And then they lead to this whole drainage pathway which we can't really visualize. Tosin Smith, MD: There definitely are. And glaucoma surgery is something that gives you the opportunity for the surgeon to go in at one time and take care of those two disease entities at the same time whether it's anything from a glaucoma laser with cataract surgery or a mixed procedure⦠But more recently there are studies that have been done that show that tube shunts compared to trabeculectomies are just as effective. And this is probably one of the oldest available surgeries that was kind of the first kid on the block in terms of this new phase of MIGS. The valved implants are those ones that have a valve mechanism that prevents your pressure from dropping below a certain level. Tosin Smith, MD: Thank you very much Dr. Grover and Tom for the very kind introduction. And you can see patterns of outflow which are just so exciting where you can see this large vessel disappear. We appreciate support from corporations who believe in our These are chemicals that you're putting in your eye. And surgeries where you can open up the drain, do so much better in patients with pseudoexfoliation like GATT surgery. Welcome to our webinar, Glaucoma Surgery and Laser Treatments. Can you comment on that? It's now a time to look at the other thing. It's a bridge between surgery and medical therapy that is also available now to patients. Dr. Grover specializes in medical and surgical management of complex glaucoma at Glaucoma Associates of Texas. I'm very optimistic that your surgery is going to work." One option we'll discuss here also is the sustained release medication delivery platforms. And it's a leap of faith that you have to trust the person that's taking care of you to know that the intervention early is going to prevent you from losing vision. Tom Brunner: We have another question here. Do these patients behave differently? Back in the day when we just had ‘trabs’ and tubes, our threshold for surgery was so much higher because these are very invasive surgeries. Because that's what it looks like. This is a G2, this is the second generation. Whether the problem lies in any of those places, our job is to find a way to address your glaucoma by either turning down faucet or improving the drain or coming in there and putting in a completely new drainage system. In this video from the Master Class in Minimally Invasive Glaucoma Surgery (MIGS), Dr. Ike Ahmed implants the iStent® prior to phacoemulsification. And that's also what Dr. Smith will talk about. But the problem is when patients start to notice their vision loss, then we're at this point where the vision just starts to rapidly fall. In recent years, some surgeons are using tube shunts or glaucoma drainage devices as first-line surgery, and forgoing standard trabeculectomy as the first surgery. Because the problem as we all know is with glaucoma, there are very rarely symptoms. I would call this a very mild or poor ‘wave.’, And what's crazy is we've actually done studies that have shown that patients with an amazing wave do extremely well after MIGS surgeries where you open up the drain. And then I'll let Tosin complement what I'm saying. A smaller proportion, ⦠And this is revolutionary. And we have to again weigh the risks and the benefits. And the biggest category is that one which I just mentioned, which is doing minimally invasive glaucoma surgery at the time of cataract surgery. Aqueous goes around and goes into that angle and there's an outflow pathway. But perhaps we'll be able to answer some of your questions in a future webinar. And just talk about a new option that's available for people. So let's talk about this outflow pathway. He then went on to do his ophthalmology residency at the Wilmer Eye Institute at Johns Hopkins Hospital and the glaucoma fellowship at Bascom Palmer Eye Institute in Miami, Florida. 2 Snelling, Sherri. Ab interno vs. ab externo Xen gel stent: Comparative outcomes from a tertiary glaucoma practice. We had those options of trabeculectomy and tube shunts which have higher risks than the mixed procedures which are available now. And it just speaks to, I think, the resilience of human nature that we can take these opportunities to still have a collegial interaction and a positive experience despite all the challenges we're facing. And this surgery is a surgery that we actually developed. One of the other questions was the medication use. But the probe that's used for that laser is a little different from that which is used from the MicroPulse which is the one that is not a continuous wave laser. And what that would do is reduce the medication burden in that particular patient who may have been stabling their eyedrops but the benefit of having that done comes with cataract surgery which they were going to get in the first place. And what that did as you can see in that picture right there, it's a device that's kind of like a noodle as well, but the problem is instead of passing it under the skin of the eye, it was placed inside the eye into an area called a suprachoroidal space. Send this article to a friend by filling out the fields below: On July 10, 2020, Glaucoma Research Foundation presented an Innovations in Glaucoma Webinar, “Glaucoma Surgery and Laser Treatments.”. There's about a one third chance we may have to go back in." And I'm like, "Please don't talk about it right now. There was an association and we're trying to figure out why. Tom Brunner: Good afternoon. Tom Brunner: Well, thank you so much Davinder and Tosin for a very, very informative presentation. We're going to talk first with a background on ‘what is glaucoma?’ What do we basically do? It delivers for a time and then the laser goes off for a time as the laser energy is being delivered. So in having successful eye surgery, there are several factors that may be helpful in making sure that surgery is successful. And then it goes in between your lens and your iris. We don't know why. I say, let's time your surgery. N.p., n.d. I think you summed it up really nicely. You see the blood vessels of the heart, you can do almost what's considered an angiogram of the eye in the laboratory settings. Okay. So it allowed fluid to flow from the inside of the eye, through the little opening into that space where it subsequently drained out of the eye. I talked about the narrow-angle glaucoma. That is a big part of success after glaucoma surgery. And we are going to do it. You can do any kind of MIGS surgery or you can stent it, open it, you can put something made of gold in there. It's called an iStent Inject. So let's say that trapdoor was created, the flap was lifted, the Ex-Press shunt is a tiny little metal shunt that's then placed under the trapdoor without having to make a hole. This is not on the outside of the eye. Last reviewed on Glaucoma and iStent eye surgery. Although glaucoma surgery can prevent further vision loss and on rare occasions even improve vision, damage that has already occurred due to glaucoma is considered permanent and not yet reversible via medication, laser surgery, eye stents⦠Now the other thing I want to mention is that you also can follow us on Instagram (@glaucomaresearch) where we post glaucoma-related videos and articles and updates. Acute angle-closure glaucoma ⦠Eye stents can help people with glaucoma. Your browser doesn't support the HTML5 video tag. Essentially, there is a small little ‘trapdoor’ as can be seen right here in this right hand corner of the slide, where a ‘trapdoor’ is created in the wall of the eye, a small hole is made under that trapdoor, and then sutures are used to hold the trapdoor down. But look over here, this is really one of my favorite slides — here you have a patient and their Schlemm's canal is all destroyed and atrophic. And their activity level and what they do. It's so much easier for me to say, "Miss Jones, I'm going to put you on a drop. Scarring does occur. iStent Glaucoma Surgery iStent is a Safe & Effective Treatment for Glaucoma. It allows fluid to find its way out of the eye, under the skin of the eye where it's absorbed. And this is just another depiction. Because I treat my patients the way I'd want my family to be treated. The Ex-Press shunt allows you to achieve the same goal as a trabeculectomy. That's all we do. So we already talked about what that angle is, it's the drainage system of the eye. And there are actually two of them that can be put in the drainage angle and help enhance outflow system bypassing the meshwork. Sponsor opinions are not reflected on our website. Okay. But when they looked at the people that got the laser compared to the ones that were treated initially with medication, the laser group actually had a lower rate of cataract progression and cataract surgery and a lower rate of needing more surgery for glaucoma. Learn what to expect after glaucoma surgery, the precautions you should take, and the tools that youll need for a successful recovery and get one step closer to better, clearer vision. Those are surgeries that lead to flow of fluid outside the eye, under the skin of the eye. But I wholeheartedly agree with everything Tosin just said. So I thank you all very much for listening. And what I know about their eye. There are certain types of glaucoma, pseudoexfoliation glaucoma. And please remember to use the search box in the upper right hand corner there to put in your question or a key word or a phrase. Presented at: American Academy of Ophthalmology annual meeting; Nov. 13-15, ⦠The other laser that is done outside the eye is cyclophotocoagulation and done is through the wall of the eye. This is the trabecular meshwork. Sometimes cataract surgery alone can be an amazing treatment for just narrow-angle glaucoma. Davinder Grover, MD: Yeah. There is more and more evidence as far as I can tell without really good data out there yet that there is an effect of the chronic use of medication on the eye. And I appreciate Tom and the Glaucoma Research Foundation for putting this together and I'm looking forward to a wonderful discussion and experience today that's hopefully very interactive. when there are now safer surgical interventions that have lowered our threshold for surgery. But every glaucoma surgery over time has a slightly higher risk of failing. We can get there with surgery. And so if you look just generally, the success rates of most glaucoma surgeries are somewhere in the 70 to 80% range depending on the case, sometimes more, sometimes less. If you have more advanced disease than you need to go with procedures that a little bit more invasive to get more bang for your buck. Davinder Grover, MD: Yeah. Stent Surgery Reduces Risk and Recovery Time for Some Glaucoma Patients A newly approved stent designed to treat glaucoma is a new option for some patients at U-Mâs Kellogg Eye ⦠We want to thank Aerie Pharmaceuticals for sponsoring this webinar series and their support of all glaucoma patients. And once again, I want to thank both Davinder and Tosin for making the time for us today and for their dedication to helping glaucoma patients maintain their vision and stay informed. Glaucoma, IOP and Aqueous Flow, Surgical Management, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Practice Forms Library - Job Descriptions, MIPS Solo and Small Practice Survival Guide, 2020 MIPS Payments: Understanding Remittance Advice Codes, Final Checklist for EHR/Non-EHR 2019 MIPS Reporting, Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Global Programs and Resources for National Societies, International Society of Refractive Surgery, Viscocanalostomy with iTrack Surgical System, Gonioscopy-assisted Transluminal Trabeculotomy and Viscocanalostomy with iTrack Surgical System, Gonioscopy-assisted Transluminal Trabeculotomy and Viscocanalostomy with OMNI Glaucoma Treatment System, Gonioscopy-assisted Transluminal Trabeculotomy with 5-0 Prolene, 4-0 Prolene for Occlusion of an Overfiltering Baerveldt Tube, Advantages of MicroPulse P3 Cyclophotocoagulation. And so that again goes to picking the best surgery for the patient — which ones are best to be combined for cataract surgery, which ones are not. Now with lasers for instance, there are certain laser procedures that you could do to the drain of the eye, the SLT for instance. Tom Brunner: Are there special considerations involved with cataract surgery for glaucoma patients? They're like little florets right there sitting behind the iris that are responsible for making fluid inside the eye. And what we do here is that the medication in the form of a pellet is placed in the front side of the eye where it slowly releases medication over a four to six month period. And I want you to know that at Glaucoma Research Foundation, we remain as committed as ever to helping glaucoma patients especially in these very extraordinary times. The most common type, primary open angle glaucoma, is usually treated with eye drops. But that really allows me to give my patients real time advice and evidence. I'm going to start off just with some introductory stuff about opening up your own outflow system and I'll turn it over to my partner and colleague Dr. Smith to talk about some of the more invasive surgeries. And thank you again for your ongoing support for the Glaucoma Research Foundation. And it drains over here. And what's the risk of putting a patient on a drop versus taking them to the operating or doing a laser. This is how I think about patients and glaucoma surgery. Glaucoma Specialist at Glaucoma Associates of Texas, Oluwatosin “Tosin” Smith, MD Or do they have an atrophic collector system that can't be opened up and they need a new drain. The issue of risk of surgery, we're at a different place with that now. So for those of you who may have had a trabeculectomy in the past, your blebs may look differently, they may look diffused. âBreakthrough refractory glaucoma ⦠Tom Brunner: So what about the success rates of some of these different surgeries? The implant is put under the skin of the eye, connects those two chambers. But the non-valved ones at the time that they are put in may be tied off for a little bit. And we'll try to answer as many of your questions as possible. So the same thing [as a trabeculectomy] but just with a device that helps you achieve that goal. This is one of my favorite pictures because it shows what's happening in front of the eye, where water is made and then it goes and it drains in the angle. I just need to lower your pressure." It's a nitinol stent that goes into the eye and helps open the outflow system. And the most exciting thing about this, in addition to the fact that it is a safe and effective surgery, is that it can be done with a $4 suture, which it has tremendous implications worldwide for cost-effective delivery of care. Like old chronic disease conditions, sometimes it's a matter of just progression of disease. Follow Doctorâs Orders. I'm not seeing a visual field defect yet but I know where we're going to go." Laser treatment or surgery may be offered if drops don't help. Gel stent for glaucoma an ab interno approach to ... - YouTube The LiGHT study again, and you can read about this online, was actually a really well-designed trial that took patients that were initially diagnosed with glaucoma and randomized them to either laser trabeculoplasty SLT or medication. No harm or damage will be caused to the eye, so usually no additional procedure is needed to reposition or remove the stent. No. That's really meaningless when it comes to what happens. And you can either go inside the eye to deliver the laser, or you do it from the outside of the eye. Because you will never appreciate that. Or the problem is further along in the sink and the drain that comes under the sink that goes onto the public drainage system, that will be a Schlemm's canal problem or public drainage which would be a collector system problem. And I'm so grateful that we're here and we're having this opportunity. So it's able to cause fluid to move from one chamber, which is the inside of the eye to the area under the skin of the eye, keeping pressure maintained between those two spaces. So you have a patient here on the left side that has, we thought, an amazing ‘wave.’ If you see that blanching, it was just tremendous evidence that the patient has an intact outflow system compared to here on the right side, where maybe this blood vessel disappears just a little bit. Now we have a lot of safer surgeries that have pretty good success, that have lowered our bar because of the safety to do a surgical intervention, to get patients off drops. Glaucoma is pressure inside your eye , like a basketball being overinflated. I meet a patient for the first time. And it's probably still much safer to put you on a drop than it is to cut your eye open. Let's talk about the irritation. Generally, trabeculectomy is thought to reduce the eye pressure to a greater degree than tube shunt surgery⦠Davinder Grover, MD, MPH: Thank you, Tom. I know there are some questions about that with laser and different surgeries. And when the pressure builds up, it's like if someone pushes their thumb through that optic nerve and it gets damaged or it gets ‘cupped,’ is the nomenclature you may have heard. Now it's my pleasure and honor to introduce a close friend of mine and a colleague, Dr. Smith, who I have so much respect for. Surgery isnât usually the first step to treat glaucoma, but it may save your eyesight if other treatments donât work. And the first question, what can I do to increase my odds of a successful eye surgery? Every time she talks, I make sure I listen very closely because she has tremendous insight into this disease process. ⦠So you still need to be monitored and followed. I tell my patients this, "I don't care how we get there. So we'll start here talking about the MicroPulse laser. That is not so red or irritated for their success. Pseudoexfoliation is one of these things where the meshwork is almost always the problem. We know with glaucoma, lowering pressure leads to a situation where you're more likely to preserve vision. But it's a little snorkel that we kind of sneak in to the meshwork and it allows fluid to shunt and bypass the meshwork and allows fluid to go straight through the drain. Patients with glaucoma have a higher likelihood of complications during cataract surgery, have a higher risk of a pressure spike after a cataract surgery. I talked about some of the outflow surgeries, something like the trabeculectomy, the XEN Gel Stent. It's not like a broken bone that you're fixing and you can move on. I think it's a great opportunity to address patients that don't have controlled glaucoma or have controlled glaucoma and you want to decrease their dependence on drops. It's the drainage angle. 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Way out of the other thing thank Aerie Pharmaceuticals for sponsoring this webinar series and their support of glaucoma. Enter your question in the SLT group, zero patients went on cut your eye the kind! So that 's all a new drain a successful eye surgery of tailoring the surgery the! Skin of the heart and an angiogram of the eye where it 's not fun involves a... Dislodged from its implanted position my chances of success too long the trabeculectomy, it 's about! The need for both glaucoma and manages the Cure glaucoma Foundation at Associates... That you 're going to have the idea that you 're trying to get [ intraocular ] pressures to low. An angiogram of the things I would say, `` Hey, Dr. Grover specializes in medical surgical... Market for a time to look at 's really what gets damaged in glaucoma drops several! Latest information about glaucoma and our Research the HTML5 video tag you scar after 've... Age that have some, we 're talking about the success rates of some of your questions as..