Manjool M. Shah, MD, moderated a panel addressing “Surgical Management of Glaucoma” on Saturday. Conducted in an entirely virtual format, the 30-minute, intermediate level session addressed questions participants sent in live feed for instructors Lorraine M. Provencher, MD and Shivani S. Kamat, MD.
Questions included their most notable case of the week, which led to a discussion of suprachoroidal stents. Dr. Shah thinks suprachoroidal stents will be “an interesting part of our toolkit,” but asked the panelists where they thought this technology would fit in the glaucoma surgical armamentarium.
Dr. Provencher was excited about the reemergence of suprachoroidal stenting as an option for glaucoma patients. When it comes to fitting this in her algorithm, she commented that she would likely continue to optimize conventional outflow first, via trabecular meshwork (TM) stents or excision, before accessing the suprachoroidal space.
Dr. Kamat agreed and also mentioned supraciliary stents could be good for patients who are otherwise out of options. For patients with refractory disease who have failed multiple other interventions, she said supraciliary procedures could offer a new pathway for treatment.
Next, Dr. Shah introduced the topic of the “mild or moderate plus” glaucoma patient for discussion — those who might have relatively mild disease, but have high pressures and/or high medication burdens. “Do you think those patients are still good conventional TM-based candidates, or would these patients potentially receive suprachoroidal procedures first?”
Dr. Provencher agreed with the logic of this question and stated, “For patients who have a very high starting IOP, long-standing or heavy topical drop use, or who have failed conservative TM-base intervention, the conventional outflow may be unsalvageable and the supraciliary route may be a better option.”
While all the participants agreed that more data on safety and efficacy are needed, the conversation then shifted to a discussion about what upcoming innovations the surgeons were most excited about. For Dr. Kamat, it was sustained drug delivery systems. “We just got iDose (Glaukos),” she noted. Dr. Provencher’s pick: “I can’t wait to get my DSLT [direct selective laser trabeculoplasty].”
“It’s exciting that we are trying to take control of the patient’s eye pressure back into our own hands. For so long, we have had to rely on patient compliance and adherence to topical therapy, which is understandably imperfect. As we work to create a consensus regarding more efficacious treatment options, I think we need to start pushing the treatment paradigm to focus more on interventional glaucoma.”
Participants naturally turned the subject to MIGS. If the surgeon is not in residency or fellowship anymore, how does the surgeon start? Both Drs. Provencher and Kamat advised new surgeons to get very comfortable with the angle in clinic by performing frequent gonioscopy, with the goal of understanding angle anatomy before going into the OR.
“The importance of gonioscopy cannot be overstated,” said Dr. Kamat. She tells her trainees to perform gonioscopy on every single patient in order to get comfortable with it, as it is a logical segue to intraoperative gonioscopy. “Get comfortable with turning the head during cataract surgery, turning the scope, and reproducibly obtaining a perfect en face view of the angle.” Once one is able to get a view, then they can begin to work within the confines of the angle. Fortunately, essentially all of the MIGS procedures have these basics steps as the foundation to safety and success.
The session ended with a discussion of the surgeons’ top surgical pearls. One shared by both: “Listen to your instincts: If something feels off, resist the temptation to ignore it,” Dr. Provencher said.
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