixture preoperatively. patient's support and confidence. Be definitive, either in the solution or in a timeframe for the solution, Dr. Solomon said. It's important to never let patients feel disrespected. Never say they are wrong and never get into an argument. Being considerate and courteous are extremely important, he said. Finally, Dr. Solomon spoke about the importance of document- ing all steps of care and what is discussed with the patient. When in doubt, you could also consult a malpractice carrier/legal counsel. Editors' note: Dr. Solomon has no financial interests related to his presentation. Dr. Koch has financial interests with a number of ophthalmic companies, including Alcon, Johnson & Johnson Vision, and Bausch + Lomb (Bridgewater, New Jersey). Glaucoma: The pressure is on! Thomas Samuelson, MD, Minne- apolis, presented on risk mitigation in glaucoma surgery, first discussing how MIGS was initially received in the ophthalmology community. Comprehensive ophthalmologists seemed to be relieved that this type of technology was available after so long, but the glaucoma community mostly met it with skepticism, he said. Now, it seems MIGS is here to stay. It's all about disease severity, Dr. Samuelson said. For those who see mostly severe disease, surgical risk may seem more acceptable. If you see mostly mild to moderate disease, surgical risk is unacceptable, he said. The traditional glaucoma interven- tions—drops and laser—work well for the low end of the spectrum, he said, and trabeculectomy and tube shunts work well for those with severe disease, but MIGS has helped to fill the gap between the two. Dr. Samuelson shared his five tools of glaucoma surgery: phacoemulsification, canal proce- dures, supraciliary procedures, trans- scleral procedures, and cilioablative procedures. In his opinion, if any one of these tools is eliminated, a surgeon's toolbox is weakened considerably. An incremental ap- View videos from COS 2017: EWrePlay.org Sumitra Khandelwal, MD, discusses medications that predispose to IFIS and ways to manage this intraoperative complication. continued on page 120

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