Transcript Clear Cornea Cataract Surgery - Minnesota Optometric Association

Surgical Therapy in
Glaucoma 2014
J. James Thimons, O.D.,FAAO
Ophthalmic 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
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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
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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
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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
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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
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Expense
Foreign body
Metal in eye
Corneal contact
Patient Selection
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Same as trabeculectomy
May work better in high risk patients
ICE patients
NV patients
Shallow/synechiae
Resident Surgery with ExPRESS
• 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)
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Seider
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).
Good TJ. Assessment of bleb morphologic features and postoperative outcomes
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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%)
Lankaranian D. Intermediate-term results of the Ex-PRESS(TM) miniature glaucoma
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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
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
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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–
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Less severe hypotony
Less bleeding
Less inflammation
Faster visual recovery
Similar long term IOP control
Baerveldt
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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
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Invasive- extensive dissection
Large foreign object
Diplopia possible
Need some conjunctiva
Very low pressures difficult to acheive
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ECP
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ECP Advantages
• Quick procedure, especially in cataract
setting
• Titratable
• Can be done with outflow procedures
• Hypotony unlikely
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ECP Disadvantages
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Some learning curve to avoid complications
Inflammation possible
IOP does not decrease rapidly
Difficult to do in some eyes
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Canaloplasty
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Effects of Suture Tension
Ex-Vivo Perfusion Study, Utilizing Morton Grant Flow
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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
IOP All Enrolled Eyes
35.0
IOP [mm Hg]
30.0
25.0
20.0
15.0
10.0
5.0
0.0
Baseline
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1D
1W
1M
Noecker
3M
6M
12M
18M
24M
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Canaloplasty Advantages
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Non-invasive
No destruction of anatomy
Hypotony unlikely
Rapid recovery
High Safety Profile
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Canaloplasty Disadvantages
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Longer operating times
Learning curve
Sometimes cannot cannulate
Extensive prior scarring may eliminate
possibility of performing procedure
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Trabectome
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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
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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
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SLX Clinical Results
Gold Shunt Advantages
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Straightforward procedure
Suprachoroidal space attractive to work in
No bleb
Hypotony unlikely
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Gold Shunt Disadvantages
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Still in evolution
Very low IOPs are not possible
Device is fragile
Titrability not proven in humans
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iStent (Glaukos)
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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
Study Visit
Day 1
Day 7
Month 1
Month 2
Month 3
Month 6
Month 12
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Mean IOP (mm Hg)
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3.4
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4.1
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4.4
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5.3
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5.9
5.7
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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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[email protected]
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