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30 | EYEWORLD DAILY NEWS | MAY 17, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING Video-based MIGS course for the comprehensive ophthalmologist available with XEN. Tradition- al implantation is ab interno with a closed conjunctiva. Ab interno with an open conjunc- tiva might be used for more complex cases that have a higher risk of scarring. There are also ab externo open con- junctiva and ab externo closed conjunctiva/transconjunctival implantation options. Other presentations in this instruction course, which can be viewed at IC-2, include an overview of intraoperative gonioscopy, OMNI (Sight Sci- ences), ab interno canaloplasty (ABiC, Ellex), Hydrus Mi- crostent (Ivantis), iStent (Glaukos), goniotomy-assisted transluminal trabeculotomy (GATT), and Kahook Dual Blade (New World Medical). Editors' note: Dr. Shoham-Hazon has financial interests with Allergan and other ophthalmic companies. Dr. Pandit has no financial interests related to his presentation. (Allergan), describing it as a microinvasive, ab interno, sub- conjunctival implant. He said XEN is meant for all surgeons and all stages of glaucoma. Dr. Shoham-Hazon said XEN uses the "gold standard" mechanism of action for out- flow in a minimally invasive way, bypassing all potential ar- eas of outflow resistance while sparing the conjunctiva. He went on to discuss the impor- tance of prepping the ocular surface prior to this procedure with steroids, oral antibiotics, and consideration of preserva- tive-free glaucoma drops. Looking at clinical data, Dr. Shoham-Hazon said in the APEX trial there was at least a 25% reduction in mean IOP, a mean reduction of medications from 2.6 to 0.6 at 12 months, and 55.5% of patients were drop-free at 12 months. Two- year results were similar in terms of mean IOP, and mean percent change of IOP was nearly 30%. XEN as a stand- alone vs. phaco-XEN combined yielded similar results. He also noted various implantation techniques throughout the procedure, and a suture is used to close at the end of the case. Dr. Pandit said to enter the meshwork by gently press- ing onto it, creating a bit of a wrinkle in the meshwork to then allow you to penetrate into Schlemm's canal. Slowly advance the tip in Schlemm's canal, ensuring the foot pedal is in position 3 (electropulse activated). Ensure you re- main in foot position 3 as you advance forward, ablating along the arc with the incision acting as a fulcrum, Dr. Pan- dit said. Continual handpiece withdrawal toward the surgeon minimizes friction on the pos- terior wall of Schlemm's canal while advancing along the arc, he explained. Postoperative care includes a topical antibiotic, steroid, NSAID, and pilocarpine 1–2% that's tapered alongside the steroid/NSAID (though some surgeons don't use pilocarpine at all). Anticoagulants can be restarted 1 day postop unless there is significant hyphema. The suture is removed after 1 week. Dr. Pandit mentioned a study that showed Trabectome as a standalone procedure had a higher mean IOP reduction compared to the procedure combined with phaco, but the combined procedure had a higher 2-year success rate. When looking at the overall cohort of these patients, Tra- bectome lowers IOP by about 31%, decreases medications by less than one, and has a 2-year success rate. It is well tolerated and has a low rate of serious complications. Nir Shoham-Hazon, MD, New Brunswick, Canada, pre- sented on the XEN Gel Stent by Liz Hillman Editorial Co-Director A video-based instruc- tional course on Sat- urday gave attendees detailed, step-by-step techniques for various MIGS procedures. Discussion includ- ed patient selection, surgical pearls, adjunctive therapy, and management of complications. One presentation focused on performing goniotomy with Trabectome (NeoMedix). Rahul Pandit, MD, Houston, Texas, explained that the Trabectome technology includes automated irrigation and aspiration along with the electrosurgery that se- lectively ablates the trabecular meshwork and the inner wall of Schlemm's canal. It works by creating a plasma cloud that has a highly confined heat dissipation cone with minimal thermal transfer to the outer wall, Dr. Pandit said. Patient selection for Tra- bectome is broad, Dr. Pandit continued. It can be performed as a standalone procedure or with cataract surgery for any patient needing a pressure reduction or those who need a reduction in the number of drops they take. Dr. Pandit en- couraged caution with patients on anticoagulants that can't be discontinued, those with prior stents in the nasal quadrant, and patients with limited neck mobility. A 1.8-mm clear corneal incision is made, followed by rotating the patient's head and the microscope 30–40 degrees. Under goniolens view, the Trabectome tip is inserted. Dr. Pandit said there is a total of 90 degrees of ablation, with 45 degrees in one direction and 45 degrees in the other. Irrigation and aspiration occur Cross-section of the Trabectome handpiece in Schlemm's canal Source: Rahul Pandit, MD, screenshot from presentation

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