Lecture: Cataract Surgery and Glaucoma

Dr. Kahook: Welcome, everybody. I am super-excited to do this session on Cybersight, this is another focusing on glaucoma and I’m thrilled to see as many people as we have seen prior to the start of the session. I’m going to go ahead and share my screen so we can take a look at what we’re going to be talking about today. I’m going to share some of the details with you and as you can see, the title is Cataract Surgery and Glaucoma, it sounds like a very broad title. I’m Malik Kahook, I’m Professor of Ophthalmology at the University of Colorado. My practice covers both glaucoma and cataract surgery.
We always have some new attendees who may not be as familiar with what Cybersight is and what the resource actually provides. If you go to cybersight.org, you will see resources for everybody all along the tree of learning. You can see you have access to a consult service where you can talk about specific patients, can you reach out to specific consultants, I’m on the list, for example, so you can go in and pick me if that’s what you wanted or you can pick any of the consultants. It’s also a learning resource and in my opinion it’s the premiere learning resource for ophthalmology. You can get multiple courses not just nor ophthalmology but for also some of the other services like nursing. There are live teaching sessions like today where we have experts around the world to talk about a specific topic and very unique to Cybersight is the AI service where you can upload photos and have the AI service look at retinas and help you what you’re doing at the clinic.
I would encourage you all to sign up and at least visit cybersight.org and take part in the completely free resources that are online.
I’m going to talk a little bit about the session on hand. I know I say I’m always excited about the webinars that we do but in this case I’m particularly excited because we have several speakers that I’ve been waiting a very long time to do a session with, drug Avni Shaw, Dr. Sandy Sieminski and Professor Sid.
Avni Shah I’ve known for a very long time. She did her fellowship at Tufts as well as in global ophthalmology at the Global Ophthalmology Center.
Sandy Sieminski is clinical Associate Professor and director of the glaucoma service and vice-chair of clinical affairs at the University of Buffalo, you can see she’s very active on campus with several leadership roles and we’re very excited to have her on the webinar today.
Dr. Russell Swan is from Vance Thompson Vision. He covers a couple of location in Montana and he really holds down a lot of the glaucoma care that’s done in that state and surrounding areas where he’s a funnel for complex glaucoma coming in to see him. He also has extensive global ophthalmology experience, particularly in Honduras with the training program there and again he’s probably well known to all of you with the global ophthalmology work that he does and we’re excited to have him today.
And finally is Professor Sid. I was thrilled that he could join in and cover an important topic that will discuss cataract surgery at the time of filtration surgery. He works at the VST center for glaucoma care. as well as LV Prasad in Hyderabad. You can find me on social immediate at Twitter, you can also go through Orbis or Cybersight if you have ideas of what we can do in the future.
So I’m going to turn off my screenshare and I’m going to ask Dr. Shah to share her screen and let’s see if we can do a smooth transition here, Avni, and you can get started on your talk and we’ll sit back and listen. Thank you for joining us, Avni.
> Dr. Avni Shah: All right, thanks to everyone for joining the session, enthusiastic to Dr. Kahook for that great introduction, through, Cybersight for something me. I will be — can everyone see my slides here? So I will be discussing IOL selection in the glaucoma patient. Oftentimes we’re doing cataract surgery in patients that have varying degrees of glaucoma and how do we select the lens implant for them keeping in mind the different options we have including premium lenses.
I will be talking about some lenses that we have available here in the United States that are FDA approved but I will be also talking broadly about categories of lenses so wherever you are, hopefully you can apply that information.
So I have no financial interests, and this is my first poll question here for the audience, so you have a 70-year-old patient comes in like this for a cataract surgery evaluation. He’s got two diopters of regular bowtie astigmatism and says he wants minimize his dependency on glasses. So which of these would you offer him? And that’s his visual field, as well.

All right, so looks like pretty split. About a quarter of you would just do a monofocal nontoric, some of you would also offer a toric lens, some of you would offer extended focus lens and some a multifocal lens. There are no right or wrong answers to these questions. I’ll just kind of talk about, you know, what I think. In this case, you know, this patient has signs of pseudoexfoliation, and we’ll talk about how that might affect your lens choice.
So what are some features of glaucoma that could affect your IOL selection? So zonular stability, contrast sensitivity, pupil size and visual potential.
And particularly for zonulopathy in cases of pseudoexfoliation or primary angle closure, we do need to worry about IOL tilt and decentration, sometimes late decentration and identify which of these lens choices are more sensitive to that and which ones are more forgiving of that.
Contrast sensitivity, patients that have any amount of preexisting optic neuropathy, we’ll talk about how some of the lens implants that you might have access to may further decrease this contrast sensitivity and so you would have to weigh that against the benefit that they might receive.
Pupil size will effect depth of focus and some of the premium lens implants do dependent somewhat on pupil size for full function
And then for patients with severe glaucoma who maybe have limited visual potential, generally for those patients he, we do want to maximize lens quality and we’ll talk about which are best in that situation.
Contrast, this is a big issue with patients with glaucoma. Oftentimes we have these patients complaining of contrast-related visual quality issues before we even see a drop in their visual acuity. So we do want to make sure, with patients with moderate or severe glaucoma that already have decreased contrast sensitivity, we may not want to put in the lens. We may want to at least discuss with the patient if we put in a lens that may further decrease their contrast and I’m talking in specific about extended depth of focus or multifocal lenses which have light-splitting technology.
This kind of de-focuses the light or it spreads the light out among different focal points, which reduces the amount of light hitting the macula at any given focal point. This can lead to decreased contrast sensitivity and sometimes to decreased image quality, as well, compared with monofocal lenses.
Another thing to note is in patients with glaucoma who are being monitored with visual field testing, the decreased contrast this they might get from these again will actually affect the parameters in the field. So just important things to know when it comes to contrast.
So monofocal lenses, we have a couple of different designs, the spherical monofocal lenses are older. Although we still see some of those. The natural cornea does have some degree of positive spherical aberration, and the spherical lens will add to that positive spherical aberration.
So spherical aberration basically means that light rays coming in off the edge of the lens are refracted more than light rays going through the center. This means those peripheral light rays will converge in front of the macula. That can decrease image quality and contrast sensitivity, can increase the depth of focus a little bit, and as we’ll see, these lenses are not very sensitive to tilt and decentration, so maybe a good choice in some patients where we worry about that.
The newer models of lenses available in the mono.folk type are aspheric. There are negative spherical aberration lenses which try to offset the cornea’s positive spherical aberration. This can improve image quality and sensitivity.
And positive spherical aberration lenses are almost never used especially, in post refractive eyes.
And we also have toric lenses, as well. Here’s just a schematic of an aspheric lens and how it bends light to improve image quality.
So when it comes to some of these things that we want to be aware of in these glaucoma patients, spherical lenses will not be sensitive and so they’ll be good in patients where we’re worried about tilt and decentration. They do increase the depth of focus, but they can decrease contrast sensitivity and image quality.
A neutral lens, not sensitive to tilt or
Your improved contrast, but they can be sensitive to tilt and decentration, so caution in patients that may have a zonule issue.
And the toric lenses are somewhat sensitive to tilt and decentration but will give a better image in patients that as astigmatism.
So here is my poll question 2 here.
You have a 70-year-old patients who presents for cataract surgical evaluation. He has 2 diopters of regular bowtie astigmatism. And which of these choices would you offer him? This is his visual field here.

All right, so pretty split, as well. Looks like some would only offer a monofocal nontoric, some would offer a toric, some extra depth of focus and some a multifocal.
So this patient based on visual field criteria has some moderate glaucoma, some visual field defect and so we will talk about different stages of glaucoma and how some of these lenses can affect the contrast sensitivity and image quality issues that we say.
So multifocal and extended depth of focus lenses available now on many platforms, many countries, our lab has their own version.
I’ll talk about the technical ones that we have here.
So extended depth of focus lenses, there’s some different optical technologies at use here, the Vivity has a dome-shaped bump. These do increase the depth of focus, they often give patients good visual quality at distance and intermediate, but can be pupil-dependent and so important to know, you know, with your glaucoma patient, if there’s a difference in the pupil size that might affect how much they would benefit from these lenses and then the important thing here is that because they’re defocusing light, they will split the light which will decrease contrast in low light, decrease image quality somewhat compared to monofocal lenses. So compare the risks and benefits, look at the level of glaucoma, you know, the progression, and the prognosis of the patient and have a conversation with them about whether they would benefit and what some potential drawbacks might be.
Multifocal lenses, the ones that we have available here, PanOptix, Synergy are the most common ones here.
In patients where you worry about tilt and decentration, talking pseudoexfoliation or primary angle closure patients, we probably would not recommend these lenses. These lenses can cause coma after they decentered, and worse, glare, halos, there can be side effects.
These split light more over a wider defocus curve. There’s also some loss of photons in the process, so that does lead to decreased contrast, decreased image quality, though it does increase the depth of focus, which is the main point of the lens. So again, in patients with, you know, I would say moderate to severe glaucoma, I would probably avoid these lenses because of that decreased contrast and image quality. And in mild glaucoma, definitely worth a conversation.
So for zonular stability issues, I would say spherical and aspheric neutral, spherical aberration lenses would be my choice. For patients with decreased contrast sensitivity, negative aspheric or neutral aspheric lenses would be my choice here.
If there’s an issue with pupil size, you should make sure that if if you’re thinking about putting in a lens that has an extended depth of focus or defracted rings that the patient would benefit from the full diffractive zone,
So the Vivity is an extended depth of focus lens. This study was looking to see if there’s a clinically significant decrease in glare. So it’s a point-3 log unit decrease, and you can see here the blue line is the Vivity lens, the gray line is the monofocal lens and even though there is an increase in contrast sensitivity with the extended sensitivity lens, it doesn’t always meet in the binocular. In the monocular it almost meets, so take it with a grain of salt, it’s done by the company Alcon itself that is putting this lens out, and in theoretically it’s shown here there is an increase in contrast sensitivity, maybe it doesn’t affect things as much as we think and perhaps we should be having these conversations with our patients if they’re quite motivated, this might still be a good option for them.
So this is my kind of thought process when it comes to these different categories of patients, ocular hypertension and glaucoma suspect patients at the top. I think they are probably good candidates for all of these lenses. If a patient is a high risk glaucoma suspect and if they’re young, we think they may develop glaucoma in their lifetime, you do want to make sure you assess their risk and have a candid conversation with them about some of the drawbacks of the multifocal lenses. And pseudoexfoliation, I would probably only stick with a monofocal lens and within that try to stick to a neutral or aspheric lens. If these patients do have zonulopathy later in life, they will have problems with these lenses here.
In general the monofocal are going to maximize contrast,
As you see a standard monofocal lens is a great choice with any of these patients, even if you’re working somewhere where you may not have access to premium lenses, so to speak, monofocal lens is still an excellent choice and probably what I’d put in the vast majority of these patients. In general, we do need better had studies, so we can have more informed discussions with our patients that are less theoretical. And you always want to weigh the risks and benefits, have an honest conversation with patients, because it is very individualized about their expectations and their motivation.
So last question here, a 70-year-old truck driver presents for cataract surgical evaluation, she’s a high-risk glaucoma suspect. She would like to minimize her glasses dependence, which of these choices would you offer to her?
All right, also pretty evenly split. So I think my answer here is you could offer all three. I would have a conversation with her being a high-risk glaucoma suspect, you know, she may have another 20 years of life ahead of her, and there’s a possibility that, you know, because she drives a truck, she’s likely driving at night. Those are going to be low-light conditions where she would want to maximize her contrast. I might steer her away from a multifocal lens. She might also get unwanted side effects of glare and halos, which are more noticeable at night. So I would probably steer her away from a multifocal but have a change conversation with her that if she does develop decreased contrast sensitivity later in life, that could affect her overall contrast sensitivity if she has one of theses lenses in.
>> Dr. Kahook: One of the things that I noticed about the polls is it is reflects tive of the.
>> Sandy has Herculean task to cover cataract surgery with MIGS in 15 minutes. Dr. Sieminski: As you said, a Herculean task to get through a lot of information.
So we already know what glaucoma is, a progressive optic neuropathy characterized by nerve tissue loss and associated peripheral vision loss and we can only really intervene on increased IOP. And of course all of you are using topical medications, laser and trabeculectomy which is not dead. I don’t exclusively do MIGS, but there is a great place for MIGS.
So what is MIGS, microinvasivive, some people call it minimally invasive glaucoma surgery.
It’s ab interno, minimal disresumption of normal anatomy, good efficacy, and a quick recovery time.
Now, there’s also a term called MIGS plus. We’re not going to be talking about MIGS plus today but I will go over it to be complete E
So MIGS plus, maybe ab externo, cause more than minimal disruption to normal in the my, still retains good efficacy, high safety profile and relatively quick recovery.
And I’d like to quickly go over the conventional outflow pathway. So this is a trabecular meshwork and the juxta canicular measure is where the highest so we’re trying to augment that. So MIGS and MIGS plus is a huge surgical space. Again, I don’t have time to go over all of them but I’d like to go over some trabecular, some canal-based, cyclodestructive. Some people don’t call this MIGS, but micropulse is part of MIGS.
Supra choroidal we’re not going be to talking about today.
So I’ll be focusing on trabecular and canal based and just to review terminology. When I was in residency, I thought, OK, I know what a againot my is, a trabeculotomy is done from an external approach. So that becomes a little bit confused when we’re talking about an ab internal trabeculotomy. It’s a creation of a direct opening in the TM from within the AC, it produces a direct communication from the AC to the out R. outer wall of Schlemm’s canal and the collector channels and all ATs are built as a gon iotomy, so now that we have all that all cleared up or maybe all confused we’ll talk about trabecular MIGS.
And we’ll start with given that this is Dr. Kahook’s webinar here we’ll talk about the Kahook goniotomy first.
This is one of my videos and I’d like to just start by saying you can use a variety of gonioprisms, I do really like the hand-held one because in this case I’m actually following along with my gonioprism. You can see that there’s a blush of heme in Schlemm’s canal, which makes it very good for visualization, and you can see I’m following along with gonioprism and here I’m actually demonstrating one of the strips. This is an inside-out technique, you can do out side-in, you can leave the strips there or you can remove them.
Another is GATT. In terms of cost and I know a lot of you who are international are thinking about cost and this is probably going to be, once you get the instrumentation, the microforceps, this is simply a suture, so it’s going to be very low-cost. This is an ab intero trabeculotomy device, a nasal goniotomy is created and micro-catheter is placed and advanced using microforceps.
And I’m going to advance to this video here, is simply pulled centrally and so the goniotomy is created 360, or trabeculotomy, again, kind of used interchangeably sometimes. So tissue is not actually excised, but it is definitely incised and you are pulling through a 360 degrees of the trabecular meshwork. Jot next one I want to talk about is TRAB360 omni surgical system. I have both of them here. TRAB360 came first. Omni is a combination of TRAB 360 and Visco 360.
Generally a combination approach I find is best with these devices. That device then can be flipped around to do the other 180. What’s nice about this is you can titrate your treatment, especially with the omni, so you can just dilate Schlemm’s canal, you can do a trabeculotomy, you can do 180, you can do 360, really dependent on the patient.
So this is Dr. S doing just the TRAB 360. This looks a little bit larger in the eye, I would say when you enter. It is a blunt tip and you do need to do a little bit of wiggling to engage in the Schlemm’s canal and also tilting the device up about 15 degrees to really get successfully into Schlemm’s canal.
And this is the omni, this is Dr. Steve Safran and this is going to be a combination of the dilation of Schlemm’s canal with the Visco elastic. I’m really looking for a clear view, for some reason in my hands, I feel like Celon is a little bit cloudier than Visco disc which is what I use.
Now he’s actually retracting the catheter, kind of moving backwards, and as you move backwards and retract, a little bit of viscoelastic is getting injected into Schlemm’s canal. Then you recatheter and pull 360.
SION just came out with Sight Sciences. This is a bladeless device used in goniotomy, the SION grasp and removes diseased tissue as it is swept along Schlemm’s canal. In the center of this slide you see the TrabEX, this one is a little bit serrated and is hinged.
Moving on to canal-based MIGS, so we have the streamlined surgical system. This is again another newer device approved in October of 2021. A cannula, when you click on the button here, the canal emerges and then 7 microliters of OVD is actually injected on either side of the cannula to dilate Schlemm’s canal. You can actually create the cannula to create a larger goniotomy, to sort of titrate your treatment.
So this is Michael Greenwood, this is just showing you one example of the streamlined device. You deploy and prime the device in the eye by clicking and then once you press the button, you can actually see there was a previous otomy made sort of on the left side and there was blood that actually refluxed through there as he deployed it in a second site. So this can be deployed up to 3 times in half of angle and generally I use about three.
First I like to highlight how much as we deploy the Schlemm’s canal actually balloons up and dilates there, but also I’m keeping my hand on the button and using the tip of that to enlarge my otomy. So again titratable to a certain extent.
Also, we have stents, so we have an iStent which I’m sure all of you are familiar with. On this picture on the right is actually the first generation of iStent which I loved, snorkel shaped and this was three devices deployed in the eye. In the US, only one was really FDA approved but certainly there were studies in Canada and Europe that really proved that more stents were better. So iStent of course created other devices that allowed us to inject two or more into the eye.
And now it’s actually approved as a stand-alone device, not with cataract surgical surgery.
I’d like to keep your eye on the first one that I deployed and you can actually see some blood reflux through the center of that which is really what you want to see and this is the iStent inject, so there are two devices inside the one applicator and four clicks. So you can deploy multiple stents and that’s FDA approved, of course.
Again, I do that after cataract surgery. I do this iStent as a second procedure, you can do all of these procedures before. But again, what’s nice, and you can see in this slide here, this is the hydrus, which is again a trabecular stent that’s actually used to dilate Schlemm’s canal and that the scaffolding actually is nice, because it occupies Schlemm’s canal, but the scaffold design allows to access the collector channel. So it’s not just a tube, there’s actually a scaffolding so that the aqueous can flow freely.
So this is again tilting 15 degrees superiorly while you’re deploying this can allow entry into Schlemm’s canal easier.
Lots of great dater with hydrus and their five-year data is looking very promising.
Another thing you can do is dilate Schlemm’s canal first and then place the hydrus.
So I’d like to go over some case examples, because I certainly use these devices in many different ways, in many different types of glaucoma. I am not going to go over angle closure glaucoma. I did see a couple questions about that in the poll prior to this, and I will say that you can use some of these devices, like the heel of a goniotomy blade or the streamline to sort of open up some areas of the PAS and still place it some of these devices, or do these surgeries in some angle closure, but I’m not going to go over angle closure in this talk.
So I first have a 65-year-old white male with open angle glaucoma. He was hypertension for years and then he has some thinning on his OCT and a lull bit of field of vision abnormality. Ocular hypertension can certainly turn into glaucoma as you follow these patients as long as I have, and I’ve not been practicing as long as others, but certainly people morph into that position.
His pressure is 16 and 12, but his maximum pressure is 24/26. He has a stable early nasal step in the right eye and full in the left. I like to emphasize stable, OK, because I think that some of these devices I do not really recommend using if somebody’s pro-progressing and we’ll talk about that in my algorithm at the end. And the OCTS shows border thinning, so here’s his visual field and then we have his disc photos.
I did a cataract surgery in 2016 and he’s been followed regularly since 2016. His visual acuity is great, his IOP range has been 14 to 19. Based on his T max, that might be acceptable, but of course things can change, you may need to add back the patient’s drops. I also published a study on using SOT after iStent. That’s very, very efficacious if that’s where the patient is going and they’re progressing.
But this has been stable for 7 years on just one of his two drops and if you’re not familiar with this, this is essentially just a guided progression just highlighting none of these cells on this spreadsheet are highlighting, which means he’s not progress, everything is stable according to their algorithm. So you know, that’s just one of the very nice examples of iStent which I’ve been following this patient for, you know, several years.
Now we’re going to go on to somebody that’s a little bit more advanced here. So this is an 80-year-old white female with pigmentary glaucoma and she had kind of a tough cataract surgery in her left eye, IOL repositioning, but also in the right eye, too, but the right eye has only had SLT on post-op again. Her pressure was 16 with a pretty high T max in the left that’s really based on her cataract surgery complications but 23 in the right.
And she also has cataracts that are worth addressing. And here I’d like to highlight she is progressing in the right eye. Visual field is stable. On the right side of the screen is her right eye. She has real disease there. And here we have her right eye has a disc hemorrhage. So we all know who are following glaucoma and practicing glaucoma, disc hemorrhages are bad. That really is progression, precedes progression, we want to take that seriously and this is her OCT. Obviously some red in her OCT.
So in this patient I did a Kahook dual blade in 2016. I’ve been following had person for a while. And her pressure has been 12 to 14 on no drops. And visual field has remained stable for 3 years.
Again here’s one of those pronounced now the cell is highlighted as yellow, possible progression, so I’m considering adding one drop, but again, coming from a combination of really on no drops, that’s a win for me. When I was not doing MIGS, I would have done a TRAB on this lady and there’s nothing wrong with TRABs, again, there’s a definite place for TRABs in glaucoma. But I think I saved this patient from TRAB.
Next patient is a 68-year-old white mail. Significant cataracts, vertical cup to disc ratio .7 to .5. And the OCT shows stable borderline thinning, so I believe some of this is artifact. He’s had some full fields in the past and since then, and then some borderline thinning, so compared to the OCT we just saw, this is more mild, OK? And she’s also stable on one drop. So this is a patient that I did a streamline on just this past year, and since I’ve been following her she’s been 2020, 2025, and her pressure has been 10 and 12. So a definite stable and no drops since we did the streamline.
So this is my algorithm. Of course, everybody is different and everybody has different tools in their toolbox, but this is how I sort of see patients and how I book them. So mild glaucoma or ocular hypertension, stable on 0-1 meds I’m going to think about an iStent or a streamline. Mild to moderate glaucoma and mild hypertension, again stable, but maybe on more meds, there’s a little wiggle room there, you could get the patient stable, maybe get them off of one of one or two of their drops.
However, moderate glaucoma progressing on more than two meds or two meds or severe glaucoma that’s stable on two meds, this is where I call it like an extensive KDB so I’m going to go almost 180 degrees of the angle, not a KDB light, Om my or maybe a combo MIGS. This is where you’d want to live for somebody who actually has a little bit more glaucoma, but if they’re severe and progressing, I don’t think I would recommend doing one of these MIGS.
So in conclusion, MIGS is a continuously evolving space, MIGS target a variety of outflow pathways and can be used in combination. We can tailor the surgery to the needs of each patient and the severity of their glaucoma and again, if they need to level up and do a TRAB later, you have not put a gon.
For the first time, treating glaucoma can be exciting. I bet you this is why so many people are on today, because MIGS has actually made glaucoma very exciting and glaucoma fellowship very popular now. So thank you so much, it was very exciting to be a part of this, and I’m very excited to hear your questions afterwards.
> Dr. Kahook: Thank you, Sandy, in a short amount of time you covered a lot and I have a long list of questions here that I wrote down. One of the big questions is implant versus no implant and how people think about that and some of the repercussions of doing one versus the other. We’ll get to questions in the Q & A session, but we are going to move on to the next talk. This next talk is by Russell Swan. It’s about cataract surgery in eyes with pseudoexfoliation. We’re already getting questions in the Q & A button at the top of the screen so I want people to keep doing that.
Russell, I’ll hand over the mic to you and thank you for joining us.
Dr. Swan: Thanks so much, Malik, for being a part of this mere here. Again, my name is Russell Swan, I practice up in Montana with Vance Vision.
one of the things that Avni highlighted and obviously Sandy did, as well.
The clinical features many of are very familiar withs, with Perry pupillary defects. Difference in anterior chamber depth that can sometimes be subtle, poor dilation and zonular weakness that may be diffused and in terms of how those clinical findings affect my preparation for going into the OR, again, if it’s pseudoexfoliation glaucoma we’ve got to be thinking about adjuvant therapy for glaucoma at the time of therapy. If theres’ poor dilation I want to be prepared with Iris expansion rings or hooks.
If there’s zonular weakness, always be ready to find a little vitreous along the way, although we’re always hopeful not.
I thought I would run through. These are my ten rules of pseudoexfoliation and I would highlight in the bottom right, one of my dear mentors, Dr. Alan Crandall, really held my hand through all of these cases and I don’t think there was ever a capsular bag that Dr. Crandall saw that he didn’t think was worth saving.
So a lost are pearls that I learned through direct mentorship with some, as well as the other surgeons that I’ve had the opportunity to work with.
Number one is assume pseudoexfoliation is present always. Studies looking at dislocated IOLs, and actually 70% of IOLs that were dislocated that didn’t have a clinical history of pseudoexfoliation, when they looked at them actually did have pseudoexfoliation present. Whenever I go into any eye I want to be treating that lens like there is pseudoexfoliation and being gentle to the zonules, whether it’s clinically apparent or not.
The second thing is I don’t like to work through a small pupil and Dr. Crandall bragged about how he could do any cataract surgery through a 3 or 4mm pupil and taught courses on it and then along came a tool.
My go-to is the Malyugin ring 2.0. Comes in two different sizes, I have no financial interest. There are a lot of other great international and US-based pupil dilation devices, including uses of Iris hooks but this is kind of my go-to, I think the big thing is again making sure that we’re ensuring adequate visualization. Like to show videos when things don’t get perfect. We want to get 3 out of 4, and but then we bring it back to 2 out of 4. This is 2.35mm and easily can be explanted. The other thing that I like about Malyugin rings. But again, having adequate pupillary dilation for these cases, really, really important.
Rule No. 3, be alert for capsular wrinkling, so interesting, and again, a lot of patients who may have subclinical pseudoexfoliation, this may be the first sign that you see of zonular instability. I have a couple of videos to demonstrate this. This is a patient that ha had mild pseudoexfoliation but also a history of trauma to the eye. But as you see, I can’t pierce it and there’s a little bit of capsule wrinkling — and that just dropped out. One second, I apologize. We will resume that.
This one is going to be a little more severe and I just want to show this because I think probably a greater visualization. This is the one one case I have not been able to puncture a capsule. I had to go in and utilize assistive in this case. You’ll see the aftermath of this later. This is a case where zonular capsular support intraoperatively became important. But if he see this, you need to be prepared in your mind to have Iris hooks.
Had there’s been some studies that have demonstrated a smaller capsular rhexis. In addition a probably moderate to these patients these are ones that I’m very intentional, to I can mature that I’m making certainly greater than a 5mm capsular rhexis, if a hard nucleus, consider prechopping Mi-loop or chopping techniques that allow you to minimize the energy that you’re using and also are more zonular friendly.
So the first video is the Miyake view. This has obviously now been purchased by Zyse, but you can see as this is Mi-loop or the capsular device goes into, it will loop around the lens and as it comes and is rotated, the kind of cutting or splitting or chopping of this lens is pulled from external to central line. It would have been probably the most helpful to show up the zonular stress associated with the technique but this is extremely zonular friendly. This is that in use and again, this is a patient with severe pseudoexfoliation, capsulotomy is already created. Again, going in around the nucleus, being able to go around and then hemisect it and quadrisect it.
The next couple rules that I just put on kind of the same page, perform rotation carefully for all my patients, but particularly in pseudoexfoliation. We want to make sure we have grade whenever we’re doing any nuclear rotation, doing a bimanual with a second instrument, as well, removing the cortex in as tangential or sometimes what’s called a… technique. I like to remove the lens epithelial cells in these patients, as well.
We’re going to move on to the first case question. So this is a patient that during cataract during a cortex with a 4 + clock hour zonular dialysis is noted.
So which is the is the best option for endocapsular support in this case?
So we’ll get all your results here, so the majority of people say place a capsular tension ring in the capsule bag and some would lean towards a modified CTR.
This is kind of the way that I think about these — I have to click through to my next slide, so I apologize.
When I think about supporting the capsule, thinks kind of how I view this. So I anticipate the zonular dialysis is going to be about 2 clock hours better than the zonular appearance.
Again, as a rule of thumb I think the weakness typically extends 1 to 2 clock hours beyond that, so let’s say this is probably the case where there’s probably 5 to 6 hours of actual zonular compromise.
You’ll see some gradient systems will say 3 clock hours. As a resume of them for me if I’m seeing 3 clock hours or less.
More moderate zonulopathy, 3 to 6 clock hours. with that much zonulopathy there’s higher risk of late dislocation. And then with severe greater than 6 clock hours, this kind of becomes a clinical choice of whether you’re trying to save the bag versus sacrificing the bag and doing a scleral fixation of choice.
When I think about capsular support the way I break it down is what temporary supports I have and what permanent supports. So you want to be familiar with the supports and know what you have. I think the most common in the United States is the MACK tool. And the Yaguchi-Kozawa hook. And and then there’s permanent support.
So use of the CTR, this is actually the first case that we showed earlier with mild capsular weakness had mild zonular weakness.
I don’t do a suture assisted or snsky assisted placement.
The idea s you know, you want to put a capsule tension ring as soon as you need it, but as late as you can, and sometimes you may have to place a CTR in prior to cortical removal. So that might make it a little easier to remove cortex if you have to place it prior to cortical removal.
This is the second case that we demonstrated the capsule hook in, so again, severe zonular weakness this case, and this is in this place we place 4 cap actual hooks that help secure the capsular bag to allow for nuclear disassembly and removal of the nucleus and this is an interesting one, because there’s not a focal area of dialysis, but there is zonular weakness. In this case, I decided to place a capsular tension ring in the bag, and then you’ll see I’ll remove the capsular tension hooks and actually put a 3-piece lens in the sulcus with ocular capsule.
I’ve found this kind of belt and suspenders approach of having a 3-piece lens that’s sitting in the sulcus with optic capture and a CTR has provided nice zonular stability it for me so far in my career for the severe cases where there’s not an area of zonular dialysis. So being careful not to break the cap actual, dial this lens in into the sulcus space and doing an optic capture for this patient.
Again, a modified CTR will look very similar in terms of the way it is secured. This anterior hook actually comes anterior to the capsule and then is able to be suture fixated. Some people will use propylene, some will use Gore-Tex, but to secure the case where there’s a more severe zonular weakness.
And finally, always be prepared for vitreous, I think this is important any time you go into the eye, but particularly in patients with pseudoexfoliation, I think making sure you have easy access to Vitrecto, Miochol and Triacinolone if you need it.
And knowing you are settings, does it these are my ten rules that I kind of think about Avni do a beautiful job in highlighting — I think you want to have a Plan A and a Plan B. I still feel for patients that mild zonulopathy, or even moderate, it’s still very reasonable to place a one-piece monofocal implant in the bag, but I think having a three-piece to place. If you do have to put a lens in the sulcus, please remember the rule of 9s, if you can’t optic capture it, you want to adjust the power of that lens. 0 to 9 no change. 9 to 18, subtract half a diopter. And above that 1.5.
Thank you so much, I love being a part of this session. Dr. Kahook, thanks so much for the invitation. Here’s my contact information. I’ll look forward to the Q & A at the end. Thanks so much.
>> Dr. Kahook: Thank you, Russell, a lot of content in a very short period of time. The whole question about what do you do usually everybody is panicking and you want to hit the easy button and for me, easy button is having instructions on the wall, I certainly do that when I’m traveling and operating in ORs that I don’t operate in all the time. So we’ll talk a little bit more about that in the Q & A. We’re going to do another 15-minute talk by Professor Sid who has the big we as a surgery that we still need to masterings and that is filtration surgery in a patient who’s also getting M6 surgery. So Sid, please take it from here.
Dr. Sid: Thank you, Dr. Kahook and it’s a pleasure to be and it’s a challenge to follow the talks that I have seen.
Well, I’ll be talking about combined cataract and filtration surgery. Especially in the era of MIGS and we’ll see how this is still relevant.
I’ll be covering the talk under these headings, simple headings.
Now, what is it when we talk about a combined cataract extraction with trabeculectomy? Any kind of cataract surgery with phacoemulsification, SICS, ECCE or ICCE, forms a combined surgery when we combine it with trabeculectomy.
But these days we largely perform phacoemulsification and that is what I’m going to focus on and if time permits had talk about combined with trabeculotomy.
The question is why combine? It’s a convenient thing for us, not for us, but also for the patient. They don’t have to go through two surgeries, two post-op follow-ups, and the fact that visual recovery after the surgery provides a greater deal of happiness than a trabeculectomy alone would. Also, complications like shallow AC and aqueous misdirection might be easier to handle. Also thin cystic blebs which is a major pain with trabeculectomy is less common when the surgery is combined.
Now, how do you do a combined phacoemulsification with trabeculectomy? I’m going to touch upon it and show you how I do it. Now, very clearly there’s no one way to do a surgery really perfectly well.
A few things before when you start. It’s very important to lower the intraocular pressure as much as you can before the surgery and when you are talking about anesthesia, we have to remember that a block or a retrobulbar block affects the intraocular flow, so if you choose a peribulbular or retrobulbular anesthesia, do not use any compression with the block.
The preferred anesthesia for these patients is combining a topical with a sub-anesthesia.
If you can make out the difference, this is very thin-walled kind of bleb that you see here initially and that is when the anesthesia or the injection is going subconjunctival, but not subthemen, you see a very diffuse thick-walled rise in the conjunctiva, so that is how you can differentiate. It’s important to perform a cautery. You don’t want to work in a field that is flooded by fluid. But make sure you — the color of the sclera should be completely — the way it started with completely white, and do not cauterize only the areas of the incision, but also remember that your sutures are going to puncture these blood vessels and you don’t want to have a leaking blood vessel even then.
I use a crescent knife because it’s the sharpest knife that is usually available to make the scleral incision. I use a 4 to 5mm incision and always measure it.
Make sure it does not reach the limbus. The dissection also is carried out with a crescent knife, and my idea is that I should just be able to see the edge of the crescent knife tip. That tells me that I’m somewhere between one-third to half the thickness of the scleral thickness and that gives me a good flap thickness that I desire.
It can be modified depending on the kind of the intraocular pressure that you want. So while the flap size is constant, the thickness can be modified, so can be the tightness of the sutures, so that is what I modify.
So this goes slightly into the cornea, so that you have access to the trabecular window that you want to excise with your punch.
Mitomycin of course is used for almost all cases. I use 2 minutes of mitomycin for my moderate cases and wherever I see excessive Visco fibrosis a three-minute mitomycin is used and I apply mitomycin with soaked sponges, I’m not very comfortable with the injections but that’s my choice and I also apply one sponge under the be flap.
And do irrigate well after application after you remove all the sponges that you have placed.
In a plain trabeculectomy I always is have preplaced sutures, with a combined surgery you can possibly do away with it. But make sure that when the eye is open, you spend very minimal time reducing the duration of hypotony which is very important with patients as far as reducing the blood flow during the episode of hypotony is concerned.
I use one fixed and two resutures and tough these are placed into the before the phacoemulsification that is going on.
For patients with combined surgery, the I prefer around 5mm, not a large rhexis, where if there is a shallowing, 5mm probably gives a very good balance between the retention of the intraocular lens in the bag and preventing possible capsular … I am performing phacoemulsification because the cataract is soft. These are all personal preferences and based on the discussion that you have had with the patient.
Always suture the phacoemulsification wound. For two reasons. One, you don’t want it to leak and just in case you have hypotony, a had wound that is not sutured will also start leaking, complicating the trabeculectomy itself. Once the cataract surgery is complete, I make two grieves, you will see why these grooves are being made at the end of the surgery and why there is a technique that I have chosen to modify the field of closure.
The entries mid about a millimeter into the limbus and gives you access to the trabecular that we know that you want to access in order to punch a hole. It’s a one square mm punch that is used in mig. I use my assistant to hold the flap and then make the opening just as large as the ostium or slightly larger, in fact, and when you have used a punch, you will get a semicircular PI, which is typically may not be seen without gonioscopy. Now, when I tell my surgeons to perform a surgery, there are two things I tell them. They can choose the kind of flap that they want to use but they have to use visuals and perform a trabeculation after the surgery.
Once you have placed the two sutures on the edges, you are likely to see a pouching out of the flap. And this gives me a great pleasure, this basically means that I have — there is going to be a posterior flow.
This will be the first suture to be released when I want to, followed by the second one at the nasal edge. If I need to lyse a suture, then only the temporal edge is removed with suture lysis.
Now, what we have to realize that the present system with one fixed, two reusable sutures, the ostium that you have made, is a system which works on equilibrium, so it will allow aqueous to drain to a point of time when equilibrium stops the further flow of this fluid and I thank Dr. Pambum for teaching me this. So I want for the point of time when there is no more fluid egress through the flap. The point is not to make sure that it is filtering. It of course should filter in any good flap suturing that is performed by wait for a time when there is no more filtration and then gently top of the cornea with this instrument. At this point in time when you touch the cornea, there should be a mild indentation without any force required. This, according to me, gives a pressure of 12 to 14 millimeters mercury to start with. And what I’m even more dreaded about, no hypotony on first post surgery date.
Now, this is the closure that I learned from the safer surgery system. So a use a 9-0 nylon, because a 10-0 nylon is not strong enough to place the sutures. This gives you a good balance between suture and closure. So this is my preferred way of closing the conjunctiva, using two ring sutures with 9-0 nylon.
This is how we perform manual SICS with trabeculectomy, I’ll just play this one-minute video. Even this video that you see here is five years old, but there are situations when you have — you are bound by choices that the patient is forced to make because of certain rules when you have to use a nonfoldable intraocular lens. So SICS is typically performed with a linear incision and after the it may be bad for cataract surgery, but it’s really bad for trabeculectomy, and after placing the intraocular lens, you see a non-foldable intraocular lens here. 3 into one 1 limited ostium is created manually and it is titrated to create a good intraocular pressure.
This is the regimen that I use postoperatively, and this is how my patients follow up. I release the releasable sutures, not earlier than first week with post-op visit when the intraocular pressure goes above 12mm of mercury and the second releasable is basically a backup.
Now, in today’s age and time, the indications of performing a cataract surgery may change. The classical indications are when you need to perform a trabeculectomy because the intraocular pressure target is not met. There is confirmed progression or adverse effects or patients are not able to afford medications, along with a significant cataract. But there are other situations when the glaucoma is wide good, well controlled, and you have a significant cataract.
Now, it’s not probably possible to give you a perfect answer of which surgery to choose, whether combined or cataract alone, but it’s an interplay of these factors that you see here. You would prefer a combined surgery when you have advanced disease, the patient does not tolerate medications well, or choose them well. There is history of progression, not perform combined when you have a patient who is of really old age. Patients with angle closure benefit very significantly from lens extraction, so you tend to choose cataract alone, rather than combined surgery. Pseudoexfoliation glaucoma in our part of the world is very severe and most likely a surgical disease, so you tend to choose pseudoexfoliation glaucoma patients for combined surgery more often.
Now, if you have to summarize, this is not perfect and there is a lot of other factors as I mentioned earlier which come into play, but with pseudoexfoliation glaucoma 3 or more medications are an indication for combined surgery. Angle closure only when it’s advanced and you need 4 or more medications to control.
Pseudoexfoliation with 3 or more medications, now, in today’s age and time, it’s become a little different. And I’ll tell you why it’s become different. Our exposure to MIGS is not as wide or as long as what you see the expert panel here, but I can easily tell you by this example that comparing the list of two surgeons on two operating days in the second week of last year and this year, you clearly see that we are performing a lot more number of GATT and BANG which are two MIGS that we are performing more now.
So when is it that you choose trabeculectomy. Now, I will not show you something very different, but the capacity of MIGS to lower intraocular pressure is variant and the Schlemm canal stents. The Schlemm canal excision and ablation, we have had the pleasure of using a few, but we have not used a few, have a significantly greater efficacy than the Schlemm canal stents.
And the however, when it comes to advanced locum and going to early teens without medications nothing can beat a trabeculectomy and that’s what you need to choose when you want to perform a surgery on such a patient.
To sum it up, always be confident when you’re performing a combined surgery, because if you can perform cataract surgery well and trabeculectomy surgery well, you can always combine with confidence. Treat your combine patients as well as you do when you perform a trabeculectomy, with intraocular pressure lowering prior to surgery and minimal blocks. Twine site surgery allows you to perform trabeculectomy the way you would perform in any way without any need to modify the technique of surgery. Adequately sized rhexis, by which I mean that it should not be too large and shallow, especially when you have angle closure glaucoma patients can be tricky.
We have already spoken about the choice of intraocular lenses. As far as the power is concerned when you’re treating a patient with angle closure disease, you have to remember that a large number of these patients end up with: And to remove viscoelastic very well. They may be quite good when you’re talking about chondroitin sulfate or heel on, but they’re not something that is really natural to the eye and when it goes into the bleb, it can prevent filtration for quite some time. And do not forget that like trabeculectomy the combined success will depend on the care that you provide to the patient after the surgery, with massage, removing the — and if required, even a needling.
I thank you for the time. I overshot quite a bit what I rehearsed and will be happy to join the Q & A session.
>> Dr. Kahook: No, I think it was excellent. It was worth the added time. I’ve actually been checking some of the questions that I was going to go over, because a lot of you did a great job of preempting many of the common questions. Sid, those were great videos, how meticulous you made that flap, the initial video I think is really really nice and it’s something we should show our residents and fellows over here. I should come and spend some time with the OR with you if you’ll have me.
I know some of you have to get to clinic or maybe to dinner later on today with the different timezones. The first question, and I’m going to try and go through the various talks that were given, is just to ask the panel about advanced technology lenses, so I think Avni did a really good job of going through what she does, but Sandy, I’m wondering, do you use tops — what’s your thought process.
Yeah, I mean tops absolutely I offer to patients who have glaucoma who is not going to be dealing with decentration as Avni said and with the Divni I’m just dipping my toe into that. Looking at the data and definitely offering it to early glaucoma, not late glaucoma. We just purchased the light adjustable lens platform, too, which has not been studied in glaucoma, I hope to be part of one of their trials to look at that in terms of visual field and contrast sensitivity. Because that is really exciting technology and you can tweak it up to three times after it’s implanted, so I’m excited to try and look at that from a glaucoma perspective, because nothing has been published yet.
>> Dr. Kahook: Great, and Russ, do you do mini mono on your patients at all?
>> Dr. Swan: Yeah, for patients that have been in it before, maybe have mild disease, I still feel like it’s a nice option, and even with the EDOF lenses for me I’ve found I use Vivity primarily in that setting, but I think that mini mono will be nice. I think in the US whether there’s a place that certainly does have an effect on amount of light coming in, but it’s nondiffractive.
Dr. Kahook: Yeah, for those around the world, the IC8 lens that recently has been approved in the US and acquired by Bausch and Lomb is something we’re considering using in our patients.
Let’s say you have no bag support at all, are you suturing or using an
>> Dr. Sid: Considering the fact that if I’m in that situation, it’s typically a pseudoexfoliation glaucoma or a patient who has trauma, both of which would compromise the endothelium, I would prefer to use a lens behind the Iris now that I’ve had experience in multiple patients. ACIM I’m not very comfortable placing the intraocular lens in these patients.
>> And Avni, would you agree with that? Is that your thought process, as well? Suture versus ACIOL. If you have the option, do you always go with suturing
>> Dr. Shah: I would say mostly in glaucoma patients, specifically in pseudoexfoliation or trauma as Dr. Sid said. I would definitely not put an ACIOL in. Some situation withs maybe an elderly patient with poag that maybe had a zonular issue unrelated to their glaucoma, I might if somebody like that if I’m not too worried about the angle.
>> Dr. Kahook: And for me it’s resource-dependent, right, so I might 0 in an OR that don’t have the sutures needed.
>> So one question that came up is do you do your MIGS procedure before or after phaco? And maybe we can go through the panel and start with Sandy?
>> Dr. Sieminski: I’m always in after. One of the big reasons is that heme reflux in Schlemm’s canal seems to be an almost 100% known thing for when we’re operating you’ll see that in a lightly pigmented TM where you’re wondering about landmarks, that heme reflux is always helpful. You can also use Tripan for the cataract and that will stain, as well. I think the big drawback is if you have a dense cataract and you have a little corneal edema, that’s going to compromise your view. But that hasn’t been the case for me yet, and of course, the — you’ll have a wider angle when you remove the cataract, so lastly, if you’ve had a cataract surgery complication, let’s say you break the bag and so forth, you might not want to do the MIGS at that point, so getting the cataracts out of the way is nice to move forward.
>> Dr. Kahook: And Sid, what do you think, before or after cataract surgery? What do you think?
>> Dr. Sid: So far limited experience with KDB. Significantly more with GATT and BANG. I have tried both, but especially with BANG and GATT, when you’re likely to have a significantly more amount of bleed in the anter your chamber, I always do it after the cataract surgery. I don’t want to ruin the cataract surgery in case there is a trickle, and for reasons we just heard with the wider angle, I’ve always felt more comfortable doing the phaco first and then the MIGS, whatever it is.
>> Dr. Kahook: Russell, anything different?
>> Dr. Swan: Always after.
>> Dr. Kahook: And Avni, I can’t remember if you answered in the first question, always after?
>> Dr. Shah: Always after.
>> Dr. Kahook: I put this into the Q & A is we did a study of we took photos of the angle before and after phaco. And we asked people to rate the photo quality before or after, do they see the angle better before or after and it was a wash, basically, they couldn’t tell the difference, including me, I was part of the panel, I couldn’t tell the difference. So I’d say do whatever you’re most comfortable and for me it’s almost always after. So I think this is a rare time when we all do the same thing.
So not focusing on any specific technique or device, do you gravitate towards putting in an implant — I was going to say a foreign body, but erase that, it’s kind of like stacking the deck. What do you do when it comes to implant versus no implant?
>> Dr. Sieminski: I have to give props to my first foray into MIGS and it’s a great thing to learn if you’re just getting into MIGS, you know, we were all burned with Cypass, and then it was taken off the market. Endothelial loss and I have to go back and tell all my patients. So it really does make me think a lot about what is happening to the endothelium. Hydrus study came out, and they have proven that there was no significant endothelial cell loss with hydrus, iStent is the same thing. But there was a study that proved dimple and also you said foreign body that colors the conversation a little bit, you know, I have had to remove poorly placed iStents and even one of the iStents I did myself which was placed pretty well, I had an UGH-type syndrome and I removed it and did a MIGS procedure afterwards, so it’s there and can migrate and can cause problems no matter what and that’s kind of the advantage of not having an implant.
>> Dr. Kahook: I want to get up on my soapbox here. Everybody knows my biases they’re pretty clear. I’m going to say something that might be controversial, so in very, very early stages of glaucoma, when you’re doing phaco, pretty much anything we’re doing in the angle is going to be pretty good, right? So iStent, hydrus, KDB, doesn’t matter. When you start getting into moderate and severe, I have opinions on what should be done. But what I’m noticing in the literature and I would invite everybody to do this for yourself, go and look in the endothelial cell in the control versus the implant and see how that has changed over the past decade. So the control phaco only is starting to have worse endothelial cell loss so in comparison when you do an implant and you say implant versus control, it actually looks pretty good and that clouds the whole picture for me. We need better data, we need more head to head. So I’m hoping more more studies in the future. Where we can hang our hat on the data. I don’t think we’re there.
MIGS in severe, in glaucoma. do you consider doing a MIGS approach before doing a TRAB or tube or do you always go to a TRAB or tube in more advanced glaucoma?
>> Dr. Swan: For me I definitely do and maybe it’s a little bit practice preference than training preference. We’ve actually published data in severe primary angle glaucoma and been following those patients. Original data was published at 2 years, now at 5 years. In a large percentage of those patients we’ve been able to avoid incisional surgery. So I usually have a conversation, again, it goes into how progressive or severe is the disease? And when I’m having the conversation with the patient, I’m having a conversation it’s very possible that we need incisional surgery but maybe we could postpone or avoid that and historically people had a hesitancy to live with higher pre-implant IOPs, there is good data that the greater lowering effect we’ll see with minimal invasive glaucoma surgery. So even with patients with the higher preoperative IOP I’ll consider it and we’re trying to facilitate as many outflow pathways as possible, considering ECP, outflow procedures, as well as excisional.
>> Dr. Kahook: Phaco versus goniotomy.
>> Dr. Swan: One of the things that I think is important to know is also the patient population, so I would just say, you know, our data, the patient population in the upper Midwest is maybe considered gentleman’s glaucoma, is usually not as severe or severe. So I think that that does also play a role in regional decisions that might be made in terms of how aggressive someone’s healing
>> Dr. Kahook: Gentleman’s glaucoma is something new to me, so I’m glad you taught me that term.
>> Dr. Sieminski: I love that term. I’m going to steal it from you.
>> Dr. Kahook: MIGS in post Lasik or refractive surgery patients, do you do something different in those patients
>> Dr. Shah: I don’t. any definitely have a conversation with them. But in terms of whether they have, I don’t change my plans.
>> Dr. Kahook: Yeah, same here, Sid, Russell or Sandy, do you do things a little bit different or no, with post-Lasik eyes?
>> Dr. Sieminski: I mean it’s ironic that you’re bringing it up, because I do have OR in an hour and my first patient is a post-Lasik patient who I’m going to do gonio and phaco.
So you know, it’s really no different for me in terms of surgical planning or, you know, lens choice.
>> Dr. Kahook: Yeah, I think that’s fair and most of us feel the same way. We’ve also done studies on post KDB and post ECB eyes and there’s no difference. Looking at refractive outcomes, it’s really not influenced by that. So some rapid-fire questions that came up during Sid’s talk. Tom sponges do you use, Sid, when you’re doing a TRAB.
Dr. Sid: It’s four in number.
>> Dr. Kahook:
And what material are you using for your sponge?
>> Dr. Sid: These are not precise, but they’re cut from cellular sponges that you get for mopping up the fluid.
>> Dr. Kahook: OK, what dose of mitomycin do you use?
>> Dr. Sid: It’s zep 4 percent that I use. And it’s 80 to 90 seconds.
>> Dr. Kahook: One last question that’s come up in texting as well as in the box during the talk is SLT. That’s a big topic of course, we could have covered that another hour. Do any of you have a different algorithm in a pseudophakic versus a phakic patient? Maybe we’ll start with Russ on this one. Do you think the outcomes are the same because the studies kind of differ on that, there are different data out there.
>> Dr. Swan: I would say historically I thought differently about it and more recently have kind of pondered it a little bit more, because I think there’s emerging data that there is some potential benefit. So historically in my practice I used it as a bridge to get to a MIGS or other surgery and didn’t considering as much in the algorithm for post pseudophakic patients, now, with pseudophakic patients I will consider it. I think it is a really nice option to consider.
>> Dr. Kahook: Avni. Maybe a little bit of a twist, so primary —
>> Dr. Shah: Absolutely, yeah, I do offer it versus eyedrops for most of my new glaucoma diagnosis patients, a few situations where they’ll come in with super-high pressures and I’m concerned and I feel like we need to get low pressures quickly, then I will push them more in the direction of starting an eye drop, because I feel that a little bit more of a consistent result with that, and a quicker result, but generally if we have time, then I will offer them both, yeah.
>> Dr. Kahook: Sid, how’s the use of SLT in your direction?
>> Dr. Sid: I have very little experience with that, so I’ll pass on that.
>> Dr. Kahook: When you start talking about the world at large, we were getting some questions about CPC, you know, when do we use CPC and what’s the use of CPC? The access of CPC is very different across the globe.
>> Dr. Sid: I’m sorry for interrupting, we actually did a cost benefit analysis in our population that we usually see here, and we realized that we see the number of patients who come to us with POAG, only 2% of them are treatment live, so everyone who comes here has basically been on treatment for a few months and most of them have advanced glaucoma so there was this thought process that SLT may not be a very good option for our population subset, but we are taking the plunge and we are getting a machine very soon and next year I can talk about it.
>> Dr. Kahook: No, it would be great to share that data, as well, so we can learn from the practice. And that’s another thing, something like a light study doesn’t apply where everybody is coming in at 3 or 4 years prior to he go see you.
Sand, post. iStent, would you do it the same or would you do it differently?
>> Dr. Sieminski: The efficacy of SLT after iStent, these are mainly people with first-generation not the iStent inject, but still, the one thing that I find interesting is you’re not really looking at the angle that much after a MIGS and you know the angle is open, but when you’re doing an SLT you’re getting a really good view and there’s a lot of scar tissue that’s formed around that’s stents that we’re not really looking a, so that’s number one. Yes, it works, I think in somebody who I’ve not fully sold, but told them you can potentially get off of a drop with let’s say an iStent and then I’m telling them they need to get back on a drop, this is a nice way to say, well, we can do this, and it does work, I’m not going to say it works for everybody, but I definitely use it post cataract surgery with MIGS.
>> Dr. Kahook: Sid, you’re going to learn this when you get a machine, it’s all in how you present it. And my good friend Tony Maheeley, I was sitting in a meeting him and he said, imagine I’m the patient, go ahead and explain it to me, and I did, and he’s saying, that’s why you’re not doing as much SLT. Let me show you how to present this. And it did help a lot in how to position it to the patient. And the one thing I keep in mind is you say. I have so many options I can do and I haven’t taken it off the table, so why not try it. I do that with MIGS, as well, if it’s TRAB versus MIGS, I patient will usually pick the least invasive why. Given the time, we went a little — I learned so much. I think all of you gave excellent talks, I’m going to go back and watch this once it’s online and for everybody tuning in, this will be online, you’ll get a notice of that so check back on Cybersight to see the whole session, where you can stop, look at the slides a little bit more and entertain the teachings with a little bit more depth when you have time to do that I want to thank each of you. I hope you’ll come back on these webinars in the future and hope you’ll be receptive. I hope everybody has a good rest of their day and to everybody attending, please sign up for Cybersight and reach out for questions if we can help. Thank you everybody for attending today. Bye-bye.