Glaucoma Surgery Louis B. Cantor, MD Jay C. and Lucile L. Kahn Chair and Professor Director of Glaucoma Service

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1 Glaucoma Surgery 2018 Louis B. Cantor, MD Jay C. and Lucile L. Kahn Chair and Professor Director of Glaucoma Service

2 Disclosures Research Support: Allergan, InnFocus, Bausch and Lomb Consultant: Zeiss Meditec, Santen Investor: Mati Speakers Bureau: None

3 Laser surgery for glaucoma

4 Indications Laser peripheral iridotomy pupillary block angle closure glaucoma chronic angle closure prophylaxis for narrow angles pigment dispersion syndrome?

5 Contraindications Laser peripheral iridotomy corneal opacification or edema flat or shallow anterior chamber synechial closure of angle

6 Pre-operative treatment iopidine pilocarpine topical anesthesia Laser peripheral iridotomy

7 Argon Laser Laser peripheral iridotomy more effective in brown irises? Nd:YAG laser more effective in light-colored irises?

8 Location Laser peripheral iridotomy base of crypt in peripheral iris between 11:00 and 1:00

9 Abraham lens Laser peripheral iridotomy +66D planoconvex button magnifies and concentrates laser energy

10 Argon laser iridotomy 3 phases: μm sec mw Contraction Punch Cleanup (may take up to 300 shots!)

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12 Nd:YAG peripheral iridotomy 3 to 10 millijoules 1 or 2 pulses per burst 1 to 10 bursts usually suffices

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14 Complications Laser peripheral iridotomy blurred vision monocular diplopia and glare corneal damage iritis pigment dispersion

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16 Complications (continued) hemorrhage IOP spike lens opacities closure of iridotomy site Laser peripheral iridotomy

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18 Post-operative care Laser peripheral iridotomy re-check IOP in one hour steroid drops re-examine in one week patency of iridotomy gonioscopy

19 Case 2 58 year old WM, s/p peripheral iridotomy OU for acute angle closure attack OD 2 years ago, now presents with painful, red, blurred right eye. Va is 20/400 OD. SLE reveals hyperemia, cornea edema, patent PI OD. IOP is 45 OD, 25 OS.

20 What else do you look for? Diagnosis? Treatment? Case 2

21 Case 2 Gonioscopy reveals appositional closure of the angle with a steep iris insertion

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23 Indications Argon laser peripheral iridoplasty acute angle closure glaucoma not responding to medical therapy plateau iris syndrome other forms of angle closure adjunct to ALT

24 Argon laser peripheral iridoplasty Contraindications severe corneal edema or opacification flat anterior chamber synechial angle closure

25 Argon laser peripheral iridoplasty Pre-operative care pilocarpine iopidine topical anesthesia

26 Argon laser peripheral iridoplasty Laser parameters 500 μm spot size sec duration mw power

27 Aim at extreme peripheral iris spots over 360 degrees

28 Argon laser peripheral iridoplasty Post-operative care steroids iopidine gonioscopy

29 Complications Argon laser peripheral iridoplasty iritis corneal damage need for retreatment

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31 Case 3 73 year old WF with 15 year hx of POAG. IOPs are 19 OD, 20 OS on betaxolol, brimonidine, dorzolamide, and latanoprost. Cup:disc 0.8 OU. HVF reveal worsening of nasal step and arcuate defects OU.

32 Indications Argon laser trabeculoplasty maximally tolerated medical therapy poor compliance initial therapy?

33 Pre-operative care iopidine Argon laser trabeculoplasty

34 Laser parameters Argon laser trabeculoplasty 50 μm spot, 0.1 second, mw 50 spots per 180 degrees 180 or 360 degrees Location anterior half of trabecular meshwork

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37 Post-operative care Argon laser trabeculoplasty re-check IOP in one hour steroids continue all glaucoma medications

38 Argon laser trabeculoplasty Effectiveness of ALT for POAG About 75-80% at one year About 50% at five years Failure rate about 6-10% per year

39 IOP reduction Argon laser trabeculoplasty Depends on initial IOP Pre-laser IOP usually respond best

40 Effectiveness of ALT Argon laser trabeculoplasty good for phakic POAG, PXE, and pigmentary glaucoma less effective in aphakic eyes, younger persons (<40yrs), previously filtered eyes, uveitic glaucoma, angle recession glaucoma

41 Effectiveness of ALT Argon laser trabeculoplasty effectiveness more short-lived in pseudoexfoliation glaucoma, pigmentary glaucoma, African-Americans.

42 Onset of effect Argon laser trabeculoplasty 4 to 6 weeks for most POAG earlier effect for PXE and pigmentary glaucoma

43 Argon laser trabeculoplasty

44 Repeat ALT Argon laser trabeculoplasty Usually not as effective as initial treatment If initial ALT was not effective then a repeat ALT will probably not be effective either

45 Complications increased IOP iritis PAS hemorrhage corneal damage Argon laser trabeculoplasty

46 Selective Laser Trabeculoplasty Frequency-doubled Q-switched 532 Nd:YAG laser 532 nm 3 nanosecond pulse 400 micron spot size mj spots over 180 or 360 o

47 ALT versus SLT

48 Selective Laser Trabeculoplasty Ophthalmology 1998;105:

49 ALT Ophthalmology 2001;108:

50 SLT Ophthalmology 2001;108:

51 SLT as primary treatment Arch Ophthalmol 2003;121:

52 Treatment Algorithm for Lowering IOP SLT, selective laser trabeculoplasty; ALT, argon laser trabeculoplasty. Initiating Glaucoma Therapy IOP controlled Monotherapy: Prostaglandin analogs IOP still high AAO considers 20% reduction in baseline IOP to be clinically significant Continue prostaglandin analog Surgery SLT or ALT Switch to another agent Add another agent

53 Incisional surgery for glaucoma

54 Trabeculectomy A guarded partial-thickness filtering procedure --- removal of a block of peripheral cornea tissue beneath a scleral flap

55 Trabeculectomy- Indications When IOP cannot be maintained by nonsurgical therapies at a level considered low enough to prevent further pressure-related damage to the optic nerve or visual field loss. Maximum tolerable medical therapy Maximum laser benefit Optic nerve function is failing or likely to fail

56 Relative contraindications Blind eye Ocular neoplasm Active rubeosis irides Active iritis Extensive conjunctival injury eg, s/p RD repair, chemical burn Extremely thin sclera

57 Trabeculectomy- Technique Conjunctival flap: limbus based vs fornix based Antifibrotic agent use Split thickness scleral flap Limbal fistula Iridectomy Scleral flap closure Conjunctival wound closure

58 Limbus-based vs fornix-based Limbus-based: incision 8-10 mm posterior to the limbus Fornix-based: incision at the limbus Each has advantages and disadvantages Success rates: no significant difference IOP reduction: no significant difference

59 Limbus-based vs fornix-based Limbus-based conjunctival flap Technically more challenging Usually used with SR traction suture Less likely to leak at cut edge Easier to place MMC posteriorly Subconjunctiva scar posterior to scleral flap, ring of steel More cystic, anteriorly draining bleb Fornix-based conjunctival flap Easier and faster to perform Usually used with corneal traction suture More likely to leak at cut edge More difficult to place MMC posteriorly Subconjunctiva scar anterior to scleral flap More diffused, posteriorly draining bleb

60 Antifibrotic agents Action- inhibit fibro-cellular proliferation Indications previous surgery: failed trab aphakia or pseudophakia young patients black race uveitis neovascular glaucoma Every case? Be cautious in young myope: hypotony maculopathy

61 5-Fluorouracil Pyrimidine analog: inhibit fibroblast proliferation Intra-op: 50mg/ml, sponges Post-op: 5-10mg/ ml, injections Advantage: titrated dose Disadvantage: multiple injections

62 Mitomycin-C Alkylating agent causing DNA cross-linking Intra-op: mg/ml x mins, sponges (typical dose: mg/ml x 1-3 mins) Pre-op: intra-tenon injection 5-20ug/ ml Advantage: no need for multiple injections Disadvantage: imprecise dosing for sponges

63 Antifibrotic agents Application Sponges: - LASIK shields cut in half, four halfs - Weck-cel Large surface area treated - Results in more diffuse, noncystic bleb - No Ring of Steel formation

64 Scleral flap Matter: relationship of the flap to the sclerostomy thickness: 1/2 scleral thickness Not matter: shape or size of the flap shapes: triangular, trapezoid, rectangular sizes: 3-4mm x 2-3mm

65 Limbal fistula Sclerostomy/keratectomy (punch or blade) - Anteriorly placed - Avoid ciliary body exposure - Reduce bleeding - Perpendicular alignment Ex-PRESS Shunt

66 Ex-PRESS mini glaucoma shunt

67 Ex-PRESS mini glaucoma shunt J Glaucoma 2007;16:14-19

68 Iridectomy Reduce the risk of iris occluding the sclerostomy Prevent pupillary block Avoid amputation of ciliary processes Avoid disruption of the zonular fibers or hyaloid face

69 Sclerostomy and iridectomy

70 Scleral Flap Closure Appose edges of scleral incision, 10-0 nylon sutures Adjustment of suture numbers and tension Check filtration with sponges (minimal spontaneous flow) Releasable sutures

71 Conjunctival Closure Limbus-based close conjunctiva and Tenon seperately or in a single layer Fornix-based wing sutures - purse-string sutures +/- Central sutures -compression running closure modified condon-wise sutures

72 Conjunctival closure (limbus-based)

73 Conjunctival closure (fornix-based, wing suture)

74 Conjunctival closure (fornix-based, Condon-Wise suture)

75 Close follow-up Post-op management success = 50% surgery + 50% post-op care POD#1, then qwk x 2-3, then q2wks -1mon Topical steroids (weeks to months) Maintaining aqueous flowing Fibrosis of scleral flap within 2-3 weeks Up to 2-3+ months with antimetabolite Methods: digital pressure/ massage /releasable sutures/laser suture lysis

76 Lens edge of Zeiss goniolens Hoskins lens Blumenthal lens (2-3 x) laser suture lysis Argon laser mw, S, um

77 IBAGS (Indiana Bleb Appearance Grading Scale)

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79 Complications Early Late Infection Hypotony Shallow or flat AC Aqueous misdirecttion Hyphema Cataract Transient IOP elevation CME Hypotony maculopathy Choroidal effusion Suprachoroidal hemorrhage Persistent uveitis Dellen formation Loss of vision Leakage or failure of the filtering bleb Cataract Blebitis Endophthalmitis Symptomatic bleb (dysesthetic bleb) Bleb migration Hypotony Ptosis Eyelid retraction

80 leakage Low IOP choroidal effusion Low Bleb overfiltration/leak Shallow/Flat AC high IOP aqueous misdirection pupillary block Low IOP overfiltration High Bleb High IOP suprachoroidal hemorrhage

81 Bleb Leak Hypotony, Siedel s (+) Early: wound leaks buttonholes from surgery Late: thin, avascular, cystic blebs after antimetabolites (5-FU, MMC) trauma (eyelid rubbing) contact lens wear

82 Early bleb leak management -Observation: small ones heal spontaneously -Pressure patch -Large CTL that completely covers leak -Aqueous suppressants -Hold/decrease steroids -After 3-4 days, consider closure

83 Late bleb leak management -Observation -Large CTL that completely covers leak -Aqueous suppressants -Glue: cyanoacrylate, fibrin -Tissue destruction: TCA, cryo, laser (argon, YAG) -Autologous blood injection -Tamponade compression suture -Bleb revision with advancement graft (+/- conjunctival autograft)

84 Autologous blood injection

85 Glue

86 Shallow or flat AC -Iridocorneal touch Most spontaneous deepening in 7-14 days -Corneolenticular touch Quickly causes cornea decompensation and cataract Aggressive intervention- reform AC

87 Management of Flat AC Observation Reformation of AC: Viscoelastic Air SF6 C3F8 May need choroidal drainage

88 Choroidal Effusion -Consequence of hypotony and inflammation -Usually maximum on POD #5

89 Choroidal effusion Symptoms and signs -Decrease in vision -Lens induced myopia -Decrease in peripheral visual field -Photophobia, epiphora, pain -Typically hypotonous -Shallow or flat AC -Choroidal detachment on exam -Ultrasound appearance

90 Choroidal Effusion Predisposing Factors -Hypotony and vasodilation after any ocular surgery -Choroidal hemangioma, Sturge-Weber, Nanophthalmos, Increased EVP -More common and persistent in older patients

91 Management of choroidal effusion Observation: Usually resolves spontaneously Mydriatics/ Cycloplegics Topical and/or systemic steroids Drain if : PAS concern Corneo-lenticular touch Corneal decompensation Kissing choroids Prolonged hypotony (no signs of improvement within 4 weeks) Failing filtering bleb Acute secondary angle closure

92 Hypotony maculopathy More common with 5-FU and MMC Primary procedure, young myopes >6 months: maculopathy may be permanent

93 Suprachoroidal hemorrhage H/O of straining, laughing, coughing or sneezing Occurs first 4 to 5 days post-op Acute onset of severe pain Sudden visual loss Risk factors: Advanced age Systemic vascular disease Aphakia High myopia Previous vitrectomy High pre-op IOP, hypotony post-op Nanophthalmos

94 Management of Suprachoroidal Hemorrhage -Same medical treatment as choroidal effusion -Surgical drainage: clot lysis takes 4 to 5 days so try to delay surgery if possible -Indications: Severe, intractable pain, uncontrolled IOP, Prolonged retinal apposition, RD, Vitreous hemorrhage

95 Failing bleb Elevated IOP, no bleb R/o obstruction of internal sclerostomy by gonioscopy Blood, fibrin, iris, vitreous, lens material If fibrin or blood blocks outflow, tissue plasminogen activator (tpa) may be helpful

96 Late Bleb Failure Internal: iris, ciliary processes, capsule, blood Intrascleral: small ostomy, tight flap Extrascleral: episcleral fibrosis-most common cause for failure

97 Bleb encapsulation Elevated IOP with vascular, localized bleb High-domed, taut encapsulation of the bleb -- limits aqueous filtration Up to 15% the 1st post-op month Less common with antimetabolites But 5-FU > MMC

98 Management of bleb encapsulation -Minimal response to digital massage -Medical management (Aqeous suppressants) Often all that is needed (up to 90%) -Surgical management Needling w/ 5-FU or MMC injections Revision (excision)

99 Late complication Bleb associated infection Transconjunctival migration of microorganisms through leaks, holes, breaks, or weakened thin tissue

100 Risk Factors -Thin avascular blebs -Use of antimetabolities -Bleb leaks -Blepharitis -Dacryocystitis -Inferior or interpalpebral blebs

101 Common Causative Organisms Staphyococcus sp. Streptococcus sp. Hemophilus sp. Pseudomonas sp.

102 Blebitis Pain, blurred vision, redness Inflamed eye White bleb surrounded by conjunctival injection Purulent areas in bleb Often with bleb leak Anterior chamber reaction vitreous clear (B scan)

103 Bleb associated infection Stage 1 Bleb purulence + mild AC inflammation Stage 2 Bleb purulence + moderate AC inflammation Stage 3 Bleb purulence, marked AC inflammation, vitritis Bleb related endophthalmitis

104 Incidence of bleb associated infection Retrospective chart review Trab with mmc 0.5 mg/ml minutes 239 eyes/198 patients Average f/u 2.7 yrs ( yrs) Bleb leak 20 (8%) Blebitis 5 (2%) Endophthalmitis 8 (3%) DeBry, et al. Incidence of late-onset bleb-related complications Following trab w/mmc. Arch Ophthal 120: , year probability of bleb leak 17.9%, blebitis 6.3%, endophthalmitis 7.5%

105 Management Stage 1 & 2 blebitis + Culture conjunctiva Hourly fluoroquinolone (4 th gen) and cycloplegia Daily f/u until signs of improvement, then can decrease antibiotic frequency Change to fortified drops if no improvement Consider subconj cefazolin/tobra if bolus needed or poor compliance May consider topical steroids after 48 hours of improvement Oral fluoroquinolone for Stage 2

106 Management Stage 3 endophthalmitis Frequent topical antibiotics as in stage 1 & 2 Vitreous tap for C&S Intravitreal antibiotic injection Oral antibiotics EVS protocol for treatment

107 Indications Glaucoma tube implants Previous trabeculectomy failure Excessive conjunctival scarring Neovascular glaucoma Uveitic glaucoma ICE syndrome glaucoma

108 Glaucoma tube implants - types Non-valved Molteno Baerveldt

109 Glaucoma tube implants - types Valved Ahmed Krupin

110 Glaucoma tube implants sizes (mm 2 )

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112 Conj incision Tenons dissection +/- Muscle dissection Prime Tube Plate Placement Suture Plate Trim & Occlude tube +/-Tube Slits Scleral/AC tract/tube placement +/- Tube fixation/tutoplast Conj Closure +/- Viscoelastic Tube Shunt Steps

113 Medications Post-op care Topical steroid drop Antibiotic drop Glaucoma medications if tube tied off** Hypotony precautions

114 Glaucoma tube implants - benefits Less prone to infection More amenable to contact lens wear Comfort Repeatable

115 Trabeculectomy vs Tube implant Am J Ophthalmol. 2007;143:9-22.

116 Trabeculectomy vs Tube implant Am J Ophthalmol. 2007;143:9-22.

117 Trabeculectomy vs Tube implant Am J Ophthalmol. 2007;143:9-22. IOP > 17 mm Hg IOP > 14 mm Hg

118 Postoperative Complications Tube (n = 107) Trabeculectomy (n = 105) P-value Choroidal effusion Shallow or flat AC Wound leak Hyphema Persistent corneal edema Encapsulated bleb Dysethesia CME Suprachoroidal hemorrhage Persistent diplopia Am J Ophthalmol. 2007;143:23-31.

119 Evolution of glaucoma surgery: MIGS and beyond!

120 MIGS Ab-interno (clear corneal) micro-incisional Minimal operative tissue manipulation High safety profile Rapid visual recovery Efficacious

121 Steven Vold, MD MIGS

122 Outflow Pathway Top View Distal Outflow System

123 Sources of Outflow Resistance Collector Channels / Distal System Schlemm s Canal Trabecular Meshwork

124 Canal Based MIGS MIGS: Increase Trabecular Outflow istent Micro-Bypass Gonioscopy-assisted transluminal trabeculotomy (GATT) Trabectome OMNI 360 Trabeculotomy Kahook Dual Blade Ab interno canaloplasty Hydrus Microstent Specifics / Procedure: Heparin-coated, non-ferromagnetic titanium stent; 1.0 mm x 0.3 mm. Ab interno insertion into Schlemm's canal Ab interno trabeculotomy using illuminated microcatheter (itrack; Ellex) or prolene/nylon suture passed through a 1-2 mm goniotomy into Schlemm's canal 360 and lysed through the trabecular tissue Ab interno trabeculectomy using combination of electrocautery, irrigation and aspiration Ab interno trabeculotomy using disposable, non-powered device from which a flexible nylon-like trabeculotome is advanced into Schlemm's canal for 180 and then lysed (x2 to perform up to 360 trabeculotomy) Ab interno trabeculotomy using a single use, tapered, stainless steel blade Illuminated microcatheter (itrack; Ellex) and viscosurgical device used to cannulate and viscodilate Schlemm's canal Crescent-shaped scaffold (8-mm long) composed of nickel-titanium alloy, Ab interno insertion into Schlemm's canal

125 Suprachoroidal Based MIGS Increase Uveoscleral / Suprachoroidal/ Supraciliary Outflow CyPass Micro-Stent istent Supra Fenestrated micro-stent, composed of biocompatible, polyimide material (6.35 mm x 510 mm, 300 mm lumen) Ab interno insertion between anterior chamber/sclera and suprachoroidal space Heparin-coated stent (4mm long, mm lumen) composed of polyethersulfone (PES) with a titanium sleeve. Ab interno insertion between anterior chamber/sclera and suprachoroidal space

126 Translimbal Based MIGS Increase Subconjunctival Outflow XEN Glaucoma Treatment System InnFocus MicroShunt Tissue-conforming tube implant (6-mm long) composed of gelatin and glutaraldehyde material Ab interno insertion from the anterior chamber, through sclera into the subconjunctival space, bleb forming Flexible microshunt (8.5 mm x mm, 70 μm lumen) composed of SIBS (poly(styrene-block-isobutylene-blockstyrene)) Ab-externo, subconjunctival (via peritomy) insertion through scleral needle tract into anterior chamber, connecting it to sub-tenon's space, bleb forming

127 Ciliodestructive Based MIGS Decrease Aqueous Production Endocyclophotocoagulation (Trans-scleral options also) Ab interno cyclodestruction of ciliary body epithelium using continuous energy (810nm wavelength)

128 Canaloplasty Re-establish flow from anterior chamber to the restored canal of Schlemm and the collectors: Achieve physiologic control of IOP Without requiring a bleb Without developing bleb related post operative problems Non-penetrating surgical procedure with: 360º cannulation and viscodilation of Schlemm s canal Circumferential suture tensioning of trabecular meshwork / stenting of Schlemm s canal Trabeculo-descemetic window

129 Canaloplasty

130 Canaloplasty, Viscodilation Dilation of Schlemm s canal visualized with UltraSound Imaging Preoperative Dilation of Schlemm s canal Dilation of Schlemm s canal and collector channels

131 Canaloplasty, Suture Tension Distension of Trabecular Meshwork visualized with UltraSound Imaging Grade 0- No distension Grade 1 Good distension Grade 2 Maximum desired distension

132 Canaloplasty J Cataract Refract Surg 2007;33:

133 Trabecular microstents istent (Glaukos, Laguna Hills, CA) Hydrus (Ivantix, Irvine, CA)

134 Trabeculotomy/goniotomy Trabeculectomy ab interno (Trabectome Study Group)

135 Suprachoroidal microstents CyPass (Alcon/Novartis/Transcend Medical, Menlo Park, Calif.) istent Supra (Glaukos, Laguna Hills, CA)

136 CyPass PubMed search yields 7 results Saheb H, et al. BJO 2014;98: OCT imaging

137 CyPass and Endothelial Cell Loss Voluntary FDA Withdrawal 8/2018 Alcon COMPASS-XT 2018

138 FDA IDE trials underway istent Supra

139 Subconjunctival microstent Xen implant(aquesys/allergan, Irvine, CA) Soft flexible, permanent, gelatin/collagen implant InnFocus- conj incision

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