1. 9/5/20151 Surgical Therapy in Glaucoma 2014 J. James Thimons, O.D.,FAAO Ophthalmic Consultants of Connecticut Fairfield, CT

2. 9/5/20152 Trends Streamlining of existing procedures –Express Minishunt –Use of Fibrin glue to reduce suturing –Alternative tube placement techniques Less invasive procedures –Canaloplasty –Trabectome –Gold Shunt –Glaukos shunt –ECP

3. 9/5/20153 Considerations Impact of subsequent or prior procedures Realistic expectations on intraocular pressure control and continuing medical therapy Expected and tolerable side effects and complications

4. 9/5/20154 Glaucoma Procedure Options that we have done

5. 9/5/20155 Trabeculectomy with Express Minishunt

6. Express Minishunt Advantages Reduces operating time Eyes appear to be quieter earlier in post-op course No iridectomy Uniform opening If hypotony occurs, tends to be less severe 9/5/20156

7. Express Minishunt Disadvantages Needs some suturing as in trabeculectomy Dependent on patient healing Anti- metabolites still routinely used Patient has bleb Hypotony possible 9/5/20157

8. Reasons to use the Express Simplify procedure Shorten surgery time Decrease tissue manipulation Eliminate need for iridectomy Decrease chance of ostium obstruction Regulate flow in short term Create less short term inflammation

9. Arguments Against Expense Foreign body Metal in eye Corneal contact

10. Patient Selection Same as trabeculectomy May work better in high risk patients ICE patients NV patients Shallow/synechiae

11. Resident Surgery with Ex- PRESS No difference –postoperative IOP –proportional decrease in IOP Ex-PRESS group –Significantly less medication to control IOP at 3 months –No difference at 6 months or 1 year (P≥0.28) –More Ex-PRESS patients had good IOP control without meds at 3 (P=0.057) and 6 months (P=0.076) –No difference was found in the rates of sight-threatening complications (P≥0.22) 9/5/2015 Seider MI. Resident-performed Ex-PRESS Shunt Implantation Versus Trabeculectomy J Glaucoma. 2011 Apr 25. [Epub ahead of print]

12. Retrospective Case Series Final percent IOP lowering was similar Moorefields Bleb Grading System –Less vascularity and height but more diffuse area associated with the Ex-PRESS blebs Fewer cases of early postoperative hypotony and hyphema Quicker visual recovery –The Ex-PRESS group required fewer postoperative visits compared with the trabeculectomy group (P <.000). 9/5/2015 Good TJ. Assessment of bleb morphologic features and postoperative outcomes after Ex-PRESSdrainage device implantation versus trabeculectomy. Am J Ophthalmol. 2011 Mar;151(3):507-13.e1. Epub 2011 Jan 13.

13. Ex-PRESS in prior operated eyes Success complete in 60(60%) and qualified in 24 (24%) eyes Mean IOP –27.7 ± 9.2 mm Hg with 2.73 ± 1.1 –14.02 ± 5.1 mm Hg with 0.72 ± 1.06 drugs (p < 0.0001) Failure –Uncontrolled IOP (11%) –bleb needling (4%) –persistent hypotony (1%) 9/5/2015 Lankaranian D. Intermediate-term results of the Ex-PRESS(TM) miniature glaucoma implant under a scleral flap in previously operated eyes. Clin Experiment Ophthalmol. 2010 Dec 22.

14. 5 year study Ex-press vs Trabeculoectomy EX-PRESS more effective without medication –At year 1 12.8% of patients required IOP meds after EX-PRESS implantation vs 35.9% after trabeculectomy –At year 5 (41% versus 53.9%) Responder rate was higher with EX-PRESS Time to failure was longer Surgical interventions for complications were fewer after EX-PRESS implantation 9/5/2015 deJong et al. Five-year extension of a clinical trial comparing the EX-PRESS glaucomafiltration device and trabeculectomy in primary open-angle glaucoma. Clin Ophthalmol. 2011;5:527-33. Epub 2011 Apr 29.

15. Anesthetic Injection 9/5/2015

16. Conjunctiva Dissection 9/5/2015

17. 25G Trochar 9/5/2015

18. Conjunctival Closure 9/5/2015

19. Post-op 9/5/2015

20. Results The mean preoperative IOP was 23.7 ± 9.3 and the mean postoperative IOP on the last follow up day was 10.4 ± 4.5 (p<0.001) over a mean follow up period of 199 days (range 29-608). The mean number of medications used preoperatively was 2.83 ± 1.1 and postoperatively was 0.023 ± 0.1 (p<0.001). Complications as hypotony, bleb leak, choroidal detachment, and transient hyphema were detected. 9/5/2015

21. Outcomes Studies overall suggest compared to trabeculectomy- –Less severe hypotony –Less bleeding –Less inflammation –Faster visual recovery –Similar long term IOP control

22. 9/5/2015Noecker22 Baerveldt

23. Baerveldt Patch Graft Placement 9/5/2015Noecker23

24. Baerveldt Advantages Effective for almost all types of glaucoma Able to do when other procedures are not possible Not dependent on patient healing Can implant multiple devices 9/5/2015Noecker24

25. Baerveldt Disadvantages Invasive- extensive dissection Large foreign object Diplopia possible Need some conjunctiva Very low pressures difficult to acheive 9/5/2015Noecker25

26. 9/5/2015Noecker26 ECP

27. ECP Advantages Quick procedure, especially in cataract setting Titratable Can be done with outflow procedures Hypotony unlikely 9/5/2015Noecker27

28. ECP Disadvantages Some learning curve to avoid complications Inflammation possible IOP does not decrease rapidly Difficult to do in some eyes 9/5/2015Noecker28

29. 9/5/2015Noecker29 Canaloplasty

30. Effects of Suture Tension Ex-Vivo Perfusion Study, Utilizing Morton Grant Flow Model –Pressurize globe to a range of physiologic pressures –Apply tension to a suture implanted through the canal –Measure outflow facility (uL/Min / mmHg) (Image: iScience)

31. Canaloplasty 9/5/2015Noecker31

32. Canaloplasty Advantages Non-invasive No destruction of anatomy Hypotony unlikely Rapid recovery High Safety Profile 9/5/2015Noecker32

33. Canaloplasty Disadvantages Longer operating times Learning curve Sometimes cannot cannulate Extensive prior scarring may eliminate possibility of performing procedure 9/5/2015Noecker33

34. 9/5/2015Noecker34 Trabectome

35. Trabectome Advantages Quick procedure Hypotony unlikely Ab interno approach eliminates dependence on dissection Can do in many types of glaucoma 9/5/2015Noecker35

36. Trabectome Disadvantages Need to be able to visualize angle Bleeding common Very low IOPs unlikely Cannot do in eyes with canaloplasty 9/5/2015Noecker36

37. 9/5/2015Noecker37 Gold Shunt

38. SLX Clinical Results

39. Gold Shunt Advantages Straightforward procedure Suprachoroidal space attractive to work in No bleb Hypotony unlikely 9/5/2015Noecker39

40. Gold Shunt Disadvantages Still in evolution Very low IOPs are not possible Device is fragile Titrability not proven in humans 9/5/2015Noecker40

41. 9/5/2015Noecker41 iStent (Glaukos)

42. Why Trabecular Bypass Surgery? Stent / Efficacy: Schlemm’s canal is part of the aqueous outflow pathway iStent ® restores aqueous outflow chain by bypassing only the blockage that occurs with glaucoma in the trabecular meshwork IOP reductions to mid teens

43. Glaukos Efficacy 9/5/2015Noecker43

44. Glaukos Advantages Quick to perform No dependence on prior procedures May be able to titrate with multiple procedures 9/5/2015Noecker44

45. Glaukos Disadvantages Very low IOPs not likely Need open angle Placement of earlier device is sometimes difficult 9/5/2015Noecker45

46. 9/5/2015Noecker46 Glaucoma Surgical Procedures Many evolving and new procedures Surgeon has more options at his disposal than ever before Customization can be done to balance risk and reward for each individual patient

47. 9/5/2015Noecker47 noeckerrj@gmail.com