Which treatment options do you typically offer to patients newly diagnosed with glaucoma? Drops? Laser trabeculoplasty (LTP)? Which would you choose if you were the patient?
Ask these questions of enough ophthalmologists, and you will find that many would choose initial LTP for themselves but typically suggest medical therapy first for their patients. If you are one of those practitioners, then the feeling you are experiencing right now is called cognitive dissonance, anxiety over the inconsistency between your beliefs and actions. Psychologists consider cognitive dissonance to be a strong motivator for behavioral change. In that spirit, this month’s article highlights several videos of innovative surgeries that may challenge your approach to glaucoma treatment.
WHICH SURGERY WOULD YOU CHOOSE?
If you had glaucoma that was refractory to medical therapy and LTP, which incisional procedure would you choose for yourself? In a unique and compelling video, Richard A. Lewis, MD, talks to cataract surgical pioneer Robert M. Sinskey, MD, about his decision to undergo canaloplasty when eye drops and LTP failed to control his IOP. Now 87 years old and off drops after successful canaloplasty, Dr. Sinskey is happy to have an IOP of 13 mm Hg without a bleb or any of its accompanying symptoms. “You can’t ask for anything better than that,” he says in the video. Dr. Sinskey compares cataract surgeons’ initial resistance to phacoemulsification to glaucoma surgeons’ limited adoption of canaloplasty, and he notes that the learning curves for both procedures may have decreased their initial acceptance.
Eyetube.net features multiple surgical videos of canaloplasty. In addition, the site has videos that demonstrate how several surgeons choose candidates for the procedure and how these surgeons describe the procedure to their patients. Ophthalmologists such as Samuel Masket, MD; David Richardson, MD; Michael Morgan, MD; and Sally Mellgren, MD, believe that excellent safety data1 make this procedure applicable to a wide range of patients, typically earlier in the spectrum of disease than with standard filtering surgery such as trabeculectomy or the placement of a glaucoma drainage device.
THE ORIGINAL MINIMALLY INVASIVE GLAUCOMA PROCEDURE
According to Stanley J. Berke, MD, of Long Island, New York, the first and most frequently performed minimally invasive glaucoma surgery is endocyclophotocoagulation (ECP). Based on his experience over the course of 13 years and in more than 2,000 eyes, Dr. Berke typically treats between 200º and 300º of the ciliary body in combination with cataract extraction. Even with 360º of treatment, however, he says there have been no reports of hypotony or phthisis. Dr. Berke notes that the endoscope can be used for many purposes, including for goniotomy in eyes with congenital glaucoma and for the identification and closure of a cyclodialysis cleft.
Dr. Berke’s video provides excellent images of ciliary photocoagulation (Figure 1). It also reviews ECP’s many advantages, including a paucity of long-term complications. In addition, the procedure spares the conjunctiva and requires no more follow-up than for cataract surgery alone. Dr. Berke concludes by commenting that ECP is “fun and interesting”; the same could be said about his video.
Are any new minimally invasive glaucoma surgeries on the horizon? E. Randy Craven, MD, provides the answer. His video demonstrates the implantation of the CyPass Micro- Stent (Transcend Medical) immediately after cataract surgery. This polyimide supraciliary device is 6.35 mm long and is designed for ab interno implantation. It is currently limited by US law to investigational use.
After extracting the cataract and placing the IOL, Dr. Craven injects a viscoelastic to widen the angle and positions the microscope and gonioscopic lens. He uses the tip of the CyPass, through the temporal corneal incision, to gently disinsert the iris away from the scleral spur, which creates access to the supraciliary space (Figure 2). Dr. Craven then inserts the stent into the supraciliary space and releases the device from the inserter in a manner akin to the delivery of a punctal plug. Next, he removes the viscoelastic material and concludes the cataract procedure as usual.
Dr. Craven’s video is short and simple. I am sure that, like me, many of you are anxious to learn the results of the ongoing clinical trial investigating the safety and efficacy of this device (http://compassclinicalstudy.com/pages/cypass_micro_stent.htm).
Whether you want to adopt a new surgical procedure or are just curious about the new techniques that may become available in the future, Eyetube.net features intriguing videos from enthusiastic ophthalmologists who are hoping to bridge the gap between safe (but sometimes ineffective) medications and traditional (but sometimes risky) glaucoma surgeries. Innovative colleagues can provide new perspectives and just might change what you do for your glaucoma patients.
Section Editor Nathan M. Radcliffe, MD, is an assistant professor of ophthalmology at Weill Cornell Medical College, New York-Presbyterian Hospital, New York. He acknowledged no financial interest in the product or company mentioned herein. Dr. Radcliffe may be reached at (646) 962- 2020; email@example.com.
- Lewis RA, von Wolff K, Tetz M, et al. Canaloplasty: three-year results of circumferential viscodilation and tensioning of Schlemm canal using a microcatheter to treat open-angle glaucoma. J Cataract Refract Surg. 2011;37:682-690.
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