Eyeworld

EW CATARACT 27 July 2018 gonioprism in the operating room at the end of cataract surgery with the eye still full of viscoelastic. In other words, they've taken the cataract out, put the new lens in, and the eye still has viscoelastic in it. Then, you can get a gonioprism and use a Sinskey hook to identify the angle and the angle structures. The biggest problem is that most new surgeons don't get good visualization. They're not comfortable, so they must repo- sition the head and the microscope. They don't do it enough; therefore, the visualization they get of the an- gle is poor. Then they are struggling because they're not seeing it well," he explained. Just like using more than one medication to control glaucoma, some surgeons employ more than one MIGS technique. "Sometimes procedures might have an additive effect, and sometimes they may be used in succession," Dr. Okeke said. "There is the opportunity to do MIGS after MIGS and still get good outcomes and extend the life of the eye. I think that the more MIGS pro- cedures with various mechanisms of action that you can have under your belt, the better able you are to serve your patients and individualize their care." Dr. Bettis said that cataract surgeons who are just starting out with MIGS may want to stick to one modality until they get comfort- able. "This will allow them to more quickly gain momentum and experi- ence. Once they are comfortable are comfortable with. The CyPass and the XEN are relatively new, and some of the other approaches are just coming out, so they haven't been trained, but over time, I think there will be more utilization of all of these other procedures," he noted. For cataract surgeons who have not yet performed MIGS, Dr. Okeke recommended getting started with gonioscopy. "They need to get com- fortable with gonioscopy to perform the MIGS procedure, to be able to look for ideal candidates, and to be able to monitor MIGS patients after the procedure is done. It's all about the angle, and the more comfortable you are with the angle, the more you'll be able to easily adopt a MIGS procedure. In the operating room, you can use a Swan Jacob goniolens. If you don't have one, you should order one even before you start to do any MIGS procedures. Start practicing the foundational steps of tilting the microscope toward you, tilting the patient's head away from you, and using your non-dominant hand to hold the goniolens on the cornea. The next step would be to do that plus introduce another instrument in the eye and have the two hands working together," she added. Dr. Lewis agreed. "Before they do the procedure, I think they should get comfortable using a ratio should be at least 0.75 or better. You want to have some level of reserve of nerve tissue so that in case the patient is in need of more pressure-lowering or you need to go to another surgical procedure, you're not dealing with the last bit of fragile optic nerve tissue that's available. Patients should ideally be in the early to moderate stage. MIGS procedures can be performed in patients who are moderate to ad- vanced, but most MIGS procedures are looking at good success with early to moderate stage glaucoma," Dr. Okeke said. She added that the XEN Gel Stent is indicated for patients who are in the more moderate to ad- vanced stages of glaucoma. Poor MIGS candidates are those who have severe open angle glauco- ma on maximum medical therapy. Patients with poor angle anatomy such as synechial angle closure, neo- vascularization, congenital anom- alies, or severe corneal opacity so that the angle can't be seen are also not good candidates. "If you can't see the angle, you can't treat it," Dr. Okeke said. Getting started with MIGS According to Rick Lewis, MD, Sac- ramento, California, many cataract surgeons haven't yet been trained to use some of the newer approaches. "They are sticking with what they and can see the net value added to their patients, I think they will want to explore additional MIGS modal- ities. This allows for an individual- ized treatment plan and titration of the risk and reward to a level that is appropriate. The approach for a patient with mild glaucoma on one medicine is likely different from the patient who is struggling to get in three different medications per day. For the latter patient, I would be more likely to target a larger proportion of the angle or either the suprachoroidal or subconjunctival space," he said. EW Editors' note: Dr. Lewis has financial interests with Aerie Pharmaceuticals (Durham, North Carolina), Allergan, Advanced Vision Science (Goleta, California), Alcon, Ivantis, New World Medical, MicroOptx (Maple Grove, Minnesota), and Sight Sciences. Dr. Okeke has financial interests with Aerie Pharmaceuticals, Allergan, Alcon, Ellex, Glaukos, NeoMedix, Novartis (Basel, Switzerland), and Bausch + Lomb (Bridgewater, New Jersey). Dr. Bettis has no financial interests related to his comments. Contact information Bettis: dabettis@gmail.com Lewis: rlewiseyemd@yahoo.com Okeke: iglaucoma@gmail.com MIGS for the novice John Odette, MD, discusses the role MIGS is playing in cataract practices. EWrePlay.org CyPass Micro-Stent Ultra System Source: Alcon

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