Eyeworld Daily News

EW SHOW DAILY 34 ASCRS Symposia Monday, May 9, 2016 by Liz Hillman EyeWorld Staff Writer Optimizing the many MIGS options in practice Bringing iStent into practice, targeting placement, and considering the role of ECP I t's relatively common for there to be patient compliance issues even if patients are only on 1 glaucoma medication. Add oth- er medications on top of that and adherence to medical therapies for glaucoma management drops even more. Still, patients might not be advanced enough in their disease to merit a trabeculectomy or tube shunt. The advent of multiple micro- invasive glaucoma surgery (MIGS) options has ophthalmologists excit- ed as they can be used to fill this gap for the mild to moderate glaucoma patient with either compliance issues or the patient on 3 or 4 drops with IOP that merits further control. Long-term clinical data on iStent (Glaukos, Laguna Hills, California), the only MIGS implant currently approved by the FDA for use in the United States, continues to come in, but what about incor- porating it into practice? Steven Vold, MD, Fayetteville, Arkansas, led the symposium sponsored by the ASCRS Glaucoma Clinical Commit- tee, speaking on this topic. First and foremost, he said that communi- cation and education are critical to incorporating iStent into practice, but he added that the surgeons themselves have to believe in the product. From there, talking about it with the patient—in educational meetings, brochures, or DVDs—is important as well. Dr. Vold recom- mended physicians speak of the iStent as a device that could benefit patients with minimal downsides while also preserving the conjuncti- va for filtration surgery if needed in the future. To achieve success with the iStent, placement is key. Dr. Vold advised audience members to make sure the tip of the inserter is up while taking it out of the packag- ing to avoid dislocating the stent from the get-go. He also said that viscoelastic can help facilitate better insertion and recommended that the stent be placed parallel to the corneal wound. Knowing the patient's anatomy can help avoid stent misplacement, but for difficult angles, such as narrow angles, Dr. Vold said removal of a cataract might be helpful. He also recommended looking "over the hill" or using a "corneal wedge" technique in difficult angle cases. Davesh Varma, MD, Toronto, who has 6 years of experience with the iStent, talked specifically about targeting the implant for optimal outflow. He said that physicians should first get comfortable with implanting the device in Schlemm's canal and then focus on targeting, which is when the stent is strategi- cally placed near a collector channel that is near 1 of the major episcleral veins. To target optimally, Dr. Varma said the eye should be inflated— overinflated even—with lidocaine or balanced salt solution, to drive aque- ous into the veins to identify where to place the stent. He will mark that location with ink as a general guide. After placement of the iStent, he said the physician can check the effect by seeing if the vein blanches with increased aqueous flow. "That's, for me, some proof on the table that I've hit the right target," he said. "I've found with target implantation, I'm getting much more pressure lowering, and I'm able to do it in a wider array of patients, in patients with more advanced disease." If trabecular micro-bypass de- vices like iStent are the (relatively) new thing, then endoscopic cyclo- photocoagulation (ECP) is certainly an old technique. First developed by Martin Uram, MD, Little Silver, New Jersey, in 1992, the technique uses an intraocular laser endoscope to shrink part of the ciliary body epi- thelium, reducing the production of aqueous humor. Is it still relevant? Robert Noecker, MD, Fairfield, Connecticut, thinks so. Dr. Noecker highlighted how ECP can be used in conjunction with cataract surgery, with other glaucoma procedures at the time of cataract surgery, as a re- placement medical therapy, in eyes with previous outflow procedures, eyes at risk for hypotony, eyes with conjunctival or scleral issues, or in plateau iris cases. Nathan Radcliffe, MD, New York, expounded upon this idea of combining ECP with other MIGS options. These include ICE (iStent + cataract + ECP), VICE (VISCO360 [Sight Sciences, Menlo Park, Cali- fornia] + cataract + ECP), and CAKE (cataract + Kahook Dual Blade [New World Medical, Rancho Cucamonga, California] + ECP). While some specialists think glaucoma treatment should focus on restoring outflow of aqueous, Dr. Radcliffe said he thinks there is a strong case to be made for reducing the production of aqueous. "We rely medically on reducing aqueous production—that's the bed- rock of treatment," he said. "If we use it medically, why wouldn't we want to use it surgically? In a disease where most people progress over time, I think we need all the help that we can get." As for patient considerations when choosing a combined proce- dure such as 1 of these, Dr. Radcliffe said disease severity, target IOP, current drop regimen, baseline IOP, and the presence of cataract, clear lens, or a phakic IOL should be considered. Other presentations included information on Trabectome (Neo- Medix, Tustin, California) as an ab interno trabeculotomy procedure, Trab360 (Sight Sciences), goniosco- py-assisted transluminal trabeculoto- my, and the Kahook Dual Blade. EW Editors' note: Dr. Vold has financial interests with Glaukos. Dr. Varma has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Alcon (Fort Worth, Texas), Allergan (Dub- lin), Labtician (Ontario, Canada), and New World Medical. Dr. Radcliffe has financial interests with Iridex (Moun- tain View, California), Beaver-Visitec International (Waltham, Massachu- setts), Allergan, Glaukos, Lumenis (Yokneam, Israel), TearScience (San Diego), Reichert (Depew, New York), Alimera Sciences (Alpharetta, Geor- gia), Transcend Medical (Menlo Park, California), and New World Medical. Dr. Noecker has financial interests with Beaver-Visitec International. Dr. Noecker speaks about how ECP is still a relevant and useful treatment for glaucoma management.

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