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    Overcoming resistance of making glaucoma a surgical disease

    The glaucoma treatment paradigm has always been drops first, laser second, and surgery only as a last resort, according to Reay H. Brown, MD.

    “The reasons for the resistance to surgery have been based on concerns that it is too risky, doesn’t work, and has too many scary complication,” said Dr. Brown, private practice, Atlanta. But the hard reality is medical therapy also has many problems.”

    The Charles D. Kelman, MD, Innovator’s Lecture and Medal at the 2017 ASCRS-ASOA Symposium and Congress recognized Dr. Brown for his innovations in glaucoma surgery and their influence on the development of microinvasive glaucoma surgery (MIGS).

    Delivering his lecture “Overcoming Resistance: Making Glaucoma a Surgical Disease,” Dr. Brown explained the title had a dual meaning because it refers to overcoming resistance to aqueous outflow and resistance to using surgery to treat glaucoma.

    Series of starts and stops

    Dr. Brown has been an innovator in glaucoma surgery for more than three decades and has developed several devices that never achieved commercial success.

    He said, however, that he hopes his work has contributed to the exponential growth in glaucoma surgery that is being driven by MIGS.

    Dr. Brown’s belief that glaucoma should be a surgical disease took root back when he was resident at Wilmer Eye Institute in 1979. His first innovation toward achieving that goal was a glaucoma mechanical trephine (the “trabecuphine”) he developed from a vitrectomy cutter for performing an internal filtering procedure.

    “The concept seemed simple, but it was too far ahead of its time,” Dr. Brown said.

    As the project came to an end, the era of 5-fluorouracil and mitomycin-C for modifying conjunctival wound healing began. Unable to accept that blebs were going to be key to glaucoma surgery, Dr. Brown continued on his path of innovation and developed the glaucoma tack, a device for draining aqueous through the cornea in a procedure that did not require a conjunctival incision.

    “The concept was to make glaucoma a microfluidics problem and not a conjunctival wound healing problem,” he said.

    The idea for his “glaucoma faucet” however was rejected by two companies he approached for support.

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