Eyeworld

47 EW FEATURE July 2018 • Challenging cases for younger patients—including in- fantile glaucomas—with secondary conditions. "There has been some improve- ment in the available options for the control of systemic inflammation, and that has helped some uveitic patients avoid steroid-induced IOP elevation and maintain a healthier trabecular meshwork; the better their systemic inflammation is controlled, the better it is for them in the long run," Dr. Rothman said. "Some of our newer surgical options available now and in the future are going to help these patients, since many traditional surgical procedures tend to have unacceptable survival rates and permanently distort the conjunctiva and ocular surface." Microinvasive glaucoma surgery (MIGS) procedures, as earlier surgical options for all patients, are becom- ing more prominent as surgeons gain experience in some of the more challenging patient populations. Dr. Rothman has managed pediatric patients with a history of failed tube shunt surgery who have received the InnFocus Microshunt (Santen, Osaka, Japan) outside the United States."After several months of follow-up they look good," Dr. Rothman said. Dr. Trubnik has found laser cataract surgery helpful in pseudoex- foliation patients as well as patients with multiple retinal injections who may have weakened zonules and an unstable lens. "That creates a much easier procedure where I don't have to put as much stress on the zonules," Dr. Trubnik said. Additionally, Dr. Trubnik uses expansion devices, like iris rings or hooks, to help if the pupil is small. If it is a particularly dense lens and phacodonesis is present, she finds the miLOOP (Iantech, Reno, Neva- da) has been useful to get the lens out safely in those patients in whom laser cataract surgery is not possible due to a miotic pupil. Dr. Radcliffe, one of the first U.S. surgeons to adopt MicroPulse laser cyclophotocoagulation (Iridex, Mountain View, California) about 3 years ago, has found it effective both before and after surgical pro- cedures. "It is different from all of the other options because it works by suppressing the amount of aqueous humor produced," Dr. Radcliffe said. "If a patient has failed a few other types of surgery, I have that in my back pocket, and it can be a life saver." The FDA approval of the CyPass Micro-Stent (Alcon, Fort Worth, Tex- as) offered a treatment that accesses a different pathway—the uveal scleral pathway. "If someone has failed a few tubes, for example, the CyPass is a different mechanism, and it may work uniquely well," Dr. Radcliffe said. "I love trabecular meshwork surgery and do plenty of it but usu- ally these patients have already had that surgery because that is part of many surgeons' routine algorithm for cataract/glaucoma surgery." Dr. Radcliffe described the XEN Gel Stent (Allergan, Dublin, Ireland) as "very helpful because it can achieve low IOP and get people independent of drops but without the risk of a trabeculectomy." New medicines that have espe- cially helped Dr. Radcliffe's patients are Vyzulta (latanoprostene bunod, Bausch + Lomb, Bridgewater, New Jersey) and Rhopressa (netarsudil, Aerie Pharmaceuticals, Irvine, California), both of which help with aqueous outflow through the trabecular meshwork. "Having new medical options always helps surgeries work better because it gives us more flexibility if patients are having intolerances," he said. Coming treatments Several companies are looking at devices that will drain externally in a controlled fashion, Dr. Rothman said. "Those devices hold great prom- ise for situations where significant scarring has been a problem, which tends to be the case with inflamma- tory glaucoma, chronic medication usage, and failed prior surgery," Dr. Rothman said. "Those future devices are going to be helpful in the man- agement of many of these patients." Dr. Rothman is also looking forward to trying new medications for patients with contraindications to or lack of efficacy from some of the current therapeutic options. "Traditional medications have worked poorly in patients with Sturge-Weber syndrome," Dr. Rothman said. "I am excited to try Rhopressa in patients with this problem to see how they respond, as it is the first topical agent that may directly impact episcleral venous pressure." EW Editors' note: Dr. Radcliffe has finan- cial interests with Aerie Pharmaceuti- cals, Alcon, Allergan, Bausch + Lomb, and Iridex. Dr. Rothman has financial interests with Allergan, Aerie Phar- maceuticals, Bausch + Lomb, Camras Vision (Research Triangle Park, North Carolina), and Qura Inc. (Boston). Dr. Trubnik has no financial interests related to her comments. Contact information Radcliffe: drradcliffe@gmail.com Rothman: rothman1@optonline.net Trubnik: vtrubnik@ocli.net Poll size: 140 In regard to LASIK, PRK, or SMILE: I currently perform these procedures I refer the patient to one of my partners I am considering starting to perform these procedures We do not perform corneal refractive surgery in my practice In the management of a patient with a cataract and glaucoma: I perform cataract surgery alone I perform cataract surgery with a trabeculectomy or tube shunt as indicated I perform cataract surgery with a MIGS device I refer the patient

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