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    Early surgical intervention with stent advantageous for certain glaucomas

    Approach may help physicians, patients avoid compliance, other medical therapy issues

    Dr. VoldIt is well known that with most disease, the earlier it is detected, the better the outcome prognosis. Along with early detection comes the need for early treatment.

    Traditionally, options for glaucoma have been limited. Medications can be effective when used properly, though patients are notorious for compliance issues.1

    Micro-invasive glaucoma surgery (MIGS) procedures are useful in controlling IOP without introducing significant adverse events--overall improving the quality of life of patients.

    While medical therapy traditionally preceded surgical treatment, I strongly feel that patients benefit significantly when MIGS intervention is introduced earlier in the disease process. With newer-generation, extended-range-of-vision IOLs now available, patients with dysfunctional lens syndrome or mild cataracts should consider undergoing refractive lens exchange with placement of a trabecular micro-bypass stent (iStent, Glaukos) to treat their glaucoma before permanent damage occurs.

     

    The trabecular meshwork

    David L. Epstein, MD, performed extensive research in the area of aqueous outflow, believing it was key to treatment of glaucoma.2

    While Dr. Epstein focused on the impact of pharmaceuticals on the trabecular meshwork, I believe that the use of a stent to bypass the outflow resistance is consistent with his findings. This has been proven in clinical trials that show placement of a single trabecular micro-bypass stent reduces both IOP and the need for medications3-7 in the short and long term.8

    The stent works well for patients with early mild-to-moderate glaucoma. Dr. Epstein believed the normal aging process caused a gradual decrease of aqueous outflow through the trabecular meshwork. The more advanced the glaucoma and the longer patients are on topical glaucoma medication, the more damage there is to the trabecular meshwork and outflow system.

    The trabecular meshwork is a complex system that undergoes significant change with age and the onset of glaucoma. This includes a considerable increase in the accumulation of extracellular material which intensifies resistance in the outflow pathways.9,10 In turn, decreases in outflow facility can be triggered by changes in the extracellular environment and may be a factor in IOP increases.11-13

    Therefore, it is logical to begin treatment earlier, before damage becomes too severe. As the natural path of aqueous flow is through the trabecular meshwork and Schlemm’s canal, when the trabecular meshwork becomes clogged the outflow of aqueous is blocked. Opening that pathway with a stent allows for the aqueous outflow to be restored and IOP reduced.

    However, patients who have had glaucoma for a sustained period may have a trabecular network that is too clogged for a stent to help. Those who find that the stent is ineffective may not be selecting the right patients for this treatment.

    3 merits of early stent intervention

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