Eyeworld

EW GLAUCOMA 68 October 2017 by Maxine Lipner EyeWorld Senior Contributing Writer do cataract surgery and keep them stable on their drops,'" Dr. Okeke said, adding that many such patients would opt for MIGS if given the choice. For many, the next question is which MIGS procedure to attempt first. She started with the Trabec- tome (NeoMedix, Tustin, Califor- nia), which she thinks is natural for beginners. In her book, The Building Blocks of Trabectome Surgery Vol- ume 1: Patient Selection, she guides practitioners of all levels through patient considerations and provides case studies and pearls with this and other MIGS devices. Surgeon shares MIGS success secrets T he acronym "MIGS" seems to be everywhere today in ophthalmology, although only approximately 20% of anterior segment surgeons are currently performing this, ac- cording to Constance Okeke, MD, assistant professor of ophthalmolo- gy, Eastern Virginia Medical School, Norfolk, Virginia. Among those in the glaucoma world, use is far great- er, she thinks. No matter where you are on the microinvasive glaucoma surgery (MIGS) adoption spectrum, here are some success secrets to consider. At the start For those who are just beginning to consider MIGS, the first step can be as simple as deciding to perform a certain procedure. "One just has to say, 'I'm going to enhance my arma- mentarium starting with one MIGS procedure,'" Dr. Okeke said. It also comes down to giving patients a "MIGS choice," Dr. Okeke said. This is akin to the options practitioners now offer with pre- mium IOLs and astigmatism cor- rection. "We're used to the concept of: 'If patients are comfortable and controlled on their drops and I have to do cataract surgery, let me just Broadening the glaucoma surgical plate continued on page 70 Gonioscopic view of CyPass Micro-Stent in good position in the angle The mechanism of action for the iStent is to act as a conduit bypassing the area of trabecular meshwork, known to be an area of high resistance for outflow. Source: Constance Okeke, MD Dr. Okeke discusses a routine Trabectome procedure illustrating the ability to ablate nearly 180 degrees of trabecular meshwork with the Trabectome handpiece. One of the things she likes best about the Trabectome is its ability to provide the surgeon with an excel- lent view, something that she finds particularly important for novices. She attributes some of this to the Trabectome's irrigation and aspira- tion system. "The system provides the fluidics to maintain a stable chamber throughout the procedure. What's important about that is once the eye is well pressurized, it enables you to have a clear view of the angle," she said, adding that the flu- idics also mean that there's minimal or no blood in the eye while doing the procedure. She finds that even beginners can get good long-term results with this because it is kind in terms of wound healing. In her experience, the Trabectome, along with ade- quate use of steroids early on, tends to cause less scarring through its use of electroablation to seal the leaflets remaining where the trabec- ular meshwork tissue is removed. "I get much more open clefts when I look at patients years later with the Trabectome compared to my results with some of the newer meshwork removal devices," Dr. Okeke said. Many new MIGS practitioners might begin with the iStent (Glau- kos, San Clemente, California). One issue with this for beginners could be the insertion technique, which is typically done after cataract surgery. "The corneal incision that's made for cataract surgery is a lot wider than the width of the handpiece for the iStent," Dr. Okeke said. A new surgeon getting used to using a gonio lens in one hand and holding the iStent in the other can inadvertently put a lot of pressure on the wound. This can cause egress of the viscoelastic that's supposed to keep the chamber maintained. "You're getting ready to place the iStent and you might touch the trabecular meshwork and it starts to bleed and your chamber is getting

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