Eyeworld

EW GLAUCOMA 70 October 2017 this with a Trabectome. That way she obtains a pressure reduction immediately while waiting for the Baerveldt to open. Those who are more experi- enced should also keep in mind that sometimes a MIGS device can be used in more than one way. "There have been situations where someone has peripheral anterior synechia in the angle where there is some scar material. The Trabectome handpiece works great in removal of synechia," Dr. Okeke said. "You can use the instrument for synechia lysis." Using the tip of the handpiece to remove pieces of iris that are sticking to the angle can open this up, and one can follow by removing the now exposed trabecular meshwork. For more advanced iStent users, better targeting of episcleral vessels, which can be seen at the time of surgery, can improve outcomes. Dr. Okeke uses a marking pen to indi- cate where the most prominent of these are and extends the marks to the surface of the cornea. That way, she can see where the marks are and can target those, placing the iStent in that area to maximize efficacy. "I put the iStent near one of the out- flow channels, which is represented by those episcleral vessels, so that I can get the most outflow," she said. Dr. Okeke encourages practi- tioners of all levels to get involved with MIGS. "I think there's a lot of excitement right now and that users should jump in. They need to decide that they're going to adopt a proce- dure and contact the company so that they can get started," she said. "MIGS has changed the way I treat glaucoma in such a positive way for my patients and for myself." EW Editors' note: Dr. Okeke has financial interests with Alcon, Glaukos, and NeoMedix. Contact information Okeke: iglaucoma@gmail.com more shallow because you're putting pressure on the wound and visco- elastic is coming out," Dr. Okeke said. "Suddenly, you have corneal folds and you can't see and you have to stop, go back in, and put more viscoelastic in." To avoid this, Dr. Okeke recom- mends putting the iStent in first and then proceeding with the cataract surgery. "If you do the iStent first, you use a smaller blade," she said, adding that this tighter wound protects against egress of fluid and ultimately allows for a better view when trying to place the iStent. While some worry about iStent dis- lodgement, Dr. Okeke has not found that to be an issue. Proper patient selection is important for starting out with the iStent. "Patients who have ocular hypertension, early primary open angle glaucoma, who are stable on one or two medications tend to be the ones who I find do best," Dr. Okeke said, adding that if the iStent is being used for those who have more moderate or even severe glau- coma, practitioners may find they don't get the results they want. This may cause them to feel disgruntled about how the approach is working with the single iStent that is cur- rently approved for use. A major strength of the iStent is the ability to get a stable patient off at least one medication, which can greatly improve his or her quality of life. More versed users Those who are more intermediate MIGS users may take things up a notch. In more aggressive glaucoma cases, if they can't do an iStent but aren't ready to do a trabeculectomy or tube shunt, physicians may con- sider other MIGS. Dr. Okeke finds that procedures such as the Trabec- tome, the Kahook Dual Blade (New World Medical, Rancho Cucamon- ga, California), the Trab360 (Sight Sciences, Menlo Park, California), and gonioscopy-assisted translumi- nal trabeculotomy (GATT) can treat a wider range of patients. "I think that for physicians who have a MIGS procedure down, they have the technical skill set to adopt another procedure that may have another mechanism of action." The CyPass (Alcon, Fort Worth, Texas), for example, goes in a different portion of the angle, the suprachoroidal space, she explained. The Xen Gel Stent (Allergan, Dublin, Ireland) can also provide another step before going to a trabeculecto- my or tube shunt. Advanced users can consider combining procedures. For example, since a Baerveldt glaucoma implant (Johnson & Johnson Vision, Santa Ana, California) is closed initially until a suture dissolves or is pulled out, Dr. Okeke sometimes combines Broadening continued from page 68

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