00:02 [Tom] Welcome and good morning.

00:04 While we get together here, I'm gonna have our speakers come up.

00:08 Jella, you can come up.

00:09 We're gonna have the whole group up here the whole time.

00:11 It's not a long session, not long enough for everything going on in glaucoma.

00:16 So we've got a terrific faculty and we'll just have them come up.

00:20 A few announcements before we get started.

00:22 To claim CME credit, review the information on the back of your name badge.

00:27 You gotta log into the meeting app and follow the instructions there, but it's all right there.

00:32 Feel free to submit questions for the speakers also using the meeting app.

00:37 You can scan the QR code for audience polling.

00:41 And make sure you register for next year's meeting.

00:43 There's some incentives to do that early.

00:45 You know, on the housing side, there's some gifts for those that register early as well.

00:51 And again, scan the QR code in the back of the program notebook for all the information there.

00:57 And that offer expires June 2nd.

00:59 I think today is the last day of May.

01:01 So I'm Tom Samuelson.

01:05 I do glaucoma anterior segment surgery in Minneapolis and it's great to be back at Kiawah Eye.

01:11 Congratulations to Carrie and Eric for another outstanding meeting this year.

01:17 We titled the session "Glaucoma 2025: Settling into the new interventional normal".

01:24 You know, we all realized that glaucoma is much more interventional than it was.

01:31 And so how are we utilizing some of the new tools we have?

01:34 These are my own personal disclosures and we have everyone back from last year's faculty, but we also have Jella An, who's new to Charleston area and does glaucoma. at Storm Eye, so it's great to have Jella here today.

01:53 And we're gonna get right into it.

01:54 I'm gonna show, you know, a real brief case just to start us off.

01:59 This gentleman was sent to me on three-drop therapy.

02:03 I knew he was using his drops because it was quite obvious he was adherent despite what was going on with his lids coming in from rural Minnesota.

02:14 He was on three-drop therapy and his glaucoma, this is not a reliable field, but it demonstrated that he didn't have severe glaucoma anyway and previous to the current era, to intervene surgically would've subjected him to a fair amount of surgical risk.

02:34 And so the question for the audience is, you know, is there any one thing that you could do or combination of things that you could do to alleviate what's going on here?

02:44 And here he is on no drop therapy after laser trabeculoplasty and intracameral drug therapy and it absolutely transformed him.

02:55 And so we've got these new tools, let's find out how our panel uses them.

03:01 And so to get us started, Davinder Grover, "How can I tell if my glaucoma patient is stable?

03:07 Glaucoma diagnostics."

03:11 [Davinder] Thanks.

03:13 Alright, good morning.

03:14 Short answer is glaucoma patients are never stable.

03:16 No.

03:17 So good morning.

03:18 Thank you all for joining us today.

03:19 Thanks for having me at this meeting, it's always fun to be here.

03:24 These are my disclosures.

03:25 I'm gonna speak on some things that Reichert and CATS are involved in, but I'm gonna start with a case presentation, you know, and then discuss actually just varying methods of IOP, checking IOP, and then introduce the idea of corneal hysteresis, and then wrap this up.

03:41 So, you know, we don't have to always wait for this.

03:43 This is one of my partner's patients, you don't ever show your patients that get worse.

03:46 But this is a gentleman that's been followed for a long time, refuses really treatment and therapy, and just gets worse right before your eyes.

03:53 And sometimes that's because the patients don't understand or don't want a surgical intervention.

03:58 And sometimes, it's just what happens.

04:01 But we don't need to wait for this to intervene.

04:04 Here's a nice example.

04:05 This was a patient I saw several years back, presents to me with a disc hemorrhage, referred by an optometrist in the community.

04:12 Mild myopic, average corneal thicknesses, pressure is 13/14 on Goldmann applanation.

04:19 And then you look on exam and, well, he has a resolving disc hemorrhage.

04:25 But I'm gonna kind of orient you guys to this thing.

04:27 So this hysteresis, show of hands, how many of you guys have heard of hysteresis before?

04:32 And how many of you use it in your practice?

04:36 Okay, so it's evaluating the biomechanics of the eye, but it gives you an output of a couple things.

04:42 The CH is corneal hysteresis and average worldwide is about 10.

04:46 So this gentleman had a low hysteresis, which has been shown to be associated with worsening glaucoma risk, increased risk of worsening glaucoma.

04:55 But it also gives you another output, IOPcc, which is what the machine thinks the true pressure is.

05:00 So this gentleman had a low hysteresis in the eights and then, but the IOPcc was 16 and 17.

05:07 So, you know, this is a pretty classic, slightly myopic glaucoma in his eyes.

05:13 You can see on OCT, although it looks reasonable, the right eye, you do see a little bit of loss inferiorly.

05:19 How many of you would call this glaucoma?

05:22 Yeah.

05:23 And he has a somewhat normal field, right?

05:25 But you can see on the right eye, you do have a visual field defect.

05:30 You know, you can have glaucoma without a visual field defect.

05:35 Sometimes we have conversations with colleagues that don't think patients can have glaucoma without a visual field defect.

05:40 Glaucoma is an optic neuropathy.

05:41 And if you have loss of nerve tissue, you have glaucoma.

05:44 So I would say this patient definitively has glaucoma, but I put 'em on a latanoprost.

05:50 And his initial Goldmann applanations were 13/14.

05:53 He comes back two months later, his pressures are 13 and 12.

05:57 This case just rocked my mind as far as how I thought I understood glaucoma 'cause I didn't do anything to him.

06:03 This is a non-responder.

06:04 In every FDA trial, this is a non-responder, right?

06:08 But look what the IOPcc did, right?

06:11 So his IOPcc went from 16/17 down to 12 and 13 or 12 and 12, right?

06:18 So what the hell is going on here?

06:19 How can that be possible?

06:20 Right?

06:21 Did something change?

06:22 Did I do something differently?

06:23 No.

06:24 And you say this did at a go home meeting and you get tomatoes thrown at you, but Goldman is wrong.

06:29 You know, Goldman was wrong and it missed something.

06:34 And, so, you know, there's a lot of different ways of checking pressure.

06:38 These are kind of what I usually depend on a lot, but I'm gonna go briefly through it.

06:42 I think Nate's the only one that still uses digital tonometry.

06:48 But are there any other ways of checking pressure that you all use routinely?

06:54 No.

06:55 So I'm gonna talk a little bit about some of this.

06:56 So the pneumotonometer, it's a pain.

06:58 How many of y'all have a pneumotonometer?

07:00 Anyone?

07:01 All right.

07:02 You have to wheel it in the room?

07:03 It's a pain.

07:04 It's a little expensive but it's really accurate.

07:07 And I'll use that on occasion.

07:10 Tonovera just came out by Rietchert.

07:13 It's kind of a, I think it's a slightly more accurate version of eyecare, although it still is influenced by the corneal thickness.

07:21 The other thing that I don't like about it is that it has this digital display.

07:24 So you're checking it and the family members that's behind you in your lane can see what the pressures are and they freak out before you can tell them what it is.

07:32 CATS tonometer, I don't wanna go too much into this, but it fits on a Goldmann applanation thing, just on your slit lamp.

07:38 But it's thought to be less influenced by the biomechanics of the eye, corneal biomechanics.

07:43 And this is the output of the corneal hysteresis machine, the ORA.

07:47 It gives you an IOPcc, which is the corneal compensated IOP, the hysteresis is in a waveform.

07:53 But it's kind of, corneal hysteresis in a quick, quick nutshell is kind of just looking at the eye as a kind of a shock absorber and not just what's going on in the front of the eye, the cornea, but what's happening in the optic nerve head?

08:06 And this is just a, there's so many studies out there, but just to stay on time, this was a study, a prospective study in patients that had glaucoma and they followed him for four years, done out of UC San Diego with Weinreb and Medeiros when he was there.

08:20 And again, the worldwide average of hysteresis is 10.

08:23 I'm a glaucoma guy, so I need to simplify things high and low.

08:26 So anything above 10 is good.

08:28 They're less likely to get glaucoma, less likely to get worse with glaucoma.

08:32 Below 10 is bad.

08:33 If you guys take anything, that's the one thing I to want you to take from.

08:36 So look at this.

08:37 So in the group of patients they followed for four years, the patients had a hysteresis of less than 10, these are patients being followed by a glaucoma specialist every four to six months.

08:46 And over four years, some of them just tanked, a lot of 'em did well, thankfully, but some of them just tanked.

08:53 You don't see that in patients in the group that had a hysteresis of above 10.

08:57 But we've all had these patients that just get worse on us and we're like, what the heck just happened?

09:01 And that's always in, usually in patients that are in the low hysteresis group.

09:06 And it was found to be more predictive of visual field progression than corneal thickness.

09:10 More predictive of visual field progression than Goldmann applanation.

09:16 And it is an important factor to consider in a patient's risk factor of getting glaucoma and getting worse with glaucoma.

09:23 And this little IOPcc is kind of a separate thing that you can look at that kind of gives you more insight.

09:30 So, you know, there's not a single method for pressure lowering that's perfect, they're all flawed.

09:36 And you've gotta put your thinking cap on.

09:38 You know, one thing I don't ever make decision, treatment decisions on glaucoma without knowing the patient's corneal hysteresis 'cause it really helps me risk stratify them.

09:47 If their hysteresis is 12, it's a very different approach than if their hysteresis is eight.

09:52 If you think a patient's getting worse, but they're still low on Goldman, you gotta put your thinking cap on and say, hey, let me look and find some other way of measuring their pressure.

10:00 Invariably pneumotonometer and IOPcc will read it higher than Goldman.

10:05 And you know, I would say that corneal thickness is a poor man's hysteresis, I think hysteresis is a more sophisticated way of looking at the biomechanics of the eye.

10:16 It represents how good of a shock absorber it is.

10:20 And really, I found that when the hysteresis is low, that's when Goldmann applanation misses it.

10:27 So I think that's really why it's a risk factor, is because Goldman is just wrong when hysteresis is low.

10:33 And anyway, thank you. (audience applauding)

10:40 [Tom] Thanks, Davinder.

10:41 That's a really important topic and one that is vastly underutilized and you could speculate why that might be.

10:49 I would imagine reimbursement and paying for the device is one of the important barriers.

10:55 How does that work?

10:55 And then also, you know, we have five offices, do you get one at every office?

11:00 Do you have one at all your offices or do you have one at your main office?

11:04 [Davinder] Yeah, so it's not a money maker, but it's not a money loser.

11:09 I think the machine is something like $15,000 or something in that rangeish.

11:16 But at least in Medicare, in Dallas or in Texas, you get reimbursed like 15 bucks for it, right?

11:24 You don't get reimbursed for pneumatonometer or for eyecare for anything like that.

11:29 But measuring a corneal hysteresis, you actually do get reimbursed with Medicare, most private insurances don't pay for it.

11:36 I will tell my patients the private insurance, hey, I think this is, it's a vital sign of a glaucoma and I won't make a decision on treating you without understanding your risk factor.

11:45 And, you know, whether they pay for it or not, I'll still do it on them, but we'll charge 'em like 25 bucks, 50 bucks, so you're not gonna lose your shirt on it, right?

11:54 And we probably paid ours off within the first year.

11:56 We have one in every office.

11:58 And yeah, for, you know, glaucoma practice, I think it's a vital sign.

12:04 [Tom] Is it a once in the patient's clinical lifetime that you do it?

12:09 Do you do it annually?

12:10 [Davinder] I'll probably do it once, there's some patients where I know Goldman is off, and it's low, and I'll do it every time I see them.

12:16 But I won't charge them every time.

12:17 I'll just charge 'em like once a year.

12:19 We usually tie it to like photos where we do it once a year.

12:22 [Tom] And do you have 600-micron corneas that have low hysteresis scores or how well does pachymetry correlate?

12:31 [Davinder] Yeah, yeah.

12:32 [Tom] 430-micron corneas that have stiff hysteresis?

12:36 [Davinder] You've been shocked.

12:37 It's not necessarily an assumption that if they have thick corneas they're gonna have a high hysteresis.

12:41 You do see that discrepancy sometimes.

12:45 [Tom] Anyone from the panel want to comment on their own experience with corneal hysteresis?

12:50 [Jella] We used it a lot when we were at Wilmer but we used it more for research purposes, didn't really incorporate it in clinical practice, but I think it does have a, it's very valuable information, just more so than corneal thickness.

13:05 My question is, is it, you know, it probably changes after refractive surgery, so how do you, you know, compensate for that one?

13:13 [Tom] Yeah, the gentleman right next to you published a paper on how hysteresis can change after latanoprost treatment.

13:19 [Nate] Yeah.

13:20 Yeah, it's a dynamic variable.

13:22 I think, it both captures the eyes inherent stress level and how poorly it will handle additional load and also reflects how much intraocular pressure related strain the eye is under.

13:33 So hysteresis will come up when you lower the pressure with drops.

13:38 In fact the axial length will change more after say trabeculectomy in someone who started with a low hysteresis.

13:45 So again, it's explaining how much stress that eye was under.

13:49 Hysteresis does change after LASIK for example.

13:53 But that's a good way to keep track of the patient's pressure.

13:55 So you use that corneal-compensated intraocular pressure doesn't change between, you know, pre and post-LASIK.

14:01 So if you have a glaucoma patient who's very mild, young, wants to have refractive surgery and you think it's reasonable, using this to track their pressures before and after is gonna be, you know, probably the best way to do it.

14:13 I do use a machine.

14:15 And, you know, I must have seven of these machines spread across my offices.

14:19 I also like the fact that it's not technician-dependent, it's objective.

14:23 So that's what we use to measure pressure.

14:25 I never mind having two pressures on the chart.

14:28 So that's one of the things, if there's an eyecare circulating around, I have, you know, a hysteresis, you know, or this machine plus an eyecare, you know, I usually feel pretty good about having a second number, but I'll use this as my main pressure assessment in practice.

14:43 [Tom] Thanks, Davinder, outstanding talk. (audience applauding) Next speaker.

14:49 The next speaker is Analisa Arosemena. "Glaucoma drops.

14:53 Can we live without them?" And Davinder your comment about, you don't need a visual field defect to have glaucoma is absolutely spot on and I love identifying afferent pupillary defects in the fields totally clean and they absolutely exist.

15:08 You can show a resident or a fellow a definite afferent pupillary defect, and you show 'em the visual field and they're both normal and you show 'em the nerve fiber layer and they understand why.

15:18 [Davinder] Yeah

15:19 [Tom] But that's absolutely a phenomenon and visual fields only show that they don't have moderate or worse glaucoma that definitely don't demonstrate if they have early glaucoma.

15:29 [Analisa] Okay, can we live without drops?

15:31 And the answer is we should but they are still here and they're still here to stay, I think, for some time.

15:39 Few disclosures, Davinder touched on something, patients don't get what they have, they don't understand that the disease is progressive or they don't believe that the disease is progressive and the worse the patient gets, the lower the target pressure is, and the harder it is to achieve that low target pressure.

15:58 So I am here to say we should break this cycle and change that compliancy to change that understanding issue and allow the patient to stay at a higher pressure that is constant without fluctuation and without depending on compliance in order to prevent progression of damage and keep that target pressure higher.

16:20 Because even though our patients really try, not always they can do it.

16:28 And if it takes seven drops to get a dose in your eye, you're gonna run out at the end of the month.

16:37 You're not gonna get in time to buy it.

16:40 And sometimes you may get a full dose, sometimes you may not.

16:44 So I think when we take into account not only the patients lying and saying they do their medicines but also the fact that sometimes they simply cannot perform this task because it's not easy to get a drop in the eye.

16:57 We need to be able to take control.

17:00 And I may waste a few slides on this because I think the driving point in glaucoma as of 2025 is changing the mindset of being interventional because instead of doing drops, drops, drops then do something.

17:16 The idea is to do laser, MIGS, incisional surgery, trying to not get to the end stage glaucoma.

17:25 And I think extended-release fits perfectly in between laser and MIGS.

17:32 We know from the HORIZON, from the LiGHT study that keeping that pressure stable, even if I don't drop it that much, will allow that eye to be healthier on the long run.

17:45 So keeping the patients and keeping that diurnal fluctuation stable for getting that delta between that patient that comes in with a pressure of 25, you put them on a prostaglandin, magic, they are at 14.

18:00 But we know when the patient goes on a drug holiday and decides not to do that drop, that pressure spiked right back up to those twenties.

18:06 And I think that delta really affects the nerve.

18:11 So what can we do?

18:12 Well, it's the new sexy.

18:13 There's lots of studies being conducted, it's the new frontier in glaucoma.

18:19 There was once in a blue moon they had a bimatoprost ring.

18:24 It never really amounted too much.

18:27 It was a little bit of discharge that the patients may have.

18:32 They have travaprost punctal plugs that go in the canicula.

18:37 They have intracameral travaprost, we have extended-release implants from travaprost, we have latanoprost implants, we have microdosing of latanoprost, we have nanotechnology, we have prostamide 408 coming, we have the Trex for travoprosts coming and we have the spyglass intraocular lens that also will elude bimatoprost.

19:09 So there's lots of things happening right now.

19:12 But we have two that we actually have available.

19:15 The bimatoprost sustained release, that is 10 micrograms, which is basically one drop of bimatoprost that will be released over four months.

19:25 It's biodegradable, it's one millimeter long, preservative-free, and it comes in a 28-gauge needle already pre-loaded for implant.

19:37 It is only approved from one dose for patients with ocular hypertension and glaucoma.

19:43 I am not gonna dwell a lot.

19:44 I think prostaglandin is our strongest medication and both of the implants we have are prostaglandin based.

19:51 And they will be delivering good IOP drop.

19:54 But the kicker is that you diminish the side effects and you diminish the need for compliance.

20:01 Side effects, in the case of the bimatoprost implant, they were stuck in implants, they could have endothelial cell loss.

20:08 That's why it's approved for one implant.

20:11 I have seen the bimatoprost lasting much longer than the four months, I think.

20:17 I always offer around eight to my patients.

20:19 Some patients get way more and that's kind of where I stand on this.

20:24 The irritation and the application depended a lot on the prepping of the patient.

20:30 I do it in the office, I put a speculum, sometimes yes, sometimes no, the patients don't feel it at all.

20:38 And for purposes of this video, I am aiming more horizontal.

20:42 I usually aim inferiorly but you have to go in two bevel lengths into the eye and as you see I'm gonna, and there it goes and it should settle nicely in the inferior angle.

20:57 As I said I aim inferiorly but for video purposes, I want to be able to show the implant coming out.

21:05 I tell my patients to stay vertical because if they don't and they go to sleep on their side, the implant is gonna go to the side.

21:14 And as we can see we have baby implants at eight months that you can see in the iris.

21:20 And we shouldn't confuse it with the dexamethasone implants that are much larger.

21:25 They have found in the MORPHEUS study that it does flatten your curve diurnally and they also found that at 18 months more than 80% of the patients were, I'm sorry, at 18 months, almost 80% of the patients were still able to be without additional treatments.

21:44 The second implant we have, it's different, it's not a biodegradable, it is actually a canister that eludes travoprost over a period of up to three years.

21:56 It has a 1.8-millimeter canister. 1.2 is still visible in the AC and it has 75 micrograms of travoprost honey that will be alluded over time and again achieving great pressures because it is a prostaglandin.

22:14 And all of this intraocular save you from all of these intraocular, extraocular side effects.

22:22 Very little hyperemia.

22:23 And in the case of the travoprost implant, they did not see any endothelial cell loss.

22:30 On the long term, we've been able to see results in a very large cohort of patients even after washout of eight millimeters of mercury drop.

22:40 And when they combined it with cataract surgery, they were able to see up to 10 millimeters of mercury drop at three months.

22:48 And I think it went up in what's coming up in the future when they are reporting these six-month studies.

22:54 So this is done in the operating room.

22:59 You're gonna tilt the patient like you tilt any other MIGS.

23:02 And you're gonna dimple harder than you dimple when you put a stent in the eye, once you deliver it, you're gonna tap it and make sure it's in place and this will elude travoprost.

23:15 It's noticeable in the superior nasal angle but the patients hardly realize it's there and they do pretty good.

23:23 So I think that in conclusion we are gonna be seeing a change in the way we treat and taking compliance out of the patient's hands to me is the most important.

23:32 Thank you. (audience applauding)

23:39 [Tom] Almost too many questions for the time we have.

23:41 I've got so many things I think we should address with this.

23:45 One thing that I think is a barrier, and by the way, if those in the audience aren't using intracameral drug delivery with either of the two systems we have, you really need to start.

23:56 That patient I showed at the outset, the gentleman with the excoriating lid changes, I told him straight up, there's no one thing I can do in the office here that's gonna get you off all three of your meds But I can, let's just plan on doing SLT.

24:10 That was before we had our DSLT.

24:12 We're gonna do SLT and when you come back for your two-week pressure check or whatever, we're gonna do a dose of Durysta in his case, and we were able to get him off all his drops.

24:25 And I have a whole sequence of patients where I've done both within like a two-week period, SLT and Durysta.

24:35 And I asked him, which was harder for you?

24:36 Which was a more difficult thing?

24:37 [Analisa] SLT.

24:38 [Tom] The SLT was.

24:39 No, DSLT changes that 'cause that's patient-friendly but the Durysta injection is hardly anything.

24:46 [Analisa] Patients don't feel it.

24:47 [Tom] And it's a perfect platform too to then do something more long-lasting 'cause once they come back and maybe the Durysta has worn off, then you do maybe the travoprost.

25:00 [Analisa] Changing the way we treat it, it's really important.

25:03 I love the whole combo SLT intracameral.

25:07 Sometimes I will actually book them both kind of back-to-back, I know that it's coming.

25:12 [Tom] Yeah.

25:13 [Analisa] So the patient is already knowing what the plan is for them.

25:15 [Tom] They like having the plan.

25:18 Any other tips?

25:19 Nate, one of your terrific quotes is, "Repeating Durysta is off-label, it's not illegal." And I've done it certainly.

25:30 I've also gone from that to going to eye dose.

25:34 You tell the patients, okay we did well with that.

25:37 It's worn off.

25:38 Let's do something a little longer lasting or combining eye dose with one of our MIGS procedures.

25:44 How are you utilizing these options these days?

25:49 [Nate] Yeah, yeah.

25:49 So, you know, I'll just make one comment is that the Durysta lasts remarkably longer than you would expect given that there's only drug in the anterior chamber for four months, it's routine to get 18 months out of a single placement.

26:03 And the way I realized that is in the patients where I was planning to repeat it, I found I often wouldn't repeat it until, you know, a year and a half later.

26:11 It wears off very slowly too.

26:13 So you have time to kind of plan out which visit and which month.

26:16 It doesn't just stop one day and then the pressure's back to baseline.

26:20 A millimeter a month is about the fastest I've seen it climb when it's wearing off.

26:24 So, you know, I'll get the most I can outta my Durysta and then I dose, you know, and then, fortunately, it's usually the same types of insurance that pay and cover for both.

26:34 So you really can migrate from one therapy to the next.

26:37 And, of course, SLTs in the mix as well.

26:40 [Analisa] I have seen the longer response and I will not repeat if there's still a big pellet in the eye, but when you have the little baby pellet, I, off-label, of course, have offered it.

26:52 And I found that if you change the year, if it's 2024 and then you put it in 2025, they respond much better than if it's 2024 and 2024.

27:02 So just keep that in the back of your head.

27:05 [Jella] I'm starting to add Durysta to every MIGS procedure at the time of the surgery and so that we can get them off the PGA right away after surgery and they tend to do really well.

27:15 Dr. Betch told my resident presented her case of AlloFlo combined with Durysta on Thursday and they tend to do better than doing just AlloFlo.

27:28 [Tom] Is anyone doing eye dose differently than, is anyone doing office based for example?

27:36 [Analisa] I can't wait till I can do it office based.

27:39 I think that would be amazing.

27:41 It's just, I think that the biggest hurdle to get that is getting the approval and the coverage to do it.

27:47 It's a very elegant procedure that can easily be done in the office.

27:51 [Tom] It is.

27:52 And when you think of, you know, there's advantages to eye dose, it lasts longer, it's a bigger load but it's an office or it's a gonioscopic-based procedure.

28:03 You have to go to the OR, you have to get a pre-op H&P often you need to get a family member to drive them in if they're sedated.

28:10 It's a much bigger hurdle as opposed to an in-office lamp delivered system.

28:15 But they each have pros and cons.

28:18 Does everyone jump through all those hurdles every time they do an eye dose?

28:21 For example, get an H&P, you're gonna get sedation, you're gonna get an IV, you're gonna, are we doing all that?

28:28 [Analisa] Well, that's what the ASC requires.

28:30 I think the minute that we can have coverage at an OBS, we just open our OBS and it changed everything.

28:36 It's the best thing I've ever seen.

28:39 I never thought I was gonna be that happy.

28:40 [Tom] So just rapid fire.

28:41 How many do, so when they're doing your slit lamp delivery, speculum?

28:48 I do, I mean.

28:49 [Analisa] Do what?

28:49 [Tom] Do you use a speculum when you do eye dose?

28:51 I do.

28:52 I just, if they happen to blink and you get lash touch on the needle,

28:56 are you gonna throw it away? [Analisa] I don't.

28:57 [Tom] What you gonna do, you gonna?

28:58 So I do use a speculum.

29:00 I don't know that it's necessary.

29:02 Everyone do Betadine?

29:04 [Analisa] Betadine, yes.

29:05 [Tom] Everybody does Betadine?

29:06 Does anyone send 'em home on an antibiotic?

29:10 I don't.

29:10 How many do bilateral?

29:13 I do.

29:14 Anyone against bilateral?

29:17 [Davinder] I don't do bilateral.

29:19 I mean I guess you, I'm not horribly opposed to it, but I kind of, I'll just say, hey, listen, let's just give it a try and then a week later we'll do the other eye and if there's a transportation issue or something like that, I wouldn't be opposed to it, but I don't think there's a rush.

29:31 [Tom] Is your concern infection risk or what is your concern about not doing bilateral?

29:35 [Analisa] You already paid for the second eye?

29:36 [Davinder] Yeah, I made them somewhat paranoid about the bilateral thing, I haven't jumped on that idea.

29:41 The only time I still do bilateral cases now is my tiny babies that, you know, I don't wanna sedate them twice, but they live down the street.

29:48 If they live five, 10 miles away, like I don't think there's any harm in separating it by a week.

29:54 But that's-

29:55 [Tom] And Jella, you mentioned you do Durysta with your MIGS.

30:00 Eye dose with your MIGS or do you preferentially pick Durysta or is it just 'cause it's available earlier?

30:05 Some, you know, carriers are slower to adopt eye dose.

30:10 Is there any reason you do one or the other when you're already in the eye?

30:13 [Jella] For now it's just a coverage and availability issues.

30:17 [Tom] Sure. [Jella] Yeah.

30:17 [Tom] Okay.

30:19 Thank you, Analisa.

30:20 [Analisa] Thank you so much. (audience applauding)

30:26 [Tom] So Nate Radcliffe, "DSLT/SLT.

30:30 Can it live up to the hype of the LiGHT Trial" And a little bit about the title?

30:35 The LiGHT Trial surprised me.

30:37 The data was unbelievable and I said, well, I don't really see that.

30:41 But I think as you look at the LiGHT Trial, you have to understand that it was a group of patients that we weren't doing laser on before. 30% of them were ocular hypertensive and not, you know, manifest glaucoma.

30:52 So this was a much earlier treatment for a group of patients we're not used to lasering and perhaps we should be.

31:00 Nate.

31:01 [Nate] Yep, great.

31:02 So make sure I'm on the, okay.

31:12 Just making sure I have the right remote controls here.

31:15 Am I clicking this?

31:16 Okay, something's working.

31:17 [Tom] This one? [Nate] Okay.

31:19 Alright.

31:20 So I think we're all familiar with Selective Laser Trabeculoplasty.

31:23 You know, I'll typically do around one millijoule.

31:27 I was doing 0.8 millijoules for a hundred shots over 360 degrees.

31:32 Mechanism is to, you know, encourage some sort of biological response that lowers the outflow facility through the meshwork.

31:41 So here you have an example of a laser just being performed.

31:45 So the LiGHT study, as Tom mentioned, really was unique multicenter prospective randomized trial.

31:56 Most of the patients in the drops arm were on latanoprost, overwhelmingly so.

32:01 But it really showed us some important things.

32:04 And I think it illustrates the concept of maybe a tipping point where if you take that leap of faith and start doing laser very early in ocular hypertensives, in early glaucoma patients, you can run into a situation where the laser is able to perform better than that laser would be able to perform if done later in the patient's disease.

32:25 We learned that 75% of so patients were unaugmented after laser at three years and it was cost effective.

32:35 Some of the outcomes data, however, was even more interesting with more disease deterioration in the eye drop arm, with infinitely more surgeries in the medication arm, with 11 out of roughly 350 patients on latanoprost needing trabeculectomy after three years and no patients who received SLT going on to trabeculectomy.

32:59 This study was carried out ultimately to six-year data and the trends all continued.

33:08 Again, almost 70% of the patients who received SLT were still able to be controlled without medication.

33:17 Although, some of them had repeat lasers.

33:19 Again, we saw more progression in the drops arm, more trabeculectomy in the drops arm, and even more cataracts in the eye drop arm.

33:27 Which kind of leads to the question, are we really even consenting our eye drop patient's properly?

33:33 Are we explaining a 50% dry eye risk?

33:35 Are we explaining a rate of cataract surgery that's higher than if they had laser?

33:40 Or are we brushing those risks off because we've just been using drops for so long?

33:44 Now, if you look at this data, you come to the natural conclusion that SLT should probably be the first line therapy for all patients with glaucoma.

33:53 Or as I like to say, every single patient really with open or angle-closure glaucoma should start their treatment with a laser.

34:01 But, here, we know that a lot of people aren't doing or relying on their gonioscopy skills if they are doing gonioscopy.

34:08 It's probably mostly just to determine if the patient needs an iridotomy.

34:13 So enter the concept of direct laser trabeculoplasty.

34:17 This is laser just applied to the trabecular meshwork through the limbus without a gonioscopy lens.

34:25 It's the same laser and it's roughly the same number of pulses, maybe 120 over 360 degrees instead of a hundred.

34:33 The laser that we'll be discussing, the one that's commercially available, uses automated delivery that has eye registration and real-time tracking.

34:44 We use higher energy with direct laser trabeculoplasty because we have to penetrate the limbus.

34:51 And so there's an adjustment made there.

34:55 And again, a commercially available platform does have a click fee.

34:59 I thought I would just show you conceptually what direct laser trabeculoplasty is.

35:03 And here I am with my luminous laser, lasering through the sclera aiming for the trabecular meshwork.

35:12 Am I getting it right?

35:14 You know, I don't know that I'm gonna know.

35:16 Sometimes I will see cavitation bubbles come through the trabecular meshwork as I perform the laser that way, it is a little difficult to perform though.

35:25 Now, here's the commercially available laser performing DSLT.

35:30 You can see it, it looks a little bit like you're lining an eye up here on any type of, you know, platform that we use.

35:39 Maybe a femto laser, something like that.

35:40 Here's my patient.

35:42 Patients can be sitting up, standing up, or they can be seated.

35:47 And what I'm gonna show you next is gonna happen fast and furious.

35:51 So pay attention.

35:52 It's not gonna be a long video but this is the actual 120 pulses being delivered.

35:57 Here we go.

35:58 Don't blink or you will miss it and we're done.

36:03 So that's the actual delivery of the laser.

36:07 It is green light therapy as I like to explain to patients when talking to them about the treatment.

36:13 And it happens very quickly.

36:14 Here is, it's actually happening again right now.

36:16 So that's the video that the laser actually takes of the treatment and if you look up above, you can see those laser pulses leaving a little bit of air bubbles.

36:26 So I'll just show the two videos again because they were very quick.

36:30 So here's the actual video of the laser being delivered.

36:33 That's all 120 shots right there.

36:35 And then starting right now, we're watching the laser being delivered and captured by the camera.

36:41 And the reason that's helpful is if you thought the patient moved during the laser, you can go back after, check the video.

36:47 In terms of the data that we have from the glaurious trial, patients were randomized to SLT or direct SLT.

36:53 And, again, roughly similar patients earlier on.

36:59 But there were patients on two or three drops in this study.

37:03 So they weren't all previously untreated eyes.

37:06 And what you can see is just, for lack of a better word, a nice overlap between the pressure reduction from direct SLT and SLT itself.

37:18 I think the direct SLT had 6.2 millimeters of pressure reduction and you had 6.6 with traditional SLT.

37:30 Patients were mostly able to become drop-free with about 70% of those not on drops remaining drop-free and about 60 or so percent, of both direct and traditional SLT, getting off drops if they had been on one drop prior to treatment.

37:47 So again, we're seeing a good ability to stay off drops.

37:51 You know, my thoughts are that generally speaking direct SLT was designed to scale SLT in light of the LiGHT study.

38:01 It's more time efficient, it should be more reliable, repeatable, standardized, have more favorable ergonomics.

38:08 It should improve the number of doctors who feel comfortable doing the laser.

38:12 It should help with throughput and allow us to deliver the treatment to the masses.

38:17 The data, I think, supports similar efficacy.

38:20 We can talk about that.

38:21 And, ultimately, I think the machine acquisition makes sense to those who are not currently doing high volumes of SLT or who feel uncomfortable in some way with the technique.

38:34 Thank you. (audience applauding)

38:41 [Tom] So Nate, I have DSLT at two of my five offices and patients will go to one of those two offices specifically once they've kind of learned about DSLT.

38:52 But I do plenty of SLTs at my other offices for convenience for those that live close to them.

38:57 Do you see them interchangeable at this point?

39:01 [Nate] Yeah, it's interesting.

39:03 I'm sort of the same.

39:04 I have five offices or so and two of them have DSLT.

39:09 I don't typically move a patient from one office to the next.

39:13 I certainly like using the, you know, the DSLT laser.

39:16 I find it particularly efficient for big blocks of lasers, you know, so whereas, if I had 12 SLT in a row, on my traditional machine, that's gonna take a good bit of time.

39:28 But in the DSLT machine, it really can be, I'd hate to say it's 12 minutes but, you know, it's very efficient from a time standpoint.

39:36 [Tom] We have an audience question that asks do you titrate the laser energy with DSLT?

39:42 [Nate] You know, interestingly I didn't think you could, but I actually think you can change your power.

39:48 It's you know, one of the things I picked up at ASCRS, is there seems to be more and more evidence that you get a dose-response relationship between the amount of power delivered and so delivering even up to 1.2 millijoules should give you better pressure reduction.

40:04 I don't know about the longevity of that pressure reduction or the sustainability, but if you really do need the pressure down now or its surgery, in those settings, it may make sense to crank up the energy.

40:14 [Tom] Yeah.

40:15 Full disclosure, I consulted for BELKIN laser from the very beginning with DSLT and when we were going through the FDA process, there was question by the FDA, well, what about titrating to champagne bubbles and all that?

40:27 And we published a paper that showed that we don't really know what we're doing in terms of the laser energy in general.

40:35 We talk about champagne bubbles, but there's very little data that would show 0.8 in this patient is better than 1.0 millijoules.

40:46 It really isn't good data.

40:48 So in my own hands, I don't have any problem with just using the laser delivery as it is.

40:55 I've seen, virtually, no, I can't think of anyone who's had any kind of an adverse event in my DSLT experience.

41:03 And I rarely change the limbal registration.

41:06 It's very good at identifying the limbus in maybe one patient which would be significantly less than 1%, have I adjusted the limbal registration?

41:17 What are your thoughts there?

41:18 [Nate] Yeah, so, it does give you the option of adjusting what it identifies as the limbus.

41:25 My question to someone involved in the conduction of the glorious trial was were the investigators adjusting their limbus typically or not?

41:34 The answer I got was the investigators weren't.

41:36 So I always like to go with the data that I get from the trial.

41:39 And so I don't adjust the registration and I don't adjust the power.

41:44 Although, I do think you're able to, if for some reason you want to.

41:47 The one thing I'd add is that we learned from the COAST study that 0.4 millijoules really will have a higher failure rate at one year than 0.8 millijoules of traditional SLT.

41:59 So we know there's a bottom part to the response where you start to knock at enough longevity out of a treatment, yeah.

42:07 [Tom] Yeah.

42:07 Any experience with the panel?

42:09 [Jella] Yeah, the limbal registration is I think very important part.

42:13 You know, you can manually adjust it but you have to be careful 'cause sometimes it's a little bit too closer to the iris.

42:19 You can accidentally do the iridoplasty in that case or if it's too further out then you may be doing cycloablation.

42:25 Yeah.

42:28 [Tom] Following SLT or DSLT, are you using any anti-inflammatory drops?

42:33 [Nate] Yep.

42:35 I'll occasionally, with traditional SLT, I'll give a treatment, particularly if the patient has very darkly pigmented trabecular tissue.

42:43 I think with DSLT, I haven't been treating enough, I've been okay.

42:48 [Tom] Let's just go down the list.

42:49 Any end to inflammatory drops after either SLT or DSLT?

42:53 We'll just go right down, Leon.

42:55 [Leon] I don't have DSLT yet, but ketorolac for SLT.

42:58 [Jella] Yeah, ketorolac for four days.

43:01 [Davinder] Yeah, I'll just do like a steroid once a day for five days or something like that, but.

43:06 [Tom] Okay.

43:07 [Analisa] I actually give them a steroid prescription and I tell them to take them only if it bothers them.

43:12 [Jella] Yeah, I do that too.

43:13 [Analisa] I just don't want the callback.

43:14 The callback, it's a killer in the clinic so only if they need it but they leave with it.

43:21 [Tala] We do ketorolac.

43:22 But if there's someone who's had a lot of inflammation with previous laser or, you know, history of uveitis and they're quiet for a long time, I'll just go ahead and give them a steroid.

43:31 [Tom] Yeah.

43:32 And I used to do a NSAID four times a day for four days or once a day if you were on one of the once-a-day dosing.

43:39 But I stopped doing that.

43:41 But I do like the idea of giving a script and telling 'em, it's optional.

43:44 Fill it if you want.

43:46 That way it might prevent them from having to call back.

43:49 We got a couple minutes to address some of the other questions from the audience.

43:53 There was a question, if Durysta adheres to the needle tip, you know, do you have to stay in the eye until it lets go?

44:03 Can you just leave the eye and hope it doesn't track back?

44:08 [Analisa] So the first thing is don't panic, don't pull out, you know, it's like a phaco, you just stay in there for a second.

44:15 I just sweep it on the pupil.

44:17 It's very easy to just sweep it off.

44:20 It will dislodge, don't pull out because then it ends up in the wound and then you end up with a whole new can of worms.

44:26 [Tom] Well, I mean, that's what I always adhered to as well.

44:30 I would stay in there, I'd bump it against the iris.

44:34 Nate's talked about putting the needle behind the iris, but the implant in front of it to try to cleave that adherence.

44:40 And I've started just coming out, frankly, and I've not had any issues.

44:45 You wanna make sure you don't deflate the eye by torquing it too much.

44:51 I just come straight out and it's never once got stuck in the wound.

44:56 Bubbles will keep it hanging around sometimes, but it makes it a much nicer procedure to just go in and out and not have to, you know, do gymnastics inside the eye.

45:08 So let's just again go down 'cause I did exactly what you were saying, but it gets annoying sometimes if, you know, you're in there for a long time and it just won't let go and I've just come out and it's not been a problem.

45:20 Anyone have comments on that?

45:23 [Davinder] I'll do a couple things.

45:24 You know, if you put your hand and it's still there, you can use the other hand and kind of just flick the handle and that little vibration will make it go.

45:32 One thing, if you press the injector pretty hard, it shoots out, if you click down on it pretty hard, it shoots out.

45:40 If you don't click down on it hard and just kind of do a slow jack and it doesn't click, then you can actually keep clicking on the thing and that plunger will come in and out and that can help dislodge it.

45:49 So I think there's a couple different techniques you can try, but I find that if you just click hard, it'll actually shoot out and you won't have that problem.

45:57 [Jella] One of my first fellows case, the Durysta actually got follow through the track and it got impregnated there.

46:06 You know, don't worry about it, just take the 30 gauge needle and go through the same track and you can push it right away.

46:11 I think our rep actually called you to see what to do 'cause our rep didn't know what to do at that time.

46:18 [Analisa] And I think a good tip, if you're starting Durysta, since it's refrigerated, I have them pull it out of the fridge.

46:26 I think when the Durysta is a little warm, I tell my technician, she kind of like keeps it in the scrubs for a little while so that it kind of gets a little warmer and I've felt that it sticks a lot less.

46:40 Just not having it super cold.

46:42 [Tom] And our next talk is Dr. An. "Choosing the right MIGS for the right patient." And while she's coming up, there was a question about the click fee for DSLT and what we thought about that.

46:55 And frankly, we haven't, at least I haven't as moderator this session, got into some of the reimbursement things too much.

47:01 My feeling is it'll work itself out.

47:05 Someone called it dumb on the poll here.

47:10 It may be, if it's not working for consumers, they'll probably modify the plan.

47:16 But you gotta pay for the technology somehow, I presume.

47:20 And I think the cost will work itself out.

47:24 Dr. An.

47:26 [Jella] Hi, everyone.

47:26 Thank you for having me here today.

47:28 Well, what's your favorite MIGS or what's the best MIGS?

47:33 I get asked that question a lot and my answer is almost always, how much time have you got?

47:41 You can spend the entire fellowship just learning which MIGS to choose for which patient and when to operate.

47:49 So as we have more surgical options, the answer is becoming more challenging and nuanced.

47:55 So today, we have seven minutes.

47:57 So let's go.

47:59 These are my disclosures.

48:01 Well, we know the goal of the MIGS is to be able to intervene earlier in the disease to reduce the morbidity of progression and to reduce the need for more aggressive surgery in the future.

48:12 With all these different surgeries in our armamentarium, it's important to know how to classify different types of surgeries.

48:19 Not just the MIGS but all the glaucoma surgeries.

48:22 And a good way to think about it is a target areas.

48:25 What are you targeting?

48:26 You can increase the trabecular outflow.

48:28 That's a conventional outflow pathway.

48:31 You can bypass the TM or just inflate the Schlemm's canal or you can make the alternative outflow pathway, either in the subconjunctival space or suprachoroidal space or you can just reduce the inflow by targeting the ciliary bodies.

48:45 If all of these target areas can be accessed ab-externo or ab-interno, and you can do that with or without stents.

48:54 Now, if their approach ab-interno with minimal tissue disruption with superior safety and at least a moderate efficacy, they're called classic MIGS.

49:05 However, these days, everything under the sun that's not trabs, and tubes, and cycloablations are called MIGS.

49:10 So, you know, if you're a purist, you can just call them MIGS plus.

49:15 So the reason that we have so many options is because none of them are superior to the other.

49:23 You know, there's a use for each of these procedure for each patient.

49:27 So every procedure has a balance of risk, and benefit, and effort ratio.

49:33 But in general, more invasive the surgery is, the better outcome in terms of IOP and medication lowering, but also higher risk.

49:42 So higher risk, higher returns.

49:45 So these are just like summary of advantages and disadvantage because we only have seven minutes, now, we have five.

49:52 The main advantage of the trabecular MIGS, these are classic MIGS are its favorable safety profile.

49:59 You cannot cause hypotony because you're not making alternative outflow pathway.

50:04 But the main disadvantage is also, you can't cause hypotony even if you want to.

50:10 It all has a floor effect.

50:12 So you can't go any below episcleral venous pressure.

50:15 In most patients, it's a mid-teens.

50:17 It is highly dependent upon the functionality of the distal outflow pathway, which we know it's pretty minimal in severe glaucoma patients.

50:25 Also, cannot bypass a sterile response.

50:29 Supraciliary devices or stents create a control cyclodialysis cleft.

50:34 So it has a huge potential to lower the IOP below the episcleral venous pressure and it's relatively short learning curve.

50:41 However, it's outcome is less predictable as Dr. Vegetal has presented on Thursday.

50:48 It can range from hypotony to IOP spikes.

50:51 Some patients get Hyphema and prolonged uveitis.

50:55 Risk of endothelial cell loss is actually pretty minimal with the recent devices.

50:59 But proper positioning is important because cornea doesn't like to be touched.

51:04 Now, subconjunctival MIGS has the greatest IOP production potential.

51:09 It works in a familiar subconjunctival space that we all know how to manage and predict, thanks to our decades-long experience with the trabeculectomy.

51:18 But they are all bleb-forming procedures with all the complications that's related.

51:23 It does require high-dose antimetabolite, including mitomycin and 5-FU.

51:28 Requires a frequent post-op visits and interventions, including needling.

51:33 So how do you determine between angle surgery versus filtering surgery?

51:37 Obviously, angle surgeries are much safer, but filtering surgeries more powerful.

51:41 Now, classic indications for angle surgeries, or angle-based MIGS, is mild to moderate open-angle glaucoma, well controlled on one to two medications with concurrent cataract surgery.

51:52 However, patients outside of this narrow category can also benefit from angle surgery if their IOP target is mid to high teens and especially, if they can tolerate some medications.

52:04 However, those people who are poorly controlled on maximum medications, you have to be careful 'cause you cannot bypass a steroid response.

52:12 If these patient get steroid response in the first month, you're gonna have trouble 'cause, you know, you will have to decrease the steroid a lot faster and they're gonna be at higher risk of CME.

52:22 However, on the other hand, if the patient is at higher risk of hypotonia and bleeding, then I'll lean towards the angle surgery, leaving the filtering surgery options for later.

52:31 Distal outflow resistance is that you can't really measure the clinically, but we know that these are limited for severe glaucoma patients, especially if they've been on medication for a long time.

52:41 So it's more art than science you, it's important to personalize it to each patient treatment goals, and risk profiles, and risk tolerance.

52:49 Let's go into a little details of the Schlemm's canal procedures because these are the classic MIGS.

52:55 All of these classic MIGS are doing the one thing, you bypass the trabecular meshwork, which has the highest resistance.

53:02 You can stent it, you can disrupt it, you can remove it, or you can just cause a micro-perforation by inflating it with the physical dilation.

53:12 We have many different options, but they have little nuances and advantages and disadvantages.

53:17 Stents are probably the least invasive option because all you need is a small little opening to just stent it, least hyphema risk, minimal tissue disruption.

53:27 And my, you know, I think the main advantage is the fact that it's most rigorously studied with a high-quality RCT thanks to USID requirement by FDA, but it's disadvantage is also the FDA requirement leads to restrictive coverage.

53:45 Now, TM resection can be done either with a dual-blade or electrocautery or suture.

53:51 It has the shortest learning curve, it is most economical, can do in a secondary and angle-closure.

53:56 You can do the goniosynechiolysis with the dual blades easily, but it has probably the highest hyphema risk.

54:03 You are cutting the most amount of the TM, frequent reclosure, and limited long-term data in adult patients.

54:11 Schlemm's canal dilations, probably the least hyphema risk.

54:14 However, it has the limited data without the goniotomy.

54:18 Most of the times, we do the Schlemm's canal dilation with the goniotomy using OMNI device or VIA, ABiC or iTrack.

54:27 So that's it.

54:28 These are the main things to look for.

54:29 Disease type and severity that leads to target IOP.

54:32 Remember the mid-teens is what most of the TM makes arrive.

54:37 Lens status, medication tolerance and adherence, angle anatomy, and comorbid conditions.

54:42 So make sure that you stay updated with evolving devices and studies.

54:46 Thank you. (audience applauding)

54:52 [Tom] So Jella, being in a training program, how do you introduce your residents to MIGS?

54:59 Is there a kind of a stepwise approach you take, are there certain procedures you have them do initially?

55:05 [Jella] Well, I found the goniotomy procedure the easiest to teach and correct.

55:12 So if someone has never done an angle surgery, I start with the goniotomy because, you know, the worst thing that can happen is you're in the wrong plane and maybe you make a little bit of an iridodialysis.

55:22 It's not a big deal.

55:23 Hyphema really not a big deal if you're familiar with angle-surgery and if they're not enough, I can always go back and do a little more.

55:30 Stents are probably the hardest to correct because if you lose it or if you end up making too large of a goniotomy with the device, then it's really hard for me to, like, there's not enough real estate for me to put the stent in, especially if you're doing the hydrus.

55:46 So that's probably the last step.

55:48 [Tom] And a mature angle surgeon then, do they need to know all these or can they pick one or two of their favorites or is there a one-size-fits-all approach to angle surgery?

56:00 Do you recommend that they become good at both stents and goniotomy for example?

56:08 [Jella] I think, I mean, stent option and non-stent option, I think there is an important distinctions in advantages and disadvantages.

56:16 So it is, I think, important to know at least one procedure in each of those categories.

56:22 So you know, trabecular, supraciliary, and subconjunctival and then pick each, and the stent and non-stent options as well.

56:31 It's also important to assess what type of procedure work the best in your own hand and also in your own patient population.

56:41 And more, you know, the better option that you can offer to your patients.

56:46 [Tom] Anyone in the panel have anything to add?

56:49 [Analisa] I think that, first of all, you have to get comfortable at looking at the angle.

56:54 If you don't get comfortable looking at the angle and finding your end phase view, seeing every layer, every surgery is gonna be difficult.

57:03 So even if you're starting, if you're a new surgeon that hasn't started MIGS, just get a gonioprism and start getting used to looking at the angle.

57:11 And I agree with you, a small goniotomy, it's in and out.

57:17 I tend to move forward to other devices faster, I guess.

57:23 [Tom] Anyone else doing drug delivery at the same time they're doing their angle surgery?

57:30 [Tala] I do a lot of that.

57:31 And actually, that's the majority of the Durystas I do.

57:34 Patients don't want a needle in clinic for whatever reason.

57:38 Crazy.

57:39 So if I tell them during surgery we're gonna, you know, clean out the drain and I can put some medicine in and they love that.

57:44 So I do a lot of combined, even eye dose with a MIGS.

57:47 [Tom] Any reimbursement issues with that?

57:49 [Tala] I have not had any issues.

57:51 [Tom] It certainly makes sense and it seems like a perfect opportunity for eye dose as well.

57:57 [Analisa] And just playing devil's advocate, because I am not afraid of it, but some people say, oh, you're doing a prostaglandin at the time of surgery, CME can happen.

58:08 I haven't noticed necessarily an increase in CME when I've combined it, but anybody has a fear of it.

58:14 [Jella] Yeah, we reviewed all of our cases that was done MIGS with or without the Durysta and there was no higher risk of CME.

58:23 [Tom] There was just a paper, I meant to get a screenshot of it showing that the risk of CME was higher.

58:32 They looked at all, it was a big database study that looked at tens of thousands of patients and the incidence of CME after the different drug types were prescribed.

58:45 And the CME risk was higher actually with beta-blockers, I want to say, than it was with prostaglandins in that study.

58:51 And it's like in the last few weeks it was published.

58:55 So I personally don't, I'm concerned about CME obviously, but I don't not use prostaglandins because of that risk.

59:03 And I think most diviatis specialists would say that's true.

59:07 Nate?

59:08 [Nate] Yeah, I would just add, I agree with you and yeah, the PGAs were the safest out of all the drug classes.

59:13 [Tom] Yeah.

59:15 [Nate] In terms of CME, I think this issue will be put fully to rest with the spyglass, which will have bimatoprost in the capsular bag delivered at the time of cataract surgery.

59:25 Their early data already looks good, what's publicly available and then, you know, we'll just have the final answer and then, hopefully, yeah, it stops coming up.

59:36 [Tom] Okay, moving on, our next talk, Dr. Kassm. "My approach to coincident cataract and glaucoma surgery".

59:48 [Tala] All right.

59:49 Okay, so I'm gonna talk about my approach to glaucoma, the glaucoma patient who needs cataract surgery.

59:56 So you're seeing this patient in clinic and they're ready for cataract surgery, they do have glaucoma.

01:00:01 Do you do anything different than a non-glaucoma patient?

01:00:04 And do you offer glaucoma surgery as well?

01:00:09 The clicker?

01:00:10 What's the thing?

01:00:11 It's the clicker.

01:00:13 Okay.

01:00:13 Okay.

01:00:14 So four questions to ask and answer, what is the severity of their glaucoma?

01:00:18 What is the current intraocular pressure?

01:00:21 How many medications is the patient on?

01:00:22 And what is their likelihood of scarring?

01:00:24 And also, not just what their pressure is now, but what's their goal?

01:00:29 So I'm gonna just go through some cases and kind of share what I would do.

01:00:32 And so a 64-year-old Caucasian male with mild primary open-angle glaucoma, this patient's on two drops and the pressure, his pressure's been ranging from 14 to 19.

01:00:43 So my plan for this patient would be a stent, like an eye stent and probably with a bimatoprost medicine implant, like I mentioned, almost all of my glaucoma patients, if they want it and they don't have any contraindications, will get some kind of medicine implant at the time of surgery.

01:00:58 There are some patients that don't want a stent in their eye.

01:01:01 They don't like the idea of an implant other than obviously the lens.

01:01:04 So goniotomy would be reasonable as well. 74-year-old African American female with moderate primary open-angle glaucoma.

01:01:13 This patient's on three drops, her pressure is ranging in 20 to 24.

01:01:17 So in this case, I would like to get her pressure lower.

01:01:20 I might try the hydrus stent and again, with the medicine implant.

01:01:24 So I kind of think of eye stent when the pressure's kind of at goal.

01:01:28 Maybe you're just trying to get off of drops and they're really low-risk of any complications when the bleeding or causing, you know, a bigger goniotomy. 54-year-old Caucasian female with mild primary open-angle glaucoma.

01:01:43 So this patient's on four medications, the pressure's higher, ranging in 25 to 35, so they're not at goal.

01:01:48 This patient though lives three hours away.

01:01:50 They can't do frequent post-op appointments.

01:01:52 So this is someone I would do a lot of counseling with.

01:01:55 I would offer some kind of a stent initially, but really letting her know that there's a high chance she might need a trabeculectomy in the future or you know, another glaucoma procedure.

01:02:05 But it's worth trying at the time of cataract surgery.

01:02:08 I don't really like to do trabeculectomy with cataracts.

01:02:12 I think the trabeculectomies in the studies show that they work better when they're done solo.

01:02:17 So that's why I would be open to trying a stent for her and maybe she'll do well and if not, we have our other options. 82-year-old Caucasian male with moderate pseudoexfoliation glaucoma.

01:02:29 This patient's on one medication, he's intolerant to most drops and the pressure is 28 to 34.

01:02:35 And there has been some visual field progression.

01:02:37 So in this case, I would consider a Xen Gel Implant.

01:02:41 Could also consider a goniotomy, but again, I would tell this patient there's a high chance you might need a trabeculectomy or a tube shunt in the future.

01:02:49 Because they're Caucasian, I would try the Xen Gel Implant.

01:02:53 Again, this tends to do better when it's not with cataract surgery, but I have had success with it combined with cataract.

01:02:59 So I think it would be worth trying for this patient. 76-year-old African American man with severe primary open-angle glaucoma.

01:03:08 This patient's on four medications, they're tolerating the medications well.

01:03:12 Their pressure is 16 to 19.

01:03:14 So in this case, I mean I'd like to see the pressure a little bit lower, so I would offer a goniotomy.

01:03:20 You know, some of this is also dictated by what is approved.

01:03:24 So severe glaucoma, you can't do the stents, but a goniotomy would be a good option.

01:03:29 It's less invasive than our traditional surgeries.

01:03:32 And since the pressure's not super high, I think it would be reasonable.

01:03:35 But I would let the patient know they're most likely going to stay on all their drops, maybe get off one, especially if we do medicine delivery device. 58-year-old African American female with severe primary open-angle glaucoma.

01:03:48 So she's on maximum tolerated medications.

01:03:51 The pressure's ranging 16 to 22.

01:03:53 She does have a history of steroid response.

01:03:55 So like Dr An said, in someone with a steroid response, the stents are not going to necessarily keep the pressure down from a steroid response or even a goniotomy.

01:04:06 With this kind of a field, you know, I don't think that pressure's at goal.

01:04:09 So I would offer a trabeculectomy with mitomycin C.

01:04:12 Like I said, I try to avoid that if I can, but in someone like this, you know, you really don't want any pressure spikes during surgery or after.

01:04:19 I would also do a lower IOP during the case as well. 64-year-old Hispanic male with a previous trabeculectomy.

01:04:29 So this patient's on no drops, the surgery, previous surgery's working well, the trab.

01:04:33 The glaucoma is severe.

01:04:35 So I would just do a standalone cataract surgery since their pressure's at goal.

01:04:38 But I would treat with aggressive steroids.

01:04:41 I would even consider a Subtenon Kenalog injection at the time of surgery.

01:04:44 And then a long slow steroid taper after, I would actually still do prednisolone as well and then keep them on it much longer, like maybe even a few months depending on how their pressure was doing after surgery.

01:04:58 So my disclaimer to all patients, there is no glaucoma surgery that works all of the time in everyone, and none of them last forever.

01:05:06 There's a reason that we have so many surgeries, drops, lasers, so many treatments.

01:05:10 So I kind of set the expectation for patients going into any kind of glaucoma surgery or combined glaucoma cataract surgery.

01:05:18 And then a couple of just, you know, exceptions.

01:05:21 So for secondary open-angle glaucomas, the stents are contraindicated.

01:05:24 So I talked about one case of pseudo-exfoliation, I would do the goniotomy.

01:05:30 And then angle-closure glaucoma.

01:05:31 So typically, you would just do a standalone cataract surgery, but if the pressure's not well-controlled before you could consider a goniotomy or a canaloplasty like Dr. An mentioned.

01:05:42 And so just kind of a flow chart to help people kind of visualize the thought process here.

01:05:47 So SIMS is the severity of glaucoma, the intraocular pressure, how many medications they're on, and if they wanna get off medications or need to, and how likely are they to have scarring?

01:05:57 So kind of looking at mild to moderate glaucoma.

01:06:00 If the pressure is well controlled, I would consider an eye stent or hydrus at the time of cataract surgery.

01:06:04 If they're not well-controlled or there's progression on testing and they have high risk of scarring, I would consider hydrus or goniotomy.

01:06:12 But if they have a low risk of scarring, maybe a Xen Gel Implant and if their glaucoma's severe and they're well controlled, more likely a goniotomy.

01:06:20 If their IOP's not well-controlled and they have progression on testing, then I would consider the tube shunt if they have a high-risk of scarring.

01:06:27 And then at low risk of scarring or they need a really low-pressure, I would consider the trabeculectomy with mitomycin C.

01:06:35 Thank you. (audience applauding)

01:06:41 [Tom] Great talk.

01:06:42 There was some questions on anticoagulants.

01:06:45 Are there some procedures that you would migrate toward if they're on anticoagulants?

01:06:50 [Tala] So I actually don't modify my procedure really.

01:06:54 I was talking with someone out there yesterday about that and hyphema doesn't really scare me.

01:06:59 Maybe I should be more concerned, knock on wood.

01:07:01 But no, I don't change my plan because of anticoagulants.

01:07:05 [Tom] Anyone else have a different approach, where their patient's anticoagulated or not, do you request that they stop them?

01:07:14 Do you do fewer goniotomies if they're on anticoagulants?

01:07:20 I mean, one place that hyphema can come into play is if you're doing sequential phaco MIGS, for example, if you do 'em a week apart and they've got a hyphema at day four, you know, they may call and cancel their second eye.

01:07:33 There's a variety of things that hyphema can be disruptive of.

01:07:36 But I agree with you, it's a transient, and I tell all my GAT patients, for example, to expect hyphema, all my referring doctors, you know, expect the hyphema.

01:07:48 So there's no surprise to anyone.

01:07:50 Davinder, you kind of do a lot of GAT, what are your thoughts on anticoagulants and either GAT or goniotomy?

01:08:00 [Davinder] Yeah, I kind of take the Disney approach when I talk to patients, I kind of try to underpromise and over-deliver, but I tell them, you know, on the first day, there's a very good chance you're not gonna be able to see anything, you know?

01:08:11 And I try to give, I really try to set expectations low.

01:08:14 I also will tell them, I was like, listen, this is different than your neighbor that had cataract surgery while playing golf the next day.

01:08:20 Like your eye is different.

01:08:22 You have glaucoma, you need to reset what you're expecting.

01:08:26 And then if they, you know, if they don't have a hyphema or a significant hyphema, then they're pleasantly surprised if they can't see anything and they've got a, you know, a four-plus hyphema with a three mil, a four-plus micro hyphema with a three-plus, four-plus layered hyphema, then they're like, oh yeah, he told me that.

01:08:43 [Tom] Yeah, it's funny you say that 'cause I say the exact same thing.

01:08:46 I say, you may not, if you use a myotic at the end of a GAT procedure and they get a hyphema, they may be light perception.

01:08:53 [Davinder] Right.

01:08:54 [Tom] And then it might, you know, scare them quite a bit.

01:08:56 Important in a monocular patient, so that my choice of procedures varies if they have just one eye, but I do tell them their vision can be profoundly reduced that first 24 hours, 36 hours, and sometimes longer.

01:09:11 I can't recall the last time I washed out a hyphema because it didn't clear.

01:09:15 I usually tell 'em, if it doesn't clear within a week, we'll wash it out.

01:09:20 Any other thoughts on the, Nate?

01:09:22 [Leon] So Tom, you sold the Davinder short, he is the inventor of GAT.

01:09:26 [Tom] Yeah, yeah, exactly.

01:09:27 [Leon] So give him his credit.

01:09:28 [Tom] Yeah, that is exactly right.

01:09:31 [Tala] I've even had hyphema, significant hyphemas with hydrus.

01:09:34 So, I mean, I think you're at risk for any of these surgeries and so that's why I don't modify.

01:09:39 Yeah.

01:09:40 [Tom] Do you pick a- Oh, go ahead

01:09:42 [Analisa] Anybody's, I mean I tell all my MIGS patients to sleep with a couple of pillows and I think that if the hyphema, it's of the pupil, you're kind of safe, they see better.

01:09:52 So just by all my MIGS patients will be told, sleep with a couple of pillows and then when they don't see the next day, I'm like, did you sleep with your pillows?

01:10:01 And when they say no, I said, ah, see? (all laughing)

01:10:07 [Tom] Do you titrate the amount of, the segment you do with your GAT procedures or your goniotomy procedures in 120 degrees, 90 degrees, 360?

01:10:17 [Tala] I do, but the most of my patients are severe, so I am trying to treat as much tissue that I safely can.

01:10:24 But if I'm doing it in a less severe patient, yeah, I'll do maybe 90 degrees or 180 degrees versus trying to get more.

01:10:31 [Tom] I do quite a bit of 360 degree, you know, GAT, am I doing too many?

01:10:36 I mean, should I be doing, you know, 90 degrees, 180 degrees?

01:10:40 I kind of look at 360 GAT as my most comprehensive angle of surgery.

01:10:46 [Jella] I almost always do 360, both canaloplasty and goniotomy.

01:10:51 But just a short note on hyphema risk, we did publish a paper of over 200 patients who got goniotomy with the phaco and we looked at the risk factor for hyphema.

01:11:01 Being on antiplatelet or anticoagulant wasn't a risk factor for a significant hyphema.

01:11:08 Three risk factors were male gender angle-closure glaucoma probably because we did more goniosynechialysis and also day one IOP lower than 10.

01:11:19 So I think it is important to keep the IOP a little bit more inflated at the end of the case.

01:11:24 And for that reason, I don't stop the anticoagulant or antiplatelet before any surgery,

01:11:28 [Tom] Did you have enough patients on anticoagulants to have adequate power to?

01:11:32 [Jella] Yeah, yeah, yeah.

01:11:33 [Tom] That's amazing that that didn't, wasn't a risk factor.

01:11:37 [Jella] And we also look at the correlation with the success, IOP lowering and medication lowering success and there was no correlation.

01:11:41 So hyphema is not a failure, it is an anticipated event.

01:11:45 [Tom] Yeah.

01:11:46 [Jella] Yeah.

01:11:47 [Tom] Completely.

01:11:47 Good.

01:11:48 All right, our next topic, how and when to do gel stent, trab or tube, Leon Herndon.

01:11:57 [Leon] Good morning and thanks Tom for having me back again this year.

01:12:02 These are my financial disclosures.

01:12:05 So I want to address all three of these procedures to look at a typical today in my OR.

01:12:11 So phaco trab, bleb revision tube, trab, TDC, tube, bleb revision, Xen, tube, phaco trab, tube.

01:12:22 So I'm gonna take one of these each Xen, trab, and tube and kind of go through my thought process of what I'm thinking about when I'm talking to patients about when I'm choosing these procedures.

01:12:35 In this day and age, we go to AI when we have these questions.

01:12:39 Claude AI is a large language model designed to assist with a wide range of tasks, including answering questions, helping with analysis and research, writing, coding, math, and creative projects.

01:12:50 So I asked Claude AI, when to do Xen stent, trabeculectomy or glaucoma drainage device?

01:12:57 So we'll look at, see what Claude had to say and I'll balance that with my thoughts and for the rest of the talk.

01:13:04 So Claude AI, the Xen gel stand is appropriate for patients with POAG including primary open-angle, pseudoexfoliative, to a pigmentary who have not achieved adequate control with topical medications and SLT.

01:13:20 Xen stent is often considered when a target IOP is in the mid to low teens, that's required.

01:13:25 A less invasive approach than traditional surgery is preferred.

01:13:28 The patient would benefit from a procedure with potentially fewer complications than trabeculectomy.

01:13:33 And you need a quicker recovery compared to traditional glaucoma surgery.

01:13:40 Xen is generally not recommended for angle-closure glaucoma, patients with previously implanted glaucoma drainage device, eyes with scarring or pathologies of the conjunctiva in the area needed for implantation, and eyes with active inflammation.

01:13:55 So one of those patients that day is the 64-year-old pseudophakic patient with moderate to severe POAG left eye, moderate POAG right eye.

01:14:05 Presentation to me had very high pressures in the forties on four medications.

01:14:10 So these were his visual fields, again, moderate to severe in his left eye, moderate to the right and I thought he would do okay with mid-teens, certainly starting out in the forties.

01:14:24 His OCTs certainly confirmed what I show you with the visual fields.

01:14:30 So here in one, Xen-ex, I do an external approach to my Xen in both eyes over the past two months.

01:14:36 Just saw 'em two or three weeks ago, pressure 16 in the right eye, 15 on no medications.

01:14:42 Totally smooth course postoperatively, no rockiness at all.

01:14:47 So typically, no, with Xens, typically, fewer complications than with more traditional surgery.

01:14:54 So I asked Claude AI about trabeculectomy.

01:14:58 He or she, I guess, said, Claude, trabeculectomies still considered for the gold standard procedure for advanced glaucoma where a large reduction in ILP is necessary, really for all types of glaucoma.

01:15:11 Oftentimes, not the first line of treatment.

01:15:13 It's performed for patients with glaucoma that is uncontrolled or worsening despite medical and/or laser of treatment.

01:15:19 And when the patient's eye pressure is not being controlled adequately with current medication, when glaucoma is worsening, despite medical and laser treatment or when there are issues taking glaucoma medications or side effects.

01:15:32 Trab performs and provides greater IOP reduction in tube shunt surgery, although, with potentially higher risk.

01:15:39 It may be less ideal for patients with high risk of failure, including those with previous eye surgery, inflammatory glaucoma, younger age or multiple topical medication use.

01:15:49 So a trab patient performed that day, 87-year-old male with severe normal tension glaucoma.

01:15:56 I'd had trab express procedures to both eyes back in 2018.

01:16:01 He went back to his referring doctor but came back to me a couple months ago with progression of glaucoma with pressures between eight and 10 in the right eye and between 10 and 13 in the left.

01:16:12 And so with severe glaucoma, I like to get 10-degree fields.

01:16:16 So you can see his 10-degree fields right and left eye clearly severe disease, although his vision is 20/30 in both eyes.

01:16:26 So we had a conversation, Claude AI didn't help me with this, but you know, TVT tells us we can do a BAERVELDT 3/2/50 next.

01:16:34 But I would argue if you need a pressure of eight or six and BAERVELDT ain't gonna get you there.

01:16:39 So I still like to keep the conjunctiva quadrants open that you didn't, that's why I don't go right at 12 o'clock.

01:16:46 I go superior nasal for my first trab.

01:16:48 So I did a standard trab in the left eye, March of this year and then standard trab in the right eye, April 28th.

01:16:57 Now, the thing you'll see with trabs is you have fewer, more complications.

01:17:01 I had no complications at all with my Xen patients and last follow-up, in fact, I just saw 'em two days ago.

01:17:07 His pressure is five, actually two now in the right eye, seidel positive.

01:17:12 So I'm taking him back next week for revision.

01:17:14 Left eye is three with a vision of 20/30 again.

01:17:17 So keep that in mind when we're talking about the different options that we're recommending for our patients.

01:17:23 And finally, with glaucoma drainage devices, Claude feels that tubes are appropriate for patients.

01:17:30 The medications, laser or other surgeries does not work to lower eye pressure.

01:17:35 They're particularly useful for first-line surgery in some cases, for going standard trabeculectomy.

01:17:42 Good for refractory glaucoma, though there's increasing evidence to suggest using these implants in the earlier stage in surgical management.

01:17:49 And patients where a valve is needed to limit how low the eye pressure can drop.

01:17:54 So another, a third patient on that day, 83-year-old lady had severe POAG, had had phaco trabs years ago, came to me with failed blebs, pressures are 33 now in the right eye, and 19 in left for progressive visual field loss.

01:18:10 Thought she needed very low pressures.

01:18:12 So these are her fields again, 10 dash twos and the OCT shows bleeding red on the right with the macular scan.

01:18:21 So both, progression on both eyes.

01:18:24 So I did a, I thought like I thought with other patients another trab would be reasonable.

01:18:29 So she had a trab express in the right eye in January and came back the pressure 56, six weeks later.

01:18:36 So clearly, this is a patient who needed a tube and she underwent Ahmed ClearPath 350 to the right eye in March.

01:18:44 We just saw her earlier this month with the pressure of four but with moderate choroidals.

01:18:49 So in summary, in the three-year clinical outcome study, trabs provided higher pressure reduction than Xen at 12, 24, and 36 months.

01:19:00 Comparing tube shunts to trabeculectomy, trab is generally thought to reduce eye pressure to a greater degree than tube shunt surgery, but with greater risk.

01:19:09 And finally, the ABC studies demonstrated that both valves and non-valve tube shunts had similar surgical success at five years, but the Baerveldt resulted in greater eye pressure lowering, but have more early and serious complications than the Ahmed.

01:19:23 So this is Leon Herndon's summary.

01:19:26 So we have loss of surgical options for patients with progressive, moderate, to severe glaucoma.

01:19:31 And as has been mentioned earlier, I'm more willing to take a risk with patients who have more to lose without aggressive surgical intervention.

01:19:38 Being mindful of the potential for complications.

01:19:41 My algorithm finally, as has been mentioned, I think Jella mentioned this before, the risk profile is greater as you go from a Xen to a trab, but you also get lowering of pressures.

01:19:52 So again, it's a balancing act with these procedures.

01:19:56 Thank you. (audience applauding)

01:20:02 [Tom] Thanks, Leon.

01:20:03 Our next couple talks I think are in the category of more severe glaucoma as well.

01:20:07 So I think we'll do those talks and then we'll chat a bit about the management of more severe glaucoma.

01:20:14 Thank you, Leon, that was terrific.

01:20:16 So Dr. An gonna come back and talk on novel minimally invasive filtration surgery introducing AquaLumen.

01:20:23 [Jella] I'm doing my first one.

01:20:25 So when I started my glaucoma practice now a decade ago, my well-meaning mentor has advised me that to be the best glaucoma surgeon just plan to move every five to 10 years before your own surgery starts to fail.

01:20:42 So I took that advice to my heart and that's why I'm here.

01:20:45 I moved twice already.

01:20:48 So most of the MIGS have been with us about five to 10 years now.

01:20:52 And even those patients responded really well initially.

01:20:56 Unfortunately, their disease has progressed despite all of our best effort and now they need a lower target IOP or they can no longer tolerate the medication that they needed to supplement.

01:21:09 But these are the patients that got the MIGS because they wanted to avoid the trabs and tubes.

01:21:15 So is there anything that's less invasive but also get the IOP lower and get them off the medication.

01:21:21 So these are my disclosures, in particular, I'm an advisory board in Blue Ophthalmic whose product I'll be discussing in this presentation.

01:21:31 Okay, so what are we looking for for these patients?

01:21:34 These are the severe refractory glaucoma patients.

01:21:37 We need efficacy of the filtering surgery, but also safety of TM-based, trabecular-based MIGS.

01:21:44 Ideally, should be reproducible, minimal tissue trauma, rapid recovery, and simplify post-op care.

01:21:50 And ideally, implant-free to avoid a, you know, risk of infection, erosion, and blockage.

01:21:57 So to address these needs, a simple, very simple device called the AquaLumen has been developed.

01:22:04 It's basically 22-gauge needle with the one side with a reverse cutting notch.

01:22:09 So what it does is that it allows us to create a bleb ab-externo in a minimally invasive way without a requirement of implant or sutures.

01:22:19 So I'll show you, this is one of my first case.

01:22:21 You can enter just like how you do the ab-externo Xen, eight millimeter from the limbus.

01:22:25 This patient already got the mitomycin injection and I start to scroll tunnel about two millimeter from the limbus.

01:22:32 Here I'm using the traction suture.

01:22:34 That's a 7-0 silk, turn out to be not sturdy enough.

01:22:39 I would recommend 6-0 nylon or sometimes even the Vivera hook on the side.

01:22:45 So once you're in the anterior chamber, you engage the reverse cutting notch and all you have to do is just pull it out and it creates a nice square lumen that's just large enough to create a bleb to give an IOP of a mid-teens or sometimes low teens without causing hypotony.

01:23:03 Very simple procedure.

01:23:05 And this is how the ostium looks in the gonia, oh sorry, let's go.

01:23:14 You will see once it stops, you see it right in between those two bubbles.

01:23:18 Basically, looking very similar to trabeculectomy ostium.

01:23:24 This is one of the first case that we operated. 70-year-old male with a previous vitreoretinal surgery, poor vision, but he does require pressure of 22 for his comfort.

01:23:33 Require three classes of medication.

01:23:35 So you can see from day one, IOP is nine and at month eight, mid-teens IOP on no medications.

01:23:42 Some may say that that's not low enough for severe glaucoma patients, but for this patient this was just sufficient.

01:23:49 On day one, nice and diffused bleb, very low, very similar to the Xen blend.

01:23:55 Patient is very comfortable.

01:23:56 No change in the vision.

01:23:57 At week one, hyperemia is starting to resolve and week two, it looks like he's never been operated.

01:24:06 A bleb has a nice filtering plane, on month eight, maybe blip has reduced in size a little bit, but still IOP is 17 on no medication.

01:24:16 Similar case, 80-year-old female with a previously failed phaco trab.

01:24:21 IOP is now 40 on maximum medication, four classes of medication and similar result at month five.

01:24:29 At month one, she has a smaller bleb probably because of the failed filtering surgery in the past.

01:24:36 I think she would've gotten a better result if you did a primary bleb needling before we did the AquaLumen.

01:24:42 But we are learning from each of the cases.

01:24:45 So far, 27 eyes in 33 patients have been operated up to 15-month follow-up.

01:24:51 This is a very new procedure.

01:24:53 Most of them have a severe refractory open-angle glaucoma with a failed prior filtering surgeries with a baseline IOP of 21 on over three classes of medications.

01:25:04 Here you can see the, at up to month 15 follow-up, most patients got about mid-teens of IOP.

01:25:11 Those people who had a higher baseline IOP had a higher IOP reduction up to 50, or over 50% and most of them got off the medication.

01:25:22 So again, this is an implant-free ab-externo filtering surgery with a pretty promising clinical finding so far.

01:25:29 It is FDA-registered in December 2024 and we'll be doing the first US clinical trial at Storm Eye in the coming month.

01:25:36 Thank you. (audience applauding)

01:25:45 [Tom] It's a little bit deja vu all over again with the brown tree find, the holmium laser sclerostomy, Saint Oculus has a procedure that creates a direct flow.

01:25:55 What was the lumen of the needle?

01:25:59 What gauge, do you recall?

01:26:01 [Jella] So that is a very good question.

01:26:05 It's hard to determine exact size of the lumen because we are using the reverse notch.

01:26:10 So it really depends on how far you go.

01:26:13 It seems like it is a 22-gauge needle.

01:26:15 I don't remember exact gauge, but it is basically double the size of 22-gauge needle.

01:26:22 [Tom] Okay.

01:26:23 And you know, if that came first, someone might say, well, boy, why not put a little stent in that opening to keep it open, i.e. Xen, for example.

01:26:35 It'll be interesting.

01:26:36 Obviously, it's efficient, very brief procedure I would imagine.

01:26:44 Not very titrable, but maybe that's one of its benefits as well that, you know, there's very little post-op management needed.

01:26:51 [Jella] You could probably titrate either by doing double passes or doing several ostium.

01:26:57 And then we were even thinking of maybe suturing a couple of them and then later opening it.

01:27:03 I mean, that would defeat the purpose of having no suture technique.

01:27:06 But I think we can come up with a, just a creative idea to titrate.

01:27:12 [Tom] Leon, will we see a bunch of those on your OR list in the future?

01:27:17 [Leon] Oh, obviously, time will tell, 'cause concern of the sclerosium might close over time, so I'd like to see the data over time.

01:27:26 [Tom] Is anyone involved, so we're a center for the Xen63.

01:27:29 You know, the current Xen is what, 45 micron lumen?

01:27:35 There's been some interest in having a larger diameter.

01:27:38 Anyone else doing Xen63?

01:27:40 [Davinder] We just got started on it, we haven't done any yet.

01:27:42 I think in the next couple weeks are our first two cases.

01:27:47 But Jella, I got a question.

01:27:48 So with the AquaLumen, you know, sometimes even we'll see this one passing a tube or you know, you kind of, well, I do, I can sometimes misjudge where I'm entering in the anterior chamber.

01:28:00 Sometimes I'm much more posterior than I thought.

01:28:02 Maybe I'm too close to the iris, and so I guess with the AquaLumen, have you ever seen or heard of a situation where you go too posterior, you're too close to the iris, and then you can't get out without traumatizing the iris?

01:28:14 Do you move to the side?

01:28:15 Or how can you exit without doing something?

01:28:19 [Jella] So one thing I learned while we're learning AquaLumen, we learned the technique in Peru.

01:28:25 So when we were doing Xen, we kind of tried to do it kind of the way that we did a tube insertion.

01:28:31 So you go in steep towards the cornea, but then right at the iris plane you change the course, right?

01:28:39 With the AquaLumen, what I learned is if you don't change the course, you just keep going towards the cornea, you actually end up getting perfect angle.

01:28:47 Now, with the stent though, you end up, well, you don't want the stent to touch the cornea, so you will have to kind of go into the 10-degrees towards the iris just to avoid the stent touching the cornea.

01:28:58 But without the stent it's actually easier.

01:29:02 [Tom] So we're gonna have one more talk before last panel.

01:29:06 Balance goggles, why, when will patients wear them?

01:29:09 Nate Radcliffe.

01:29:10 [Nate] All right.

01:29:12 Well, you thought that DSLT talk was a little out there.

01:29:17 Let's try to take things to a whole new level here.

01:29:22 And I am a consultant to Balance the company founded by John Berdahl.

01:29:29 And really a revelation here that we have some problems getting the pressure as low as we might like, particularly at night.

01:29:42 Most of our medications don't work well in the evening hours, but I'm looking at you, beta-blockers, carbonic anhydrase inhibitors, alpha agonists.

01:29:51 And so there might be a way to address this that is entirely different.

01:29:58 And John's concept is a pair of goggles that are worn and can place a negative pressure in the area in front of the cornea.

01:30:12 It comes with a very small and reasonably quiet pump that has a battery life and can apply this negative pressure for many hours and it can reduce the pressure basically up to 20 millimeters of mercury in front of the cornea, which translates to a pressure reduction inside of the eye of 10 millimeters of mercury.

01:30:40 So I'm gonna start with the indication for use.

01:30:43 This is an FDA-approved product and it got its indication for adjunctive therapy in the reduction of intraocular pressure for nightly use in adult patients with open-angle glaucoma.

01:30:54 But pressure's below 21 millimeters of mercury.

01:30:59 There's some unique things, and I'll go through the data, but it's non-pharmacological, non-laser, non-surgical.

01:31:05 It always lowers the pressure in every eye.

01:31:09 It does so safely, it's agnostic to prior procedures.

01:31:15 We could talk a little bit more about that.

01:31:17 You can titrate the amount of pressure reduction and there's some caveats there and makes the most sense to use at night, which happens to also be a time when it's tough for us to get the pressure down otherwise.

01:31:30 If you think about what eye pressure really is, you have to recognize that there is an atmospheric pressure that's always acting on our body.

01:31:40 And in fact, you know, one of John's revelation when he came up with this concept was wondering how we could be under so much pressure when we're scuba diving, for example, and not go blind from glaucoma.

01:31:51 You know, because the column of water on you is extraordinarily heavy and it really has to do with the balance between cerebral spinal fluid pressure on one end of the optic nerve and the intraocular pressure on the other.

01:32:03 And so if you can just manipulate certain aspects of this pressure by dropping the pressure anterior to the cornea, you can indeed reduce the pressure.

01:32:15 John and his group, and I was involved in some of these studies, has conducted a number of trials looking at the various patients, some primary open-angle glaucoma and others just with normal tension glaucoma.

01:32:32 But generally, you saw pressure reductions of roughly 20 millimeters of mercury down to 12 or 13 millimeters of mercury.

01:32:39 All eyes responded.

01:32:40 I think the most important sort of adverse event to consider is eyelid edema and perhaps patient discomfort during wear, which we can talk about.

01:32:54 But if you look in these, this is a sleep lab study, they're getting 37% pressure reduction in these patients from pressures of let's say 17 down to 10 or 11, 20 down to 12, out to 12 months.

01:33:11 So there's no tachyphylaxis, the effect doesn't wear off over time.

01:33:15 The pressure does return to normal as soon as the goggles are turned off.

01:33:20 And so almost all eyes will achieve at least a 20% pressure reduction.

01:33:26 Again, depending on what the level is set at.

01:33:30 I think one of the things to consider with the goggles is, you know, you'll have the option of setting it at a different level.

01:33:39 There's been many other studies.

01:33:41 Some of the things that they've looked at, for example, is, does wearing the goggle improve blood flow through the retina?

01:33:46 And that's a yes.

01:33:51 Is it associated with any intraocular problems?

01:33:55 You know, vein occlusions, anything you might imagine like that.

01:33:59 Nothing has been seen.

01:34:01 The safety profile is really quite impeccable, again, except for the eyelid swelling.

01:34:06 They've even looked and actually cannulated the eyes in a cataract study said patients wear the goggles right before their cataract surgery and they were able to show that the actual intraocular pressure does decrease.

01:34:18 Similar studies have been done on cadaver eyes.

01:34:20 So good bit of data behind this.

01:34:23 Now, again, just looking specifically at the problem of normal tension glaucoma.

01:34:29 You know, these are tough to treat patients.

01:34:31 It's tough to lower the pressure when your starting pressure is already 15 millimeters of mercury, but more can be done here.

01:34:39 When do we have the patients wear them?

01:34:42 Well, for me there's a variety of scenarios.

01:34:46 You have patients who are still progressing despite seemingly adequate intraocular pressures.

01:34:53 Patients who are on as many meds as they can tolerate, but not at target.

01:34:58 You know, I don't love operating on people with a preoperative pressure of 15 millimeters of mercury.

01:35:04 You know, because I have lots of operated patients who I consider successes, who have pressures of 15 millimeters of mercury.

01:35:12 One of the groups for me that really has been identified that would be good candidates for this are patients who are using home tonometry.

01:35:20 There are a few different services out there where the patient, not through your office, can get their hands on a, you know, home tonometry, eyecare home.

01:35:27 And those patients will call and say, you know, my pressure's, you know, at 10 or 11:00 PM are, you know, 20 millimeters of mercury even though they're always good in the office.

01:35:38 Eventually, patients who have surgery and have failures may not be ready to have another surgery yet, or may not be wise to operate again so soon.

01:35:45 This could be a bridge therapy for those patients.

01:35:48 In terms of patients wearing them, there is a little bit of a limitation there, in the FDA studies patients, were tolerating them and wearing them for about four and a half hours per evening on average.

01:36:01 I have a patient wearing this who says sometimes it just falls off in the middle of the night and he just sleeps, you know, without realizing this happened.

01:36:09 But if you look at the dropout rate, meaning the patients who just decided they didn't want to be in the study, didn't want to wear the goggles anymore, you know, these goggles fall somewhere between the dropout rate for Timolol and the dropout rate for say, repressor Rocklatan.

01:36:25 So the dropout rate is not higher than for most eye drop therapies.

01:36:29 And that's a good thing to keep in mind is that we have patients saying no to eye drops all the time.

01:36:34 And many of them might say yes to these goggles instead.

01:36:38 And again, in terms of the safety, some periorbital edema, maybe some, you know, contact dermatitis and discomfort, most mild, nothing serious.

01:36:48 So it's a very safe option when you look at it from that standpoint.

01:36:53 So I think the most successful patient will be someone who's motivated, has a good level of health literacy, kind of understands what their pressures are, where they need to be.

01:37:04 I would imagine this is similar to people who are wearing the CPAP devices for sleep apnea.

01:37:09 Maybe not everyone's gonna wear 'em perfectly, but the motivated people who want to take their health seriously might.

01:37:15 And ultimately, each patient may have their own limits in terms of what they can tolerate in terms of comfort.

01:37:21 You can adjust the pressure goal at any visit to maximize the patient's comfort and wear.

01:37:28 Thank you. (audience applauding)

01:37:35 [Tom] Thanks, Nate.

01:37:36 I think we've got just five minutes or so for a panel discussion.

01:37:41 There are two topics I want to, if we can pull up my slides.

01:37:44 Two topics I want to address real briefly.

01:37:46 One would be the superciliary space.

01:37:51 Is anyone doing the AlloFlo or the scleral stenting?

01:37:58 Several people, okay.

01:38:00 So what's the experience, Jella?

01:38:02 Experience been favorable so far?

01:38:05 [Jella] Well, I think we presented our first eight cases on Thursday.

01:38:11 Now, we solve a variety, like various outcomes.

01:38:17 Some patients do really well, some patients don't.

01:38:19 And sometimes it goes really well and then suddenly have an IOP spike.

01:38:24 I think it really depends on the patient selection.

01:38:27 Most of the patients that we selected for the first few cases were really refractory, severe glaucoma patients who have failed everything including cyclophotocoagulation.

01:38:37 So these patients were probably not the ideal patients for this procedure.

01:38:43 But again, sometimes you can argue this may be better than the third tube or CPC.

01:38:51 My challenge is really you don't know when the cyclodialysis will close because when you look at the gonio, it looks open, but probably it's closed in the stall side of the cleft.

01:39:04 So of course, you can do the UBM, but sometimes it's hard to identify.

01:39:09 So that's the main challenge.

01:39:11 [Tom] Yeah, I just wrote a commentary on a paper that was published on this and the data was actually quite good.

01:39:18 So it'll be interesting to see where it fits.

01:39:19 I agree with you completely.

01:39:20 It's not gonna replace angle surgery for those with mild to moderate, but it might be a nice option to keep aqueous in the eye, at least takes bleb-related infections off the table.

01:39:30 You know, I'm fond of trying to reduce the risk of catastrophic complications and we typically think of catastrophic complications as bleb-related endophthalmitis, suprachoroidal hemorrhage.

01:39:41 You know, this will not reduce or it won't eliminate the hypotony risk, but it certainly eliminates the bleb-related infection risk or cytopositive blebs.

01:39:52 The last discussion I was gonna bring up was that discussion of safety and efficacy.

01:40:01 I think we should consider disease velocity and likelihood of progression almost more than the level of severity.

01:40:10 I'm really getting tired.

01:40:11 This is a little bit of a call to arms to all of us.

01:40:13 We need to take control of who makes the decisions for our glaucoma procedures.

01:40:18 I'm getting more denials because a patient doesn't have primary open-angle glaucoma and I put a hydrus in or I put a hydrus in an exfoliation patient.

01:40:27 You know, those aren't contraindications, they're just not covered.

01:40:30 And it's crazy.

01:40:32 And this is a patient that, I'm just gonna zip through this really fast.

01:40:36 This guy was referred to me as monocular.

01:40:38 His pressures were extreme.

01:40:41 His real EHRs is not a made-up case.

01:40:44 He was hand motion in one eye, he was 20/25 in his only eye, only well-sighted eye, his pressures were 23.

01:40:52 But he had presented at fifties and his angle was a little bit narrow.

01:40:56 It wasn't occluded, it was narrow.

01:40:59 But he had a cataract and I was gonna do an exfoliation, I was gonna do a surgical procedure on him.

01:41:05 Here's his only, his right visual field.

01:41:08 And I would submit that almost everyone would do a trab or something on him.

01:41:14 But you know, the monocular patient with the tiny visual field that presented at 50 and now is low twenties might be fine if you get him into the upper teens, for example.

01:41:25 So I, just to cut to the chase, I did phaco hydrus on him.

01:41:30 I told him he might need a trab in three weeks, but I told him what I would want for my eye is take catastrophic risk off the table as much as you can and do the best you can.

01:41:41 And he's five years out after phaco hydrus and I've converted to 10 dash two visual fields.

01:41:48 But I took catastrophic risk off the table.

01:41:51 He's done great with phaco hydrus, it's completely off-label and probably got denied.

01:41:57 I probably had to write six letters.

01:41:59 But we need to write these letters.

01:42:01 We need to fight this battle.

01:42:03 They can't be denied because they have exfoliation or because their glaucoma is severe.

01:42:08 I've got an office full of people that have severe glaucoma, but they've been stable.

01:42:13 And why would I wanna subject them to potential catastrophic risk if I can do a much safer procedure?

01:42:20 So I just really would love if we could all write letters and fight this and not just succumb to the bureaucrats sitting at the table that won't reimburse something because it's off-label.

01:42:31 Davinder.

01:42:32 [Davinder] You know, the other thing that also just I find frustrating is when we take care of monocular patients.

01:42:39 [Tom] Yeah.

01:42:40 [Davinder] You know, you can, you know, when you do a regular cataract surgery versus complex cataract surgery, there's an upcharge for the added risk, the chair time, the mental-emotional stress for the patient, the mental-emotional stress for the surgeon to do a monocular young patient like that.

01:42:54 And then to have to fight the reimbursement nonsense.

01:42:57 You know, that's a much higher risk, much emotional, much more emotional risk for everybody involved.

01:43:02 I don't understand why monocular patients aren't reimbursed at a different level to compensate for that additional risk.

01:43:08 [Tom] Well, thanks, we're out of time.

01:43:10 There are so many great questions that the audience asked.

01:43:12 I apologize we didn't get to all of them.

01:43:13 We're certainly happy to answer questions.

01:43:15 Please visit the exhibit hall.

01:43:17 We need their support.

01:43:18 Thank you for your attention. (audience applauding) (upbeat music)

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