Considerations in the Cataract Patient with Glaucoma. Robert Noecker, MD, MBA Ophthalmic Consultants of Connecticut Fairfield, CT

Transcription

1 Considerations in the Cataract Patient with Glaucoma Robert Noecker, MD, MBA Ophthalmic Consultants of Connecticut Fairfield, CT

2 Financial Disclosure Dr. Noecker has been a paid consultant to Allergan, Alcon, EndoOptiks, Aton, and Ocular Therapeutics within the past year Speakers bureau: Allergan, Alcon, EndoOptiks, Merck, Lumenis Research Support: Glaukos, SOLX, Ocular Therapeutics, Lumenis 9/10/2013 NOECKER- 2011

3 When to do Cataract Surgery Alone? Milder glaucoma Few pre-op medications Can tolerate IOP spike Pure Narrow Angle component Not expecting needing dramatic IOP reduction Worry about complications of glaucoma surgery 9/10/2013 NOECKER- 2011

4 Which eyes do we have to be particularly careful of in terms of their glaucoma? Split fixation Central loss on both sides of horizontal midline Steroid Responders Poor IOP control pre-op 9/10/2013 NOECKER- 2011

5 What precautions do you take if you do CE alone? Thorough viscoelastic removal Glaucoma eye drops Alpha agonists, beta blockers, CAIs PGAs? Systemic CAIs Same day IOP checks 9/10/2013 NOECKER- 2011

6 When to do Combined? Replacement medical therapy Prevention of IOP spikes Eyes with previous failed procedures Chronic angle closure Cataract Surgery not expected to be adequate 9/10/2013 NOECKER- 2011

7 More Traditional Choices for Combined Glaucoma Trabeculectomy Ex-PRESS Surgery Glaucoma Draingage Devices (Ahmed, Baerveldt, Molteno) Canaloplasty Trabectome 9/10/2013 NOECKER- 2011

8 Less Invasive Options istent (Glaukos) Endscopic Cyclophotocoagulation (ECP) 9/10/2013 NOECKER- 2011

9 Why choose combined Phaco-istent or Phaco- ECP? Don t need IOP of 10 mm Hg Replacement medical therapy Eyes at risk for hypotony i.e. Vitrectomized Eyes Anticoagulant concerns Poor conjuncitva/sclera Refractive Error concerns 9/10/2013 NOECKER- 2011

10 9/10/2013 NOECKER Phaco Istent

11 % eyes Efficacy at One Year from US Pivotal Trial 4 istent + Cataract Surgery vs. Cataract Surgery Only IOP 21 mmhg w/o meds IOP 20% w/o meds p = p < Cat sx only istent + Cat sx Cat sx only istent + Cat sx istent safety and efficacy shown through extensive experience R. Noecker, MD 2011 OSN NY excludes data after 2 nd surgery 4. Samuelson, et al. Ophthalmology 2011: 118:

12 Excellent Safety Profile Through 2 Years *1,2 Event istent + Cataract Surgery (N=116) Cataract Surgery Only (N=117) Any BCVA loss 1 line 3 months 7% 10% Posterior capsular opacification 6% 10% Elevated IOP 4% 7% Elevated IOP - other 3% 4% Elevated IOP req g treatment with 1% 3% oral or IV meds or with surgical intervention Stent obstruction 4% 0% Blurry vision or visual disturbance 3% 7% Stent malposition 3% 0% Iritis 1% 5% Conjunctival irritation due to hypotensive meds 1% 3% Disc hemorrhage 1% 3% R. Noecker, MD 2011 OSN NY * Postoperative Ocular Adverse Events Occurring 3 in Either Group 1. Myers, J, et al AGS 2. Craven ER, et al ASCRS 12

13 Mean # Medications Mean IOP (mmhg) Multiple Trabecular Bypass in Combined Phaco 5 Mean IOP and Mean # Medication Over Time 50% 73% pre W1 M1 M3 M6 M12 5. Ahmed, et al. AGS 2010 R. Noecker, MD 2011 OSN NY 13

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15 Endoscopic istent Placement 9/10/2013 NOECKER- 2011

16 Combined Phaco-ECP 9/10/2013 NOECKER- 2011

17 ECP Lowers IOP Longer than Phaco Alone mmhg 1.53 Meds 1.20 Meds 1.20 Meds 0.65 Meds

18 9/10/2013 NOECKER ECP is titratable

19 ECP can be done through cataract incisions 9/10/2013 Noecker ASCRS 2013

20 9/10/2013 NOECKER ECP Technique

21 Plateau iris -sp angle closure 9/10/2013 NOECKER- 2011

22 ECP Complications are predictable, avoidable, and manageable IOP spike (retained viscoelastic) Transient Hemorrhage Inflammation (CME not at higher rate than cataract alone) Pupil Irregularity (anterior burns) Any complication associated with anterior segment surgery 9/10/2013 NOECKER- 2011

23 ECP is well reimbursed Free Standing Ambulatory Surgery Center (ASC or FOSC) Procedure Surgeon CPT Code Payment ASC Code Facility Payment Cataract only ECP only Cataract with ECP ECP done at time of Cataract

24 Advantage to each Phaco alone Least risk Least expensive Phaco/iStent No alteration in post-op medications or follow-up Least amount of inflammation Faster procedure if successful first try Phaco/ECP More efficacious Better reimbursement/ coverage Able to do in eyes with abnormal angles Able to do in poor cornea situations 9/10/2013 NOECKER- 2011

25 ECP and istent can be easliy combined 9/10/2013 NOECKER- 2011

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