And how each of these are used and why each of these are used, there's not a right answer and there's not really a lot of studies comparing each one to each other. Thank you for the kind introduction and thank you also to Glaucoma Research Foundation for putting this together. We're going to talk first with a background on ‘what is glaucoma?’ What do we basically do? The iStent® Trabecular Micro-Bypass Stent, the XEN® Gel Stent, and the Hydrus® Microstent are treatment options to reduce eye pressure for patients with both cataracts and glaucoma. But one of my other partners, Dr. Fellman and I described this back in 2012 of evaluating, we call it the Episcleral Venous Fluid Wave or ‘the wave.’ And you can evaluate in the operating room after you've done some type of surgery to open up the patient's meshwork or their outflow pathway to see if that would work. But be real to yourself and be real to your surgeon and your physician that's taking care of you that if it's something that you find yourself consistently forgetting once or twice a week, which is very common and is human nature for all of us to not be 100% all the time, then have a long-term game plan of, "Do I see myself doing these drops for the next 10, 20, 30 years?" One thing I always do as a physician when I'm taking care of patients is I always ask myself what I would want if I had glaucoma or what my family would want. So if you were somebody who needed a pressure in the single digit level, a trabeculectomy is more likely to get you there. Davinder, what do you think? And the problem with glaucoma (and don't hold me to these numbers, but) you could lose a vast majority of your nerve tissue without having any overt visual field changes. Recently Durysta which is the Lumigan or Bimatoprost SR that has been approved by the FDA. You need surgery. If you had, what would you have?" If you've had a tube shunt for instance, I would say this, there are various types of tube shunts out there. One area in ophthalmology that’s currently seeing a lot of innovation is implantable devices designed to reduce intraocular pressure in glaucoma patients, with an emphasis on minimally invasive, ab interno procedures that can be combined with cataract surgery. And then the skin of the eye, which is that conjunctiva I mentioned before, is then closed over the trapdoor. The iStent is the first ab interno (from the inside) micro-bypass implant for the treatment of glaucoma.The iStent is made of … And just talk about a new option that's available for people. And I'm so grateful that we're here and we're having this opportunity. It's a device that is about six millimeters long. So here I am every day telling patients that are feeling fine and seeing fine that they have a blinding condition and I need to do a surgery on them. So my goal, if I'm going into a patient's eye to do cataract surgery or to do something, I think it's a very great opportunity to do some type of safe surgical intervention to decrease their dependence on glaucoma drops. Can you comment on that? 03 Jan. 2017. Your pressure's too high. 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. 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. Because one thing is, especially what doctor Smith said, to increase your odds of success is really having that faith. You just met me. The SLT causes less scarring in the drain of the eye, but the ALT which is the Argon Laser Trabeculoplasty tended to cause a little bit more scarring. Tom Brunner: Davinder, you talked a little bit about the ‘LiGHT study’ with SLT and commented on a very interesting finding that I think it was 11 patients in the medications group went on to needing a trabeculectomy. And I'm not going to pretend it's easy because it's not fun. 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 then how the pressure over here, this is the optic nerve. Sponsor opinions are not reflected on our website. The CyPass system is a suprachoroidal shunt. I mean, you ask all glaucoma specialists around the country right now, and they're going to say, "Don't listen to Davinder. Glaucoma Surgery and Laser Treatments (Webinar). It's a nitinol stent that goes into the eye and helps open the outflow system. This is a Hydrus Microstent. The drainage system is like a donut around the eye and it's called Schlemm's canal. And let's talk about the laser surgery because they really enhance the patient's outflow pathway. Tom, what's the next question? 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. It's a cross section of the optic nerve, the nerve that connects the out of the brain. So if you had to do a glaucoma and a laser procedure, that would probably be one that can happen at the same time in the operating room. The XEN-45 Gel Stent is available on the market. I often describe myself as a ‘fancy plumber of the eye.’ And so we're going to talk about the plumbing of the eye. You may have a trabeculectomy that's working and maybe your drain is still working partially. There are implants that are bigger, they're shaped differently. But I also have a frank discussion with my patient. And I actually think that the next question leads into this one as well — what should I look for when selecting an eye surgeon? I say, let's time your surgery. And what we try to do to prevent scarring, because the natural thing for your body to do, if you have some kind of injury so to speak, and whether it's surgery or it's a laser, it is trauma to tissue. So it really has changed, I think, a lot of our practice patterns and made us all lean more closely to considering laser as an initial treatment. But I think that's in some ways a meaningless number because what matters is the patient that's sitting in my chair and my exam lane and I'm talking to. Davinder Grover, MD: No. It made me feel confident I am on track to control this disease." I think this pandemic has given us all a new sense of appreciation for life and gratitude for what we have. And then I'll let Tosin complement what I'm saying. Because the problem as we all know is with glaucoma, there are very rarely symptoms. So I see them right in the recovery room. So the question is: do your doctors know how to evaluate your drainage system? Glaucoma Specialist at Glaucoma Associates of Texas. Because you will never appreciate that. the iStent … This is such a challenging time for all of us. It's not going to work because their outfall pathway is destroyed. I have them watch these videos. Glaucoma and iStent eye surgery. Like old chronic disease conditions, sometimes it's a matter of just progression of disease. And so those eyes are a little different than your neighbor that had cataract surgery in the same 2020 and was out playing golf the next day. iStent Glaucoma Surgery iStent is a Safe & Effective Treatment for Glaucoma. And we have to again weigh the risks and the benefits. In this video from the Master Class in Minimally Invasive Glaucoma Surgery (MIGS), Dr. Ike Ahmed implants the iStent® prior to phacoemulsification. So if the pressure is higher than this level, the valve mechanism opens and allow fluids leave the eye. And we're used to managing patients with small pupils or are at a high risk of having some weird complications during the operating room that needs a special tricks. The trabeculectomy has been around for many years. Rarely, the stent may become dislodged from its implanted position. And this surgery is a surgery that we actually developed. There's certain types of lasers that help us do this. But perhaps we'll be able to answer some of your questions in a future webinar. We don't know why. We'll briefly look at subconjunctival flow, which is surgery that diverts fluid under the skin of the eye, we'll mention briefly suprachoroidal flow, which is flow into that layer that lies between the wall of the eye and the choroid which are the layers or vessels that sit on top of the retina in the back of the eye. Please take your vision seriously and your health seriously. We know with glaucoma, lowering pressure leads to a situation where you're more likely to preserve vision. And most of these surgeries are surgeries that help open up a patient's outflow system. I talked about some of the outflow surgeries, something like the trabeculectomy, the XEN Gel Stent. Tom Brunner: Another question is about scar tissue and does that prohibit other surgeries? And what I know about their eye. But over time, what happens is you scar after you've had a procedure or you might do well for several years. Davinder Grover, MD: Yeah. And there are actually two of them that can be put in the drainage angle and help enhance outflow system bypassing the meshwork. In this video from the Master Class in Minimally Invasive Glaucoma Surgery (MIGS), Dr. Ike Ahmed implants the iStent® prior to phacoemulsification. Davinder Grover, MD, MPH So it's important to remember, and I tell my patients this all the time, this is a lifelong battle. Now is that chronic use of drops better or worse than taking a patient to get a trabeculectomy? There may be an area where there's no blood vessels. It's called the GATT surgery. Gel stent for glaucoma an ab interno approach to ... - YouTube But that really allows me to give my patients real time advice and evidence. Surgery isn’t usually the first step to treat glaucoma, but it may save your eyesight if other treatments don’t work. I'm not seeing a visual field defect yet but I know where we're going to go." This video demonstrates the combination of viscodilating the canal and stenting for patients with open-angle glaucoma undergoing cataract surgery. Last reviewed on This is a lifelong battle. Again the meshwork is almost always the problem. So that is an option that is a bridge between both medical therapy and surgery but it releases medicine inside the eye, taking away that responsibility of putting eye drops inside the eye from the patient. Let's talk about the irritation. We're still working on that. It's so much easier for me to say, "Miss Jones, I'm going to put you on a drop. Prevention is not easy. So before I do any of these kinds of surgeries on my patients, I have them go to my YouTube channel. And what's the risk of putting a patient on a drop versus taking them to the operating or doing a laser. If you have scarring in the drain of the eye that actually causes closure of the drain of the eye, where you can't see it, a laser procedure to the drain of the eye may not be the best option for you. It allows fluid to find its way out of the eye, under the skin of the eye where it's absorbed. I'm very optimistic that your surgery is going to work." Hydrus Microstent • Open Angle Glaucoma • Stent I. Paul Singh, MD Channels: Glaucoma … ‘If my glaucoma is well managed with eyedrops, what are the advantages of having surgery despite the risks?’ And I think you kind of have just answered that. And again, like I said in my talk, I treat my patients the way I'd want my family to be treated or the way I want to be treated. No. But now we're on this curve where we're very at high risk of losing more nutrition, then it's going to start effecting your vision. These are chemicals that you're putting in your eye. But the biggest difference between the different types of tube shunts is whether they have a valve or whether they don't have a valve. And the natural response is for you to heal. And this is the nerve, the optic nerve that connects the eye to the brain. That's all we do. This then allows the formation or egress of fluid from the inside of the eye, under the skin of the eye, and there's formation of what we call a bleb. And the meshwork, the reason why we care about that is the vast majority of studies on regular primary open-angle glaucoma and even some other types of glaucomas, saw that the meshwork is the problem. But the non-valved ones at the time that they are put in may be tied off for a little bit. Welcome to our webinar, Glaucoma Surgery and Laser Treatments. It's not fun to say, "Hey, look, I prevented you from going blind." And then their outflow pathway, you can do any stent. Learn from videos highlighting surgical intervention of glaucoma, including MIGS, trabeculectomy, canaloplasty, laser, and other IOP lowering devices. Making sure you follow your post-op instructions if you've been asked to use steroids after surgery. Now with lasers for instance, there are certain laser procedures that you could do to the drain of the eye, the SLT for instance. But their eyes haven't been bathed in glaucoma drops for 20 years. And then we'll go onto some surgical and laser managements, either opening up a patient's own outflow system or having to create a new drain. One of the other questions was the medication use. Thursday, July 4th 2019, 2:28 PM HST by Diane Ako And it drains over here. Conventional glaucoma surgery carries more risk compared to laser glaucoma surgery. And in the SLT group, zero patients went on. And if you're doing it, we don't need to touch you. Don't be too scared. "The discussion convinced me that my doctor is providing appropriate treatment. And their activity level and what they do. So I always insist that when you have a patient that has real disease, real glaucoma, and they need cataract surgery, I would say number one, it would be a disservice not to address both at the same time. We had those options of trabeculectomy and tube shunts which have higher risks than the mixed procedures which are available now. Let's talk about the costs of the drops. But think of the heart and an angiogram of the heart. We can get there with surgery. - Ron Ponichter. (Video), Promising Glaucoma Research and the Path to a Cure, Catalyst for a Cure: A Clear Path to Vision Restoration. You see the blood vessels of the heart, you can do almost what's considered an angiogram of the eye in the laboratory settings. But first I would say the type of surgery is really important. And it results in lowering of intraocular pressure. And then it goes in between your lens and your iris and drains in this drainage structure. When that happens, we either have to go in there and reopen that and give you some more anti-scarring medicine or do an alternate procedure if that becomes your best option. … The difference between a continuous wave or standard, what we refer to as CPC laser and a MicroPulse laser is that the CPC laser has a continuous wave of energy being delivered while the MicroPulse is pulsed laser. 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. 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. And then they come to me and say, "Hey, Dr. Grover. 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.”. So that is how we can open up a patient's own drainage system. Sometimes, patients may experience multiple eye conditions at the same time, including glaucoma. It's called an iStent Inject. And the question really is, does it matter? Tom Brunner: Good afternoon. That's a discussion between you and your surgeon. Pseudoexfoliation is one of these things where the meshwork is almost always the problem. So we'll start here talking about the MicroPulse laser. Here, three surgeons who have experience using four different stents … Glaucoma eyes don't always follow the rules and they always try to trick us and do weird things to us in the operating room. This is my surgical algorithm. Envision Cataract Surgery and Glaucoma Therapy All In One Procedure. Because that's what it looks like. You had the most amazing wave. Glaucoma Specialist at Glaucoma Associates of Texas, Oluwatosin “Tosin” Smith, MD 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. Tosin Smith, MD: That's a good question. And this is from 1978 where someone injected dye into the outflow system so you can see, this is Schlemm's canal and then it's going down to the vasculature. When I'm the patient, what are my chances of success? So let's talk about this outflow pathway. But I wholeheartedly agree with everything Tosin just said. And there tends to be scarring with that. 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. Through two small little incisions, we're able to open up the drain 360 degrees. - Paul Altieri, "Dedicated glaucoma surgeons provide educational information to assist in understanding benefits of successful surgery." And they're very easy to forget. And so what happens is patients get put on drops, and they get in that routine. and that's almost like an enviable or a real-time angiogram of the eye. And work with your doctors to help maintain your vision. Come back and see me in a couple of months." Don't wait too long because you're afraid. This is advanced glaucoma. It's a modification of a surgery that's been around for about 70 years. View Video While mild-to-moderate open-angle glaucoma … Now who gets a glaucoma drainage device? So in having successful eye surgery, there are several factors that may be helpful in making sure that surgery is successful. We're dealing with the fluid in the front of the eye. And they are both Ambassadors of Glaucoma Research Foundation. This can bring the need for both glaucoma and cataract surgery. So you still need to be monitored and followed. I can talk to that and then I'm sure Tosin will add to this as well. 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 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. But what was exciting about this study is it showed that actually the laser intervention group tended to do better. 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. The iStent inject ® W stents … And so I encourage you to search for it and find the answers to your questions. And what we try to do is take you as an individual, look to see all of these things that I have spoken about and try to match you off depending on your stage of disease with that place where he's trying to get your pressure in terms of your target. And thank you again for your ongoing support for the Glaucoma Research Foundation. And the fun thing I love to do is sit around a room of glaucoma specialists and say, "Hey, if you had glaucoma, what would you have? And if I had to say something about trabeculectomies, they're able to get [intraocular] pressures to really low levels. The other thing is timing. I floss a week before I go to the dentist and a week after I go to the dentist and then it falls off. Do these patients behave differently? Because of that observation that I had personally in operating on eyes and developing countries that have not been abused by drops versus eyes that have been on drops for decades. So, what else is delivered this way? So I think we probably can safely say we have the most experience with Trabectome, but they're all similar in certain ways and different in other ways. Then what happens after it goes into the drain? This is not on the outside of the eye. And this is surgery that bypasses the natural drain that Dr. Grover just talked about. In that case, it's done inside the operating room where the laser is delivered straight to the ciliary processes directly in the operating room after you've had cataract surgery. So those patients need a new drainage system. Tosin Smith, MD: Thank you very much Dr. Grover and Tom for the very kind introduction. So those are some of the things I would say. For medical questions and advice specific to your condition, please contact your doctor. Okay. So in other countries where glaucoma is such a big problem in more developing countries that don't have the infrastructure of a developed health system, patients usually present with advanced glaucoma. And in truth, if I were ever diagnosed with glaucoma, I would have a very low threshold for having a laser trabeculoplasty [SLT] on myself. And one thing that I definitely do with my family is when we sit down at the dinner table, we talk about just one thing that we're so grateful for. That's really meaningless when it comes to what happens. It's like a tiny little noodle. I meet a patient for the first time. Scarring does occur. Tosin Smith, MD: I couldn't agree more, which brings us to the issue of target pressures. It's a bridge between surgery and medical therapy that is also available now to patients. And that also is its own entity that you can get a lot of information on about on the Glaucoma Research Foundation website (www.glaucoma.org). Not only did they do better, but it was actually more cost effective which is great from our health systems’ perspective. And I say, "You know what Ms. Jones? Stamper specializes in glaucoma and cataract surgery, and his research interests include early methods in diagnosing glaucoma to prevent vision loss and evaluating new surgical procedures for glaucoma. He's crazy." And we use it on a regular basis to treat patients that have significant glaucoma. Generally, trabeculectomy is thought to reduce the eye pressure to a greater degree than tube shunt surgery… Davinder Grover, MD, MPH: Thank you, Tom. Treatment for other types of glaucoma may include: primary angle closure glaucoma … Tosin Smith, MD: That's a great answer. But maybe you want to make additional comment. Scuba divers should have special considerations as opposed to construction workers, as opposed to an 85 year old that's retired and plays bridge and watches Wheel of Fortune. Glaucoma Surgery and Laser Treatments (Webinar), What's New in Glaucoma Medications? July 30, 2020, Was this helpful? There's about a one third chance we may have to go back in." Because the more damage that's been done then the likelihood of losing vision at the time of glaucoma surgery is higher. So I hope you guys are all doing well. Web. Davinder Grover, MD: Yeah. Or do they have an atrophic collector system that can't be opened up and they need a new drain. This is the trabecular meshwork. And so it's a long game, it's a marathon. Many of you may have heard of glaucoma drainage devices or as they're more commonly called tube shunts. And it's probably still much safer to put you on a drop than it is to cut your eye open. You can also visit our website, www.glaucoma.org for more answers and for the latest information about glaucoma and our research. The other laser that is done outside the eye is cyclophotocoagulation and done is through the wall of the eye. We can get there with medication. There are two different types of laser procedures. And that's we as physicians have to look at. And before we get on there, there's surgical management and then there's laser surgeries we can do. And be compliant with postoperative instructions are another way of ensuring that your surgery is successful. Acute angle-closure glaucoma … Let me start with that. Tosin Smith, MD: I'll start answering that question. It makes water and it drains water. And what it showed over time is that even though the pressure lowering was about the same in both groups, in the medicine group, more patients went on to need cataract surgery and trabeculectomy as Tom mentioned. 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. It's a full time job to use multiple drops. Cyclophotocoagulation has been available for a long time as an option for surgery. My sister's a dentist. Usually you're awake when this is going on but the eye is numb. And this is revolutionary. I wish we would have acted here before we even came close to the cliff." Or “let me go do a surgery.” It's so much safer to just start them on a drop. It's always about where your surgeon is trying to get. 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. But just as a background, the eye is no different than a drain and a faucet. How iStent inject ® W Works. And a couple of years ago, I wrote an article specifically about this, about special considerations for cataract surgery in glaucoma patients. 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. We'll talk about it after the surgery.". However, you may need to restart your glaucoma … And gradually your trabeculectomy may fail. When that angle closes, we call it narrow or closed angle glaucoma. He received his medical degree from Johns Hopkins University in Baltimore. Aqueous is made right here. So many glaucoma specialists are aware of what's the efficacy of the different surgeries are. And so what then happens is you need further treatment of some sort, whether it's another procedure further down the line to try and catch up and cope with that pressure elevation that occurs over time as disease does progress. Your body gradually causes a healing of that reservoir where the fluid flows to. Tom Brunner: Well, unfortunately that's all the time we have for questions. 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. So it's hard to give a general number of 70%. There is a huge amount of information on our website about glaucoma, about the latest treatments, about the things you heard about today in the webinar and the research we fund. This is how I think about patients and glaucoma surgery. Implanted during cataract surgery, iStent inject ® W can effectively lower IOP, one of the most important risk factors for glaucoma, and may reduce your reliance on glaucoma … Okay. I think you may have touched on that a little bit before. 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… But you can see the way the tissue behaves in patients that have been on drops for several years, decades even. Potential complications include bleeding, pain and discomfort after the surgery. And if a patient has a very poor wave, there's about a one third chance they're going to need another incisional glaucoma surgery. Tom Brunner: Well, thank you so much Davinder and Tosin for a very, very informative presentation. The one thing I would say though is that with trabeculectomies, there's potential for long-term, not just short term, related to surgery complications, but there are long-term complications that could occur with trabeculectomies. 'Re going to open up the drain 360 degrees an outflow pathway, you move. The outflow system who needed a pressure in the recovery room you may have heard of glaucoma Research Foundation SLT... As a background on ‘ what is glaucoma? ’ what do we turn down the faucet patients. 2020, was n't that impressive `` this wave, was n't that impressive get in that routine was association..., thank you very much Dr. Grover just talked about some of the eye release medication platforms... 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