Eyeworld Daily News

44 | EYEWORLD DAILY NEWS | MAY 6, 2019 ASCRS SYMPOSIA ASCRS ASOA ANNUAL MEETING by Stefanie Petrou Binder, MD EyeWorld Contributing Writer St. Louis, who warmed up to the XEN implant once he discovered the "air technique" in which the bleb is created with air a few clock hours away from the insertion site. This technique allows an easier, wider and lower bleb creation. He spoke about signs of "emphyse- ma pattern" of the bleb, which is air entering the wrong cavity, and can be corrected through finding a cystic pocket and reinjecting air into it until it fills correctly. Editors' note: The physicians have financial interests with some of the companies mentioned. Paul Singh, MD, Racine, Wisconsin, uses the "flush tech- nique" for iStent inject cases, a nuance in the implantation technique, for when the iStent becomes lodged in the loader, in which he uses the second iStent taxied behind the first in the loader to push it out. Another tip he gave was "tapping the stent" for when the stent does not completely enter the canal and can be tapped further in using the side of the loader. He said that all surgeons experience difficulties at times but that they can be over- come. Knowing the right approach can change your perspective, much like Arsham Sheybani, MD, and transscleral XEN Gel Stent (Allergan). The session moderator Jacob Brubaker, MD, Sacramento, Cal- ifornia, spoke about the Hydrus microstent, FDA approved since August 2018, that scaffolds the TM approximately 90 degrees. Both the HORIZON and COM- PARE studies have proven it to lower IOP with cataract surgery. He discussed the importance of wound placement and device insertion, particularly internal targeting and understanding the device. Michelle Butler, MD, Dallas, spoke about her experience with trabecular dilatation and ablation. Canal-based MIGS must have an open angle, can be performed alone or with cataract surgery, facilitate aqueous outflow directly into collectors, have a low risk of serious adverse events, and use an ab interno approach utilizing a gonioprism that requires head/ microscope rotation. Canal-based surgeries target IOP lowering in uncontrolled OAG, the reduction of medication burden, and the prevention of postoperative IOP spikes. The Trabectome (NeoMe- dix) has achieved 31% IOP reduc- tion according to data, with a low rate of serious complications and a 66% overall success rate after 2 years. The Kahook dual blade (New World Medical) achieved up to 26% IOP reductions with 58% of patients reaching more than 20% IOP reduction and a decrease in meds. Dr. Butler said that data on GATT revealed a 37% IOP reduction in POAG patients and a decrease in meds by 1.43. SOAG eyes achieved almost 50% reduc- tion in IOP. She said that a reverse Trendelenburg was useful and recommended generous viscoelas- tic to tamponade, leaving in 10 to 30% at the end of the case. It pays to know a few tricks and tips to help you along your learning curve with MIGS implantation. I t was all about MIGS at a symposium on Sunday morning, where specialists traded Beatles-themed MIGS experiences and updates, providing a comprehensive overview on the vast and highly debated subject. MIGS has forever changed the management of combined cataract and glauco- ma surgery, according to Thomas Samuelson, MD, Minneapolis, who said that you know you are on the right track when you become uninterested in looking back. He said that the vast major- ity of patients suffer from mild to moderate glaucoma and require far less risk-taking in their treatment than those with severe disease, for whom taking a higher risk could be justified and potentially helpful in reducing IOP and saving visual acuity. He said that the emerging paradigm for glaucoma surgery before, during, or after cataract surgery is: applying medicines and laser until surgical cataract, then surgery, then surgery for both phaco and canal (transscleral when disease warrants). He noted that the five prospective randomized MIGS trials all showed that the control arm (phaco alone) sig- nificantly lowered IOP, which is the foundation for the phaco plus canal MIGS strategy. He prefers a procedure synergistic with pha- co to enhance the physiologic outflow and will try not to com- pete with the TM. To maximize safety and visual recovery he uses the iStent (Glaukos), for more advanced disease he opts for the Hydrus microstent (Ivantis), and when he wants to maximize safety but needs more efficacy (with de- layed visual recovery), he chooses GATT. Finally, in extreme cases with extreme preoperative IOP, Dr. Samuelson prefers trab, tubes, The MIGS revolution is far from over Dr. Brubaker discusses the Hydrus microstent.

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