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Surgical Therapy in Glaucoma 2014
J. James Thimons, O.D.,FAAOOphthalmic Consultants of Connecticut
Fairfield, CT
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Trends
• Streamlining of existing procedures– Express Minishunt– Use of Fibrin glue to reduce suturing– Alternative tube placement techniques
• Less invasive procedures– Canaloplasty– Trabectome– Gold Shunt– Glaukos shunt– ECP
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Considerations
• Impact of subsequent or prior procedures
• Realistic expectations on intraocular pressure control and continuing medical therapy
• Expected and tolerable side effects and complications
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Glaucoma Procedure Options that we have done
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Trabeculectomy with Express Minishunt
Express Minishunt Advantages
• Reduces operating time
• Eyes appear to be quieter earlier in post-op course
• No iridectomy
• Uniform opening
• If hypotony occurs, tends to be less severe
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Express Minishunt Disadvantages
• Needs some suturing as in trabeculectomy
• Dependent on patient healing
• Anti- metabolites still routinely used
• Patient has bleb
• Hypotony possible
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Reasons to use the Express
• Simplify procedure
• Shorten surgery time
• Decrease tissue manipulation
• Eliminate need for iridectomy
• Decrease chance of ostium obstruction
• Regulate flow in short term
• Create less short term inflammation
Arguments Against
• Expense
• Foreign body
• Metal in eye
• Corneal contact
Patient Selection
• Same as trabeculectomy
• May work better in high risk patients
• ICE patients
• NV patients
• Shallow/synechiae
Resident Surgery with Ex-PRESS
• No difference
– postoperative IOP
– proportional decrease in IOP
• Ex-PRESS group
– Significantly less medication to control IOP at 3 months
– No difference at 6 months or 1 year (P≥0.28)
– More Ex-PRESS patients had good IOP control without meds at 3 (P=0.057) and 6 months (P=0.076)
– No difference was found in the rates of sight-threatening complications (P≥0.22)
04/19/23Seider MI. Resident-performed Ex-PRESS Shunt Implantation Versus Trabeculectomy J Glaucoma. 2011 Apr 25. [Epub ahead of print]
Retrospective Case Series• Final percent IOP lowering was similar• Moorefields Bleb Grading System
– Less vascularity and height but more diffuse area associated with the Ex-PRESS blebs
• Fewer cases of early postoperative hypotony and hyphema• Quicker visual recovery
– The Ex-PRESS group required fewer postoperative visits compared with the trabeculectomy group (P < .000).
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Good TJ. Assessment of bleb morphologic features and postoperative outcomes after Ex-PRESSdrainage device implantation versus trabeculectomy. Am J Ophthalmol. 2011 Mar;151(3):507-13.e1. Epub 2011 Jan 13.
Ex-PRESS in prior operated eyes
• Success complete in 60(60%) and qualified in 24 (24%) eyes
• Mean IOP– 27.7 ± 9.2 mm Hg with 2.73 ± 1.1 – 14.02 ± 5.1 mm Hg with 0.72 ± 1.06 drugs (p <
0.0001)• Failure
– Uncontrolled IOP (11%)– bleb needling (4%)– persistent hypotony (1%)
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Lankaranian D. Intermediate-term results of the Ex-PRESS(TM) miniature glaucoma implant under a scleral flap in previously operated eyes. Clin Experiment Ophthalmol. 2010 Dec 22.
5 year study Ex-press vs Trabeculoectomy
• EX-PRESS more effective without medication– At year 1 12.8% of patients required IOP meds
after EX-PRESS implantation vs 35.9% after trabeculectomy
– At year 5 (41% versus 53.9%) • Responder rate was higher with EX-PRESS• Time to failure was longer• Surgical interventions for complications were
fewer after EX-PRESS implantation
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deJong et al. Five-year extension of a clinical trial comparing the EX-PRESS glaucomafiltration device and trabeculectomy in primary open-angle glaucoma. Clin Ophthalmol. 2011;5:527-33. Epub 2011 Apr 29.
Anesthetic Injection
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Conjunctiva Dissection
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25G Trochar
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Conjunctival Closure
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Post-op
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Results
• The mean preoperative IOP was 23.7 ± 9.3 and the mean postoperative IOP on the last follow up day was 10.4 ± 4.5 (p<0.001) over a mean follow up period of 199 days (range 29-608).
• The mean number of medications used preoperatively was 2.83 ± 1.1 and postoperatively was 0.023 ± 0.1 (p<0.001).
• Complications as hypotony, bleb leak, choroidal detachment, and transient hyphema were detected.
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Outcomes
• Studies overall suggest compared to trabeculectomy-– Less severe hypotony– Less bleeding– Less inflammation– Faster visual recovery– Similar long term IOP control
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Baerveldt
Baerveldt Patch Graft Placement
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Baerveldt Advantages
• Effective for almost all types of glaucoma
• Able to do when other procedures are not possible
• Not dependent on patient healing
• Can implant multiple devices
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Baerveldt Disadvantages
• Invasive- extensive dissection
• Large foreign object
• Diplopia possible
• Need some conjunctiva
• Very low pressures difficult to acheive
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ECP
ECP Advantages
• Quick procedure, especially in cataract setting
• Titratable
• Can be done with outflow procedures
• Hypotony unlikely
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ECP Disadvantages
• Some learning curve to avoid complications
• Inflammation possible
• IOP does not decrease rapidly
• Difficult to do in some eyes
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Canaloplasty
Effects of Suture TensionEx-Vivo Perfusion Study, Utilizing Morton Grant Flow
Model
– Pressurize globe to a range of physiologic pressures
– Apply tension to a suture implanted through the canal
– Measure outflow facility (uL/Min / mmHg)
(Image: iScience)
Canaloplasty
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IOP All Enrolled Eyes
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
Baseline 1D 1W 1M 3M 6M 12M 18M 24M
IOP
[m
m H
g]
Canaloplasty Advantages
• Non-invasive
• No destruction of anatomy
• Hypotony unlikely
• Rapid recovery
• High Safety Profile
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Canaloplasty Disadvantages
• Longer operating times
• Learning curve
• Sometimes cannot cannulate
• Extensive prior scarring may eliminate possibility of performing procedure
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Trabectome
Trabectome Advantages
• Quick procedure
• Hypotony unlikely
• Ab interno approach eliminates dependence on dissection
• Can do in many types of glaucoma
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Trabectome Disadvantages
• Need to be able to visualize angle
• Bleeding common
• Very low IOPs unlikely
• Cannot do in eyes with canaloplasty
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Gold Shunt
SLX Clinical Results
Gold Shunt Advantages
• Straightforward procedure
• Suprachoroidal space attractive to work in
• No bleb
• Hypotony unlikely
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Gold Shunt Disadvantages
• Still in evolution
• Very low IOPs are not possible
• Device is fragile
• Titrability not proven in humans
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iStent (Glaukos)
Why Trabecular Bypass Surgery?
Stent / Efficacy:• Schlemm’s canal is part of the aqueous outflow pathway• iStent
® restores aqueous outflow chain by bypassing only the blockage
that occurs with glaucoma in the trabecular meshwork• IOP reductions to mid teens
Glaukos Efficacy
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4.14.4
5.75.9
5.3
4
3.4
0
1
2
3
4
5
6
7
8
Day 1 Day 7 Month 1 Month 2 Month 3 Month 6 Month 12
Study VisitM
ean
IOP
(m
m H
g)
Glaukos Advantages
• Quick to perform
• No dependence on prior procedures
• May be able to titrate with multiple procedures
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Glaukos Disadvantages
• Very low IOPs not likely
• Need open angle
• Placement of earlier device is sometimes difficult
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Glaucoma Surgical Procedures
• Many evolving and new procedures
• Surgeon has more options at his disposal than ever before
• Customization can be done to balance risk and reward for each individual patient
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