Developments in Glaucoma Surgery

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1 Developments in Glaucoma Surgery Marlene R. Moster, MD Professor of Ophthalmology Thomas Jefferson University School of Medicine Wills Eye Hospital Philadelphia, PA

2 When is surgery indicated? Poor control Poor compliance Medication side effects

3 Glaucoma Surgery Filtering Surgery Trabeculectomy Filter with anti-fibroblastic agents Implants Molteno, Ahmed, Baervelt New filtering procedures

4 Trabeculectomy Introduced by Cairns in 1968 Success improved with the adjunctive use of an antimetabolite (5FU, MMC) Complications: bleb leaks, bleb-related infections

5 Risk Factors Associated with Bleb Failure Previous surgery filter, cataract African American Young age Uveitis Angle recession Secondary angle closure Neovascularization Aphakia

6 Bleb Failure What causes the majority of problems? Successful trab = filtration Filtration = fistula Fistula = bleb Bleb = PROBLEMS

7 Bleb Failure 1) Large cystic blebs 2) Infected blebs 3)Bleb dysthesia dreaded patient

8 Large Cystic Blebs

9 Trabeculectomy What Do Antimetabolites Do Decrease proliferation and contractile movement of fibroblasts 5-fluorouracil (5-FU) Mitomycin C 100x more potent than 5-FU

10 Trabeculectomy with MMC Changes in surgical technique Lower dosage of MMC Diffuse MMC application Fornix-based conjunctival flap Diffuse, low-lying bleb Fewer bleb leaks Lower rate of bleb infections Improved patient comfort Jones E, et al. Curr Opin Ophthalmol 2005;16: Wells AP, et al. Ophthalmology 2003;110:

11 Trabeculectomy with MMC Fornix-based flap Diffuse application of MMC Limbus-based flap Localized application of MMC Courtesy of Dr. Peng Khaw

12 Glaucoma Surgical Directions Glaucoma Drainage Implants New Surgical Approaches Trabecutome Excimer laser trabeculoplasty Express implant Glaukos trabecular bypass stent Eyepass glaucoma implant Canaloplasty Gold micro shunt

13 Glaucoma Drainage Implants Introduced by Molteno in 1968 Tube shunts aqueous from AC or PC to episcleral plate Design differences Size, shape, and material of plate Valved and nonvalved Complications: diplopia, tube erosion

14 Ablation of TM and inner wall of Schlemm s canal Ab interno approach Handpiece has I/A port and electrocautery tip FDA approved Trabectome Courtesy of NeoMedix Corp.

15 Trabectome Minckler DS, et al. Ophthalmology 2005;112:

16 Express Implant Stainless steel device with internal diameter μm Shunts aqueous from AC to subconjunctival space Avoids need for sclerostomy and PI Placement under a scleral flap is necessary to avoid hypotony and erosion FDA approved Courtesy of Optonol Ltd.

17 Express Implant Modified guarded full thickness procedures

18 Express Implant Maris PJG, et al. J Glaucoma 2007;16:14-19.

19 ADVANTAGES Express Implant IOP CONTROL SIMILAR TO TRABS MARZETTE ET AL -08) NO PI SO LESS INFLAMATION /BLEEDING REGULAR OSTEUM SIZE LESS HYPOTONY MARZETTE ET AL -08 DISADVANTAGES MOVES WITH MRI GEFFEN ET AL ARVO-08 RECENT REPORTS REGARDING EXTRUSION EXPENSIVE TRAB BLEB PRODUCED

20 Glaukos Trabecular Bypass Micro-Stent Titanium, snorkel-shaped device Inserted into Schlemm s canal using an ab interno approach Not FDA approved Courtesy of Glaukos Corp.

21 Eyepass Glaucoma Implant Silicone Y-shaped tube Proximal end inserted into AC and each arm into Schlemm s canal via an ab externo approach Shunts aqueous into Schlemm s canal Not FDA approved Courtesy of GMP Vision Solutions Inc.

22 Microcatheter with fiber optic tip is passed through Schlemm s canal via ab externo approach Healon GV is used to dilate canal 10-prolene keeps canal open FDA approved Canaloplasty Courtesy of iscience Interventional Corp.

23 Canaloplasty All Patients (n = 94)

24 Gold-Micro Shunt 24-karat flat plate Microchannels control flow from AC to suprachoroidal space Titanium sapphire laser used to open 1 or more channels to increase flow Courtesy of SOLX, Inc.

25 Gold-Micro Shunt 16-30% hyphema rate