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    Managing glaucoma with surgical procedures (plural)

    Treatment not always single procedure that controls disease for remainder of patient’s life

     

    Re-thinking success 

    In many ways, we are improving at diagnosing and treating glaucoma earlier, which always offers the best prognosis. But we are still not where we need to be. We do not have a single glaucoma procedure that is a cure-all.

    I am frequently making adjustments to shunts that were placed 10 years previously. However, all of these options are much safer than in the past, and I find myself performing far fewer filtering surgeries and tube shunts now. 

    Excellent safety profiles have changed my criticism of efficacy. While patients may have to undergo more procedures, they are seeing well, their lives are not adversely affected by the recovery, and they are generally better off.

    Reducing medication is a big deal. Even patients who understand the importance and have good compliance still find it a daily burden. The ability to minimize in a meaningful way or replace medical therapy is a big advance. 

    Changes in mindset never happen quickly, but as convincing evidence builds, we always get there. It is true that most of these MIGS procedures are not designed to deliver home-run IOP reductions for end-stage glaucoma, but they do deliver solid singles and doubles for mild-to-moderate glaucoma patients where these devices offer significant advances in therapy.

    If we can hit a single every time and work our way around the bases while eliminating the really bad events, we have won the game. 

     

     

    References

    Fea AM, Bosone A, Rolle T, et al. Micropulse diode laser trabeculoplasty (MDLT): a phase II clinical study with 12 months follow-up. Clin Ophthalmol. 2008;2:247-252.

    Fudemberg SJ, Myers JS, Katz LJ. Trabecular meshwork tissue examination with scanning electron microscopy: a comparison of micropulse diode laser (MLT), selective laser (SLT), and argon laser (ALT) trabeculoplasty in human cadaver tissue. Invest Ophthalmol Vis Sci. 2008;49(5):ARVO e-abstract 1236.

    Neuhann TH.  Trabecular micro-bypass stent implantation during small-incision cataract surgery for open-angle glaucoma or ocular hypertension:  Long-term results. J Cataract Refract Surg. 2015; 41:2664-2671.

    Johnson DH, Matsumoto Y.  Schlemm's canal becomes smaller after successful filtration surgery. Arch Ophthalmol. 2000 Sep;118(9):1251-6.

    Traverso C. iStent Trabecular Micro-Bypass Stent: 18-Month Interim Analysis on Refractory Open-Angle Glaucoma Patients. Presented at the 2015 American Academy of Ophthalmology Meeting, Atlanta. November 2015.

    Höh H, Grisanti S, Grisanti S, Rau M, Ianchulev S. Two-year clinical experience with the CyPass micro-stent: safety and surgical outcomes of a novel supraciliary micro-stent. Klin Monbl Augenheilkd, 2014. Vol. 231(4), pp. 377-81.

    García-Feijoo J, Rau M, Grisanti S, et al. Supraciliary Micro-stent Implantation for Open-Angle Glaucoma Failing Topical Therapy: 1-Year Results of a Multicenter Study. Am J Ophthalmol. March 2015.

     

    Robert J. Noecker, MD

    E: [email protected]

    Dr. Noecker practices at Ophthalmic Consultants of Connecticut in Fairfield, CT. He is currently assistant clinical professor of ophthalmology at the Yale University School of Medicine and is clinical professor of surgery at the Frank Netter School of Medicine of Quinnipiac University. Dr. Noecker is a consultant to Alcon Laboratories, Allergan, Glaukos, Innfocus, and Iridex.

    Robert J. Noecker, MD
    Dr. Noecker, vice chair, University of Pittsburgh Medical Center Eye Center, and director, Glaucoma Service and associate professor of ...

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