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16 | EYEWORLD DAILY NEWS | MAY 18, 2020 DAILY NEWS ASCRS VIRTUAL ANNUAL MEETING Micro-shunt, Santen Pharma- ceutical), and she presented information on the material and surgical technique for each. For the XEN, she noted its flexibility, in that it's straight and rigid when dry but soft and flexible when hydrated. The XEN is designed for ab interno insertion but can also be delivered via an ab externo approach. For the PRESERFLO, she described how it induces min- imal tissue inflammation and encapsulation. The XEN and PRESERFLO use principles of the Hagen-Po- iseuille equation of laminar flow, Dr. Kornmann shared. They are made of materials that induce minimal inflamma- tion and are less invasive than traditional glaucoma surgery. Both show promising results for a wide variety of glaucoma subtypes and stages of glauco- ma, with a better safety profile. But she added that prospective randomized clinical trials are still needed comparing these devices to traditional glaucoma surgeries and to each other. Joseph Panarelli, MD, New York, New York, pre- sented on using an open XEN approach. He first noted that opening the conjunctiva may offer the following advantag- es: more predictable, more room to work, less prone to early failure, can use higher concentrations of MMC, easier to troubleshoot, much lower chance of erosion/extrusion and late infection, and overall shorter learning curve. However, he did note some downsides to opening the conjunctiva, including wound leaks, longer surgical time, and more inflammation. by Ellen Stodola Editorial Co-Director D uring a session on MIGS, Michelle But- ler, MD, Dallas, Texas, discussed targeting the canal in these procedures. She first focused her pre- sentation on figuring out who is a good candidate for MIGS, which could include glaucoma factors, patient factors, and procedure factors. In terms of the type of glaucoma, Dr. Butler suggested that good candidates may be those with primary open angle glaucoma (POAG); secondary OAG, like pseudoexfoliation, pigmentary, steroid-induced, inflammatory, traumatic, or prior corneal or retinal surgery (though with inflammatory and traumatic glaucoma, it may depend on the appearance and function of the trabecular meshwork); and juvenile onset. She suggested using caution with normal tension glauco- ma, elevated episcleral venous pressure, PAS that is present for more than 6 months, and long-standing disease. Dr. Butler also presented on how disease severity may come into play when choosing a procedure, noting that for mild to moderate glaucoma, you can use MIGS. For severe disease, MIGS may be considered, but a subconjunctival procedure may be needed. She also stressed the importance of looking at the rate of progression vs. sta- bility, correlation with OCT and clinical exam, and target IOP. She emphasized current glaucoma treatments available, mainly topical IOP medication. With these, there may be issues with compliance, tolerability, and affordability. When considering angle anatomy, Dr. Butler mentioned the use of preoperative gonios- copy to help prevent surprises in the OR. For an open angle, MIGS can be used. If the angle is closed, she suggested phaco first, then MIGS for apposition- al/narrow angle despite LPI or using goniosynechiolysis then MIGS when synechiae are present. When angle recession is the issue, Dr. Butler consid- ers MIGS if the nasal angle anatomy is preserved. If there is neovascularization, she said not to do a MIGS procedure. Dr. Butler's presentation covered patient factors. She noted that doing cataract surgery plus MIGS can help improve glaucoma control and reduce the medication burden. However, you also have to consider a patient's medical health. It's particularly important to consider patient expectations, making it clear to the patient that there is no "cure" for glaucoma, and it must still be monitored. Dr. Butler mentioned insurance coverage and the cost of the procedure/reimbursement as important considerations. Also during the session, Helen Kornmann, MD, PhD, Dallas, Texas, discussed MIGS-plus and targeting the subconjunctiva. She first highlighted the benefits of MIGS-plus, noting that it bridges the gap between trabecular bypass/ablative procedures and traditional glaucoma surgeries. It's similar to trabeculectomy in creating a subconjunctival bleb and achieving profound IOP low- ering. It's also similar to MIGS because it's less invasive and there is less postoperative intervention and faster visual recovery. She noted some of the best candidates: those with a need for low IOP, those with a healthy/unscarred conjuncti- va, those with an open angle, those with no inflammation/ history of uveitis, and those with no neovascular glaucoma. Dr. Kornmann mentioned two "MIGS-plus" devices, the XEN Gel Stent (Allergan) and the PRESERFLO Micro- Shunt (formerly the InnFocus 'Gettin MIGSy With It' continued on page 18 Experience EyeWorld 24/7 EyeWorld.org Supplements Recent articles in web-friendly format Searchable archives from 2007 to present EyeWorld Weekly news feed Trending videos Live Twi•er feed

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