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But in a procedure like trabeculoplasty, which is actually very well tolerated than safe, it gives me the confidence more so that trabeculoplasty may be an appropriate intervention. Treatment for other types of glaucoma may include: primary angle closure glaucoma … But I can tell you based on my experience of treating patients around the world, in the United States and a lot of developed economy health systems, patients are on drops for a very long period of time for exactly the problem that I have discussed. Eye stents can help people with glaucoma. Davinder Grover, MD: Yeah. This is one of my favorite pictures because it shows what's happening in front of the eye, where water is made and then it goes and it drains in the angle. Patients with glaucoma have a higher likelihood of complications during cataract surgery, have a higher risk of a pressure spike after a cataract surgery. And if a patient has a very poor wave, there's about a one third chance they're going to need another incisional glaucoma surgery. And prevention is not sexy. So water is made right here. And number two, glaucoma specialists, that's all we eat, live and breathe. So I always insist that when you have a patient that has real disease, real glaucoma, and they need cataract surgery, I would say number one, it would be a disservice not to address both at the same time. But it's a little snorkel that we kind of sneak in to the meshwork and it allows fluid to shunt and bypass the meshwork and allows fluid to go straight through the drain. This is a G2, this is the second generation. The OMNI combines two well-established micro-invasive glaucoma surgery (MIGS) procedures into one using a single device and a single corneal clear incision. I mean, you ask all glaucoma specialists around the country right now, and they're going to say, "Don't listen to Davinder. And thank you again for your ongoing support for the Glaucoma Research Foundation. Welcome to our webinar, Glaucoma Surgery and Laser Treatments. I talked about some of the outflow surgeries, something like the trabeculectomy, the XEN Gel Stent. And I want you to know that at Glaucoma Research Foundation, we remain as committed as ever to helping glaucoma patients especially in these very extraordinary times. It's the drainage angle. So we already talked about what that angle is, it's the drainage system of the eye. It's less invasive, way less invasive than doing a trabeculectomy. Tom Brunner: Well, unfortunately that's all the time we have for questions. So having talked about this, what we do essentially is all in a day's work of ‘plumbing.’ Whether we are inside the eye turning down fluid production by doing lasers or we go to the trabecular meshwork, which is that membrane that covers Schlemm's canal that's responsible for collecting the fluid and passing it out through the collector channels which I would liken to the sieve that covers your kitchen sink. There's certain types of lasers that help us do this. We're going to talk first with a background on ‘what is glaucoma?’ What do we basically do? Tom Brunner: Are there special considerations involved with cataract surgery for glaucoma patients? But you have to pick a surgeon that you trust that you want to go on this path with, you have that relationship with, you're going down that path together. So if the pressure is higher than this level, the valve mechanism opens and allow fluids leave the eye. The other thing is timing. The iStent is the first ab interno (from the inside) micro-bypass implant for the treatment of glaucoma.The iStent is made of … And then the skin of the eye, which is that conjunctiva I mentioned before, is then closed over the trapdoor. The iStent inject ® W stents … Davinder Grover, MD: Sure. There's about a one third chance we may have to go back in." And a couple of years ago, I wrote an article specifically about this, about special considerations for cataract surgery in glaucoma patients. Surgery isn’t usually the first step to treat glaucoma, but it may save your eyesight if other treatments don’t work. There are implants that are bigger, they're shaped differently. Let me start with that. Thank you for the kind introduction and thank you also to Glaucoma Research Foundation for putting this together. and that's almost like an enviable or a real-time angiogram of the eye. Don't wait too long because you're afraid. But what was exciting about this study is it showed that actually the laser intervention group tended to do better. And most of these surgeries are surgeries that help open up a patient's outflow system. And so what happens is patients get put on drops, and they get in that routine. And their activity level and what they do. And so every day I see patients, I'm telling them, "You know what sir? Your body gradually causes a healing of that reservoir where the fluid flows to. And when the pressure builds up, it's like if someone pushes their thumb through that optic nerve and it gets damaged or it gets ‘cupped,’ is the nomenclature you may have heard. Because one thing is, especially what doctor Smith said, to increase your odds of success is really having that faith. We're still working on that. And what it showed over time is that even though the pressure lowering was about the same in both groups, in the medicine group, more patients went on to need cataract surgery and trabeculectomy as Tom mentioned. You may require a few more drops or supplemental eyedrops to get your pressure as low as a trabeculectomy if you pick the tube shunt option for surgery. The CyPass system is a suprachoroidal shunt. So it's hard to give a general number of 70%. Sometimes cataract surgery alone can be an amazing treatment for just narrow-angle glaucoma. But one of my other partners, Dr. Fellman and I described this back in 2012 of evaluating, we call it the Episcleral Venous Fluid Wave or ‘the wave.’ And you can evaluate in the operating room after you've done some type of surgery to open up the patient's meshwork or their outflow pathway to see if that would work. And so really when you talk to your doctor and your surgeon, a lot of people have kind of just chosen one or two that's in their wheelhouse that they really liked that works best in their hands. So in having successful eye surgery, there are several factors that may be helpful in making sure that surgery is successful. For some surgeries like outflow surgery, trabeculectomies or surgeries that lead to subconjunctival outflow, having the skin of the eye not being inflamed or red prior to surgery is helpful to the success of that surgery. So let's talk about some of these surgeries that open up the drain. In this video from the Master Class in Minimally Invasive Glaucoma Surgery (MIGS), Dr. Ike Ahmed implants the iStent® prior to phacoemulsification. One of the other questions was the medication use. Aqueous is made right here. And what we try to do to prevent scarring, because the natural thing for your body to do, if you have some kind of injury so to speak, and whether it's surgery or it's a laser, it is trauma to tissue. And what we try to do is take you as an individual, look to see all of these things that I have spoken about and try to match you off depending on your stage of disease with that place where he's trying to get your pressure in terms of your target. Stent implantation issues, such as implantation at a non-ideal location, depth or angle. However, you may need to restart your glaucoma … And this is surgery that bypasses the natural drain that Dr. Grover just talked about. Glaucoma Specialist at Glaucoma Associates of Texas, Oluwatosin “Tosin” Smith, MD I know there are some questions about that with laser and different surgeries. Tom Brunner: Well, thank you so much Davinder and Tosin for a very, very informative presentation. But there are also those people who have sort of more advanced disease or who need a lower pressure and doing a combination of cataract surgery. iStent Glaucoma Surgery iStent is a Safe & Effective Treatment for Glaucoma. Dr. Grover specializes in medical and surgical management of complex glaucoma at Glaucoma Associates of Texas. Yeah. And this is revolutionary. If you have more advanced disease than you need to go with procedures that a little bit more invasive to get more bang for your buck. You got glaucoma when you were in your 20s or 30s or 40s or 50s. Now, what else can give a subconjunctival flow? I think this pandemic has given us all a new sense of appreciation for life and gratitude for what we have. So it's important to remember, and I tell my patients this all the time, this is a lifelong battle. Stent Surgery Reduces Risk and Recovery Time for Some Glaucoma Patients A newly approved stent designed to treat glaucoma is a new option for some patients at U-M’s Kellogg Eye … So more important, I would say, to see what your own surgeon prefers. Dr. Smith specializes in medical and surgical treatments of glaucoma and manages the Cure Glaucoma Foundation at Glaucoma Associates of Texas. More than half of people getting a certain type of glaucoma surgery may suffer from temporary, sometimes severe vision loss afterwards, suggests a new study. The MicroPulse laser is being delivered here in this case with the laser hand piece, it's done in an outpatient setting usually with the patient laying down with a speculum in the eye. - Paul Altieri, "Dedicated glaucoma surgeons provide educational information to assist in understanding benefits of successful surgery." And we come to the operating room every day prepared for those tricks to really optimize success. And then what I use for my very mild cases are things like an iStent and this is the original iStent, the G1 [first generation], which actually I don't think is being used that much anymore in the United States. And then they come to me and say, "Hey, Dr. Grover. Certainly surgeries require an eye that is more quiet. And it gently delivers that laser through the wall of the eye to that ciliary body that Dr. Grover talked about. And glaucoma surgery is something that gives you the opportunity for the surgeon to go in at one time and take care of those two disease entities at the same time whether it's anything from a glaucoma laser with cataract surgery or a mixed procedure… What I'm going to focus on here is evaluating whether they have an intact outflow pathway and whether we can do surgeries to open up their own outflow pathway, such as GATT or the KDB or trabeculectomies and all these things we'll talking about. That's all we do. It delivers for a time and then the laser goes off for a time as the laser energy is being delivered. And there are actually two of them that can be put in the drainage angle and help enhance outflow system bypassing the meshwork. But let me go and laser you.” It's hard to do that. But over time, what happens is you scar after you've had a procedure or you might do well for several years. If you had, what would you have?" So something that's somewhat similar is the Kahook Dual Blade goniotomy, instead of using electrocautery just makes an incision where you can remove that strip of trabecular tissue to have direct access to the downstream pipes. We know with glaucoma, lowering pressure leads to a situation where you're more likely to preserve vision. And when I operate on those eyes, they behave differently than eyes that have the same stage of advanced glaucoma but have been bathed in drops for 20 years. Davinder Grover, MD, MPH: Thank you, Tom. Order booklets about glaucoma for your patients. When that happens, we either have to go in there and reopen that and give you some more anti-scarring medicine or do an alternate procedure if that becomes your best option. Okay. One option we'll discuss here also is the sustained release medication delivery platforms. So in other countries where glaucoma is such a big problem in more developing countries that don't have the infrastructure of a developed health system, patients usually present with advanced glaucoma. This then allows the formation or egress of fluid from the inside of the eye, under the skin of the eye, and there's formation of what we call a bleb. But just like… I know, I floss. These glaucoma surgery procedures are used to decrease the risk of narrow-angle glaucoma developing into acute angle-closure glaucoma, which is a painful condition that causes IOP to increase very rapidly. But just as a background, the eye is no different than a drain and a faucet. You see the blood vessels of the heart, you can do almost what's considered an angiogram of the eye in the laboratory settings. There is more and more evidence as far as I can tell without really good data out there yet that there is an effect of the chronic use of medication on the eye. With any surgery, a successful recovery all depends on proper post-op care. And it drains over here. The trabeculectomy has been around for many years. Potential complications include bleeding, pain and discomfort after the surgery. Learn from videos highlighting surgical intervention of glaucoma, including MIGS, trabeculectomy, canaloplasty, laser, and other IOP lowering devices. But in general, we're talking about just doing some type of laser to the drainage system. Follow Doctor’s Orders. So we have to be very watchful after trabeculectomy surgery. Aqueous goes around and goes into that angle and there's an outflow pathway. It's like a tiny little noodle. 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