Eyeworld

EW FEATURE 76 Challenging cataract cases • October 2017 • Cataract surgery combined with MIGS is safe and offers rapid visual recovery and better IOL lowering than cataract surgery alone. • Clinicians reach for the CyPass, iStent, and Xen for their advanced glaucoma cases at the time of cataract surgery. • Trabeculectomy still has its place in glaucoma treatment despite large pressure reductions by MIGS. AT A GLANCE by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer alone in the setting of patients with advanced glaucoma who were well controlled on multiple medications. Why? Because we knew adding a tra- beculectomy or glaucoma drainage implant to the cataract surgery in this setting would greatly elevate the risk for complications and delay the visual recovery. We would also rea- son to ourselves that cataract surgery itself has a small chance of modest pressure lowering and thus we could help with glaucoma control without a trab or tube. Then, if we desired further IOP lowering or greater medication burden reduction, we could do a trabeculectomy or drain- age implant as a separate procedure months later. Taking this mentality, why wouldn't you consider doing MIGS with cataract surgery in this setting? You will give patients a pro- cedure that is comparable to cataract surgery alone in terms of safety and rapid visual recovery while giving them a much better chance at lower- ing IOP and/or medication burden. You can always go back and do the more aggressive traditional glauco- ma filtration surgeries later if you need to. In my experience, that will only very rarely be the case." Dr. Kim will typically combine glaucoma procedures in patients with more advanced disease, especially when seeking to avoid traditional filtration surgery in patients at a high risk for compli- cations, such as high myopes and those who are post-vitrectomy or post-scleral buckle. He prefers to avoid traditional filtration surgery in monocular and young patients as well because they would have to live many decades with the lifelong risks of bleb-related infections and tube-related complications. "I have used the Trabectome [NeoMedix, Tustin, California] and endoscop- ic cyclophotocoagulation (ECP) combination in post-vitrectomy and scleral buckle patients because of the high risk for trab failure and the increased risk for complications such as tube erosion after tube shunts. I have used that combination for pa- tients with very thin sclera such as osteogenesis imperfecta and scleritis where their sclera likely would not have allowed for a trab or tube. For patients with advanced disease who have already failed consecutively both trab and tube, I have often performed the gonioscopy-assisted transluminal trabeculotomy (GATT) and 360-degree ECP combination. In monocular patients with advanced disease where I want to minimize the risk for hyphema but I want greater IOP lowering than what a typical MIGS procedure might provide, I have combined limited ab interno trabeculectomy, performed with the Trabectome or Kahook Dual Blade [New World Medical, Rancho Cucamonga, California], with ab interno canaloplasty and ECP. More recently I have been utilizing the CyPass Micro-Stent [Alcon, Fort Worth, Texas] combined with mul- tiple targeted iStent [Glaukos, San Clemente, California] placement. All of these combinations can work very well and not uncommonly will produce IOP in the low teens with a reduction in medication burden," Dr. Kim said. Yes to iStent for moderate glaucoma Yuri McKee, MD, Mesa, Arizona, agrees that the more help you have in lowering IOP, the better. However, to avoid reimbursement issues, Dr. McKee sticks to the iStent, which is indicated for implantation at the time of cataract surgery. "I use the iStent in patients with mild, moder- ate, or advanced glaucoma because the higher the pressure, the better the effect of the iStent. In these cases, every little bit helps. I do not think the iStent is the last thing that will be required in cases of advanced glaucoma, as its indication is for mild to moderate disease, but it still is useful in advanced glaucoma because it is going to give you some pressure reduction, and every little bit counts," Dr. McKee said. The iStent is most effective in patients with still viable drain- age systems. Advanced glaucoma, however, is often associated with pathology of the trabecular mesh- work, blocking egress of aqueous humor through the conventional pathway. The uveoscleral pathway and suprachoroidal space therefore represent important outflow alter- natives. Despite the large absorptive capacity of the supraciliary space, Dr. McKee thinks that it may be best to avoid stenting to the supracho- roidal/supraciliary spaces. "My issue with suprachoroidal MIGS is that there is a concerning rate of CME associated with these devices. If you think about it, you are connecting the anterior chamber directly to the suprachoroidal space, so any inflam- mation in the anterior chamber is going to have a direct passageway to the subfoveal space and can cause CME. Currently, I am not doing any suprachoroidal MIGS procedures. I prefer to stick to the iStent and the Xen Gel Stent [Allergan, Dublin, Ireland]. I prefer to do the Xen as a standalone procedure," he said. The Xen is approved for patients with refractory glaucoma who failed previous surgical treatments or in patients with open angle glaucoma, pseudoexfoliative or pigmentary Devising a treatment strategy to lower IOP in glaucoma that has progressed to moderate and advanced stages in eyes with cataract now includes MIGS as a standard option P atients on maximal med- ical glaucoma therapy need new solutions. Drop regimens are tedious, with efficacy only as good as the patient's adherence to the drop protocol and their pressure-lower- ing effect in hard cases dwindling. When cataract enters the picture, clinicians are in a favorable posi- tion to maximize IOP reduction by implanting microinvasive glaucoma surgery (MIGS) devices or perform- ing trabeculectomy, if needed. Atti- tudes on trabeculectomy as the gold standard treatment for advanced glaucoma cases are divided, owing to the relative surgical simplicity and high efficacy of different MIGS implants. Yes to MIGS with cataract According to Won Kim, MD, Walter Reed National Military Medical Center, Bethesda, Maryland, MIGS has an important role in cataract cases with advanced glaucoma. "This idea that MIGS procedures are somehow off limits for patients with advanced glaucoma is misguided," Dr. Kim said. "Before the advent of MIGS procedures, many glaucoma surgeons often did cataract surgery Managing cataract with advanced glaucoma Combining MIGS procedures can improve their efficacy while maintaining the safety profile. One such combination begins with the implantation of a CyPass Micro-Stent.

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