Eyeworld

77 EW FEATURE October 2017 • Challenging cataract cases are unpredictable depending on the patient, I prefer to determine the ef- fect of one procedure prior to doing a second," he said. While the iStent, CyPass, and Xen are FDA approved, reimburse- ment is challenging for all three. Dr. McKee explained that the iStent received reimbursement but that the Medicare carrier in his area just reduced reimbursement to $200 per stent, which is untenable. The Xen is currently a cash pay procedure. He said that although patients pay cash, lifting the irritating burden of drops associated with advanced glaucoma has left them satisfied. Dr. Odette corroborated the current re- imbursement challenges for almost all glaucoma and MIGS procedures, which is even harder when trying to combine procedures. "In our prac- tice we will resort to a private pay model when necessary. However, many of the patients who have the most need for these procedures are those who can least afford a self-pay model," Dr. Odette said. EW Editors' note: Dr. McKee has financial interests with Allergan. Drs. Kim and Odette have no financial interests relat- ed to their comments. Contact information Kim: wonkim74@hotmail.com McKee: mckeeonline@mac.com Odette: jodette@austineye.com glaucoma with open angles who are unresponsive to maximum tolerated medical therapy. Yes to Xen for advanced glaucoma "Xen diverts fluids to the subcon- junctival space, and I have found that to be extremely effective in cases of advanced glaucoma," Dr. McKee said. "The iStent gives some- what less pressure reduction. My ex- perience with the iStent, of which I have done approximately 455 in the last 24 months, is a two-point reduc- tion when combined with cataract surgery. For mild to moderate glau- coma, where you want a pressure of 14 mm Hg or less, with the patient's IOP between 15 and 17 mm Hg, you can combine the iStent with cataract surgery. But if you need a pressure reduction of 8–10 mm Hg in ad- vanced or refractory glaucoma, the Xen is going to get you there 80% of the time straight out of the gate. In the other 20% of the time, you will need a little extra maneuvering, like drops or bleb needling." Dr. Kim has a similar mindset that trab and tubes have been large- ly replaced by the Xen. "Tube and trab in the setting of cataract and glaucoma, for me, are only applica- ble in those cases with severe field loss and IOP out of control on max- imum medical therapy. With the advent of the Xen, if patients have healthy conjunctiva, I will almost always choose this over trab or tube. This is because the Xen offers a more controlled and predictable postop course, with less chance for hypoto- ny. There will be no risk for diplo- pia, tube erosion, or wound leaks. It doesn't violate anatomy as much, will be more astigmatically neutral, and allows for more rapid visual recovery, making it a better partner for cataract surgery. In this setting, I would only choose a trab if the conjunctiva is healthy and I needed very low single digit IOP, perhaps in the setting of an NTG patient showing progression with relatively low IOP. I would only choose a tube in this setting if the conjunctiva was compromised," Dr. Kim said. Dr. McKee implements the following measures in his advanced glaucoma patients needing cataract surgery. "First I'd do the cataract surgery with an iStent. I'd continue the topical drops and let them heal. Occasionally it is enough, but most of the times it is not—but it does get you to a better place. From here I will do a Xen implantation. I used to do trabeculectomy and tubes, how- ever, the results with the Xen were so impressive and reliable, the safety margin was better, and the surgery was easier on both the doctor and patient in terms of it being mini- mally invasive that I only offer the Xen at this point. I do not see why I should do a trabeculectomy when I can get better results with the Xen in a minimally invasive manner, which is much less stressful on the patient," he said. Yes to CyPass for advanced glaucoma The more avenues eye doctors have to lower the IOP in patients who are already on max medical therapy, the better. John Odette, MD, Austin, Texas, said that MIGS devices have been a great addition to the physi- cian's surgical armamentarium. He thinks, however, that trabeculec- tomy and tubes will continue to play a significant role in glaucoma treatment for use in patients with refractory IOP elevations, despite the encouraging results obtained using MIGS devices to lower IOP. "I currently use both the iStent and the CyPass. Since it was approved for use earlier, I have placed more iStent devices, but I am finding the CyPass device to have more IOP-lowering effect than using one iStent. The Xen will hopefully help decrease many of the complications from bleb-related surgery," he said. The CyPass redirects aqueous flow to the suprachoroidal space and therefore has a large capacity to significantly reduce IOP. The device is FDA approved for implantation in the eye at the time of cataract surgery. Dr. Odette prefers not to com- bine glaucoma procedures, electing to perform them one at a time. "Thus far I typically do not perform more than one glaucoma procedure at a time, with the exception of cataract removal and MIGS. Since many of our glaucoma procedures After CyPass implantation, a left-going iStent is implanted in an area of Schlemm's canal thought to be occupied by scleral collector channels identified beforehand by finding the location of aqueous veins in the conjunctiva. Finally, a right-going iStent is implanted in a similar targeted fashion to maximize trabecular outflow. After completion, two well-placed iStents can be seen with appropriate reflux bleeding from Schlemm's canal on either side of the central CyPass implant. Source (all): Won Kim, MD John Odette, MD, discusses insertion of one of his first CyPass stents.

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