00:00 So I think we'll get started, right away here.

00:03 Settling into the new interventional normal, I think we're all learning how to use some of the new tools that we've gained over the last, decade or so.

00:12 And, here are my own disclosures.

00:16 And we've got an outstanding faculty today.

00:19 I think, Nate will probably run in here any minute.

00:25 But, a terrific faculty.

00:27 And what's gonna happen is each of these speakers is gonna give a talk, a didactic talk, and then present kind of a what next situation.

00:35 And, I'm gonna start just with my own what next situation.

00:39 So what would you do next?

00:41 Or, you know, what would I'm gonna have the panel chime in, but I also want your opinion.

00:45 I do have one audience response.

00:47 So apropos for this, part of the world, I have a sixty-three-year-old, club professional.

00:53 So he's not a PGA Tour, but he's a golf professional that I care for in Minneapolis, and I've been seeing him for quite some time.

00:59 He's had glaucoma for twenty years, primary open-angle glaucoma.

01:02 He's had SLT three times.

01:05 The highest pressure I've recorded for him was twenty-nine.

01:08 His current pressure is twelve and twenty-three on two meds, which is his max tolerated.

01:13 His central corneal thickness is normal to slightly generous.

01:17 He's got twenty/twenty vision in both eyes uncorrected, and he's emmetropic.

01:20 So if that factors into any procedures that you might, consider.

01:24 His angles were open, Spaeth classification, nicely open there.

01:29 And there's a lot on here, but I wanna focus primarily on the left eye.

01:33 Both eyes have progressed a bit.

01:36 This just shows a five-year period.

01:38 But the left has progressed pretty substantially, and that's the eye that had the pressure of twenty-three.

01:44 And, if you look at his NFL and his GCL, both show progression, both right and left, but left in particular. And if you look at the left visual field, the left visual field clearly looks worse.

01:57 Here you can see his pressures in the right, reasonable, middle teens.

02:02 Again, normal central corneal thickness to slightly thicker than average.

02:05 But the left, bouncing around quite a bit.

02:09 So the question is, what, what would you do next in this gentleman?

02:12 I want my au- my panel to write something down because I want them to commit.

02:16 Write down your one- We need paper.

02:18 Oh, okay, you don't have paper. Well, okay, be honest then.

02:20 You're good. Pick, pick one procedure, and then we'll find out what everyone wants to do.

02:24 But the audience wants to vote from a list of I, I put C8 things there.

02:29 There's probably more that you could do, but try to find something on that list that you maybe would wanna do, for this individual.

02:37 You can see the, the data at the bottom there again.

02:39 Sixty-three years old. Pressure's twenty-three on two meds.

02:42 The CCT is not correct there.

02:44 It's five seventy. Sorry about that.

02:46 Five seventy. Previous SLT three times.

02:50 And he's emmetropic, so minimal lens change, no anticoagulants.

02:55 Go ahead and pick your procedure of choice.

03:01 No music this year. Jela, a little acapella for you?

03:04 You wanna sing? Dun, dun, dun, dun.

03:11 All right. Okay, so people are gonna be in the canal looks like. With stents is the most popular.

03:23 XENs have got some popularity.

03:26 Let's go down the Just starting here, Jela, just what And we'll go DURAVYU.

03:30 D- Go ahead.

03:31 I don't know what his, prior experience with SLT was, but I'll probably give that a trial right away that same day.

03:38 Especially with the DSLT, it's easy to do that.

03:40 And if that's insufficient, I'll probably go to the canaloplasty, but I would like to do three sixty degrees. Okay.

03:46 All right. Just write down the list.

03:48 Just- Yeah, I, um- Short answer.

03:50 You know, these are the I know this wasn't part of the conversation with cataract surgery, but these are the kind of patients, even though they're, they're seeing, seeing well, I always tell them, "Look, I'm gonna give you a cataract unless, you know, while I'm in there." and so I would also contemplate in- involving cataract surgery in this situation.

04:05 But, just speaking to the glaucoma portion, I would probably go back and forth between just a, a either incisional goniotomy or, or possibly a GAT.

04:15 All right. And just in the interest of time, one-word answers.

04:18 I, I do have a another section that something happened with, with, what we did.

04:22 So, um- Yeah.

04:23 Go ahead, Pujaan.

04:25 Yeah, I agree with Jela. If, if I hadn't done the SLT myself, I'd probably repeat it. You never know, you know, how it was done in the past. But otherwise, I would lean towards a canal-based or incisional goniotomy.

04:35 I'm going to the Canaloplasty, and I'm taking the cataract out.

04:39 I think it does help a little.

04:42 Okay. Ray. I'm, I'm doing I, I'm getting a really bright light, shining it right in his eye, and I'm, saying, "Oh, your cataracts are progressing, and let's take them out." and then I'm doing a canaloplasty, plus an Eidos.

05:00 All right. Good. All right.

05:01 Let's see what, I did.

05:03 So I did a GAT Omni, which, I, I left his lens alone.

05:06 He had no vision complaints, and he's emmetropic.

05:08 It's hard to improve on that.

05:10 And I felt like, certainly cataract surgery would have augmented that, but he did really well pressure-wise.

05:16 But, post-op day one, this isn't him, but I'll show you him in just a second.

05:21 But he had a, comminuted attachment.

05:23 And Ray, I know this is an expert You're an expert in this area from your- No, no, no previous life. Not in, not in creating them- I've never seen a patient like this. But in preventing them because I'm an Omni guy.

05:32 I like Omni, but I like all the circumferential, catheters.

05:37 But there is some variance in how much the catheters dispense.

05:42 So Omni, the original Omni, is about a ten or T1 microliters.

05:46 The new one, the Edge, is twenty-one microliters, but you can deliver up to a hundred microliters. Ray, what are your thoughts?

05:53 I rarely develop these.

05:55 Here's, here's my guy.

05:57 You can't see quite as well. It's a lot more subtle, but it's in its peripheral, and he's twenty/twenty andKerry and Eric, why isn't the cornea edematous in that area where the des- desmets is completely separated from there?

06:07 But there was no overlying microcystic edema, nothing at all, other than my own concern that that's OBD in there.

06:16 So for residents in the audience here, you know, you blow the, the roof off of Schwalbe's line basically and, and OBD, dissects in to the subdesmet space, and he's actually got a little subdesmet hyphema there that resolved quickly.

06:32 But he had no edema.

06:33 His vision was perfect.

06:35 He was fine. He had no symptoms.

06:37 But it bothered me, I'm gonna go back one 'cause this shows that, you know, this isn't him, but it looked similar to this, but smaller and not threatening the visual axis.

06:46 But why no corneal edema in that area where there's no DSEK?

06:53 Eric and Kerry.

06:56 Kerry. Yeah. My guess is you've got viscoelastic in there, right? There is. It's- Preventing, preventing fluid from coming through to give you that cystotome.

07:03 So that's a barrier preventing aqueous from getting in there. Interesting.

07:07 All right. So do we have to do anything with this panel?

07:09 Do you have, do you have to make an incision in the cornea and, and increase the intraocular pressure and get that out of there?

07:19 I mean, I see them so rarely, but those that do deliver more- Well, if it is- may see them more often. If it is big, I mean, sometimes you do get some pretty big Descemet's detachments.

07:31 I do a stab wound and I flush it out.

07:34 Now, I leave an air bubble if, if it's at all superior, and I will leave the air tamponading it with water. I'm not chasing it all the way to, to full vitrectomy repair.

07:44 They heal. It just takes time.

07:47 And DURAVYU, you kind of invented GATT, but that was the future.

07:50 GATT doesn't do this. It's, it's the viscoelastic.

07:53 And, and so you don't get that- Don't blame him with a, a standard GATT, but you do when you combine it with a Canaloplasty.

07:59 You can at least. Yes. Yeah.

08:02 I, I would just watch this.

08:03 I mean, it, it's-- it, it goes away.

08:05 The problem with going back in is then you're gonna get blood reflux, and then it's just gonna open up a whole problem, and then you're gonna start losing control of the pressure.

08:13 If-- I would just, It, it's, it's gonna resolve.

08:16 It's viscoelastic. It's gonna resolve.

08:17 So what I would have done if I had to do something, I think, is right at the limbus I was gonna make a little incision into that space, take a thirty needle with BSS and just super inflate the anterior chamber with BSS.

08:30 Yeah. See if I can flatten it out and But I didn't have to do anything, and it, and it went away.

08:34 And, and I talked to someone who uses the more aggressive catheters that do, deliver more, and they said they see-- they've seen it, and they generally just resolve, even though it's OBD. So I thought maybe it would take a long t-time to go away. And time really doesn't allow.

08:48 But I wanna show one thing, with regard This is an interesting I've always contended that you can put stents in the inner wall of Schlemm's canal.

08:57 So, what I was gonna show is there's thickness to the inner wall.

09:01 So, I now I have, have evidence that you can do this.

09:05 So there's a, a first-generation iStent there that my Omni catheter went straight underneath.

09:10 And, show it again.

09:13 You can see the Omni catheter going right underneath.

09:14 That, that stent's not in the canal.

09:15 It's in the inner wall, and it's stuck there, and it looks perfectly positioned.

09:20 And then so when you strip, you I stripped it, and the iStent stayed right in that tissue.

09:26 So it wasn't in the canal.

09:27 It was in the inner wall, and that's really important when putting other things in circumferentially.

09:34 Here I, I show the Hydrus, but it's in front of the pigment primarily, and it really needs to be behind it, like this.

09:42 I, I won't start deploying until I know for certain I'm behind the pigment, and it's really important. It's the number one thing, I think, in getting accurate circumferential Canaloplasty is to get behind the inner wall.

09:55 So I always incise, and get visualize the back wall and then only deploy when I see the stents going behind the pigment.

10:05 The pigment's in the inner wall of trabecular meshwork, and you have to be that one case that showed that first-generation stent that was placed years ago, is very good evidence that you can, you can stick things in inner wall and, and not be in the canal at all. Kerry and Eric, terrific, meeting as always, and, I'm looking forward to hearing my other speakers.

10:28 So, so, so Tom, h-how is the golf pro's, vision?

10:33 How long follow-up do you have and- He's, he's great.

10:36 He was, he was He goes, "Why didn't we do this years ago?" Uh-huh.

10:40 And I said, "Well, we've done other things.

10:41 You've had laser and you've had meds and, and, um-" Yeah.

10:44 Well, what, what's your follow-up? But, but no, it's relatively short. Uh-huh.

10:46 He's probably two months out. Oh, two months. Okay.

10:48 Yeah, yeah. All right. But he's, But the younger the age in me, so he's had glaucoma for twenty-some years.

10:53 The closer they are to a, a jog type situation, I love unroofing the canal- Yeah with my, with my Omni or whatever your favorite, circumferential catheter might be.

11:04 But I, I generally do three sixty, three sixty.

11:06 And I am an advocate, for the smaller amounts of viscoelastic, 'cause I rarely see what I just showed. I, almost never.

11:16 Anyone have large Descemet attachments in continuity their experience?

11:20 Anybody? Which- I mean, just wait it out.

11:23 That's better. In the operating room, I will drain them some.

11:26 And I will put an, a-an air bubble in, but I see.

11:29 All right. So our next, speaker, Bhujan Dave.

11:34 Glaukos landmines and routine cataract surgery.

11:39 It's number two. All right.

11:42 Whoop. Here we go.

11:44 All right. Thank Good morning, everyone.

11:45 Thanks for having me today. We'll talk about glaucoma landmines and routine cataract surgery.

11:51 You know, cataract surgery is something we do all the time, and thankfully it goes well for most people. But glaucoma eyes can be different, challenging, and, you know, less forgiving at times.Disclosures.

12:03 So, you know, eyes with glaucoma, they can have a normal-looking cataract, but it's not uncommon for these cataracts to be surrounded by issues.

12:10 Zonular problems, a small crowded anterior segment, prior filtering surgery in the way, or advanced visual field loss with a sick optic nerve.

12:20 And we'll talk through some practical reminders about how to navigate these situations so that we don't look like this by the end of our surgery day.

12:28 Really, we wanna look more like this walking off into the sunset.

12:31 Thank you, AI, going off avoiding these landmines.

12:36 Zonular issues. Sometimes it's obvious, you know.

12:39 You look in the eye, the lens is shaking, there's phacodonesis, and you know there's trouble. But often it can be subtle.

12:48 You may have a small gap between the iris and the lens, which is easy to miss at slit lamp if you're not careful, if you're rushing.

12:54 You may have an asymmetric or shallow anterior chamber depth, suggesting that side, the zonules have given way, allowed the lens to shift anteriorly.

13:03 And those are clues where, you know, if the AC is two millimeters, you may, you know, you may realize it, but if it's a subtle difference, you may not.

13:11 Does he think two millimeters- You may or may not see blepharoexfoliation material.

13:14 And even if you do see it, the amount of material you see doesn't necessarily tell you how weak or strong the zonules are.

13:21 And in all of these situations, you may consider earlier lens extraction before the cataract becomes heavier, before the zonules become weaker.

13:30 And in all of these situations, counsel the patient.

13:35 Surgery may be more challenging.

13:36 Late IOL disla- location is very possible, and pressure issues can certainly come up in the postoperative period. If the AC before surgery is shallow or measure shallow, but when you sit down, the AC looks pretty deep, that is definitely a red alert moment that perhaps with the patient now supine, the zonules have given way and the, lens has shifted posteriorly.

13:58 In that situation, certainly don't overinflate the eye.

14:01 Viscoelastic can push and, and further stress weak zonules.

14:05 Always be on the lookout for vitreous prolapse g-going through a zonular defect.

14:09 If you're worried about that or if you see that, disperse some viscoelastic in that area can help tamponade and avoid AC shallowing, keeping the eye formed at all times.

14:17 And of course, if you see striae on the rhexis or have difficulty starting a capsulorhexis, you know the zonules are not providing countertraction and the zonules are weak.

14:26 I err on the side of a larger rhexis in these situations, which is more zonule friendly when you're phacoing.

14:35 Other considerations are just make the entire experience zonule friendly.

14:39 Don't stress the lens.

14:40 Don't manipulate inside the bag if you can.

14:43 Don't push the lens when sculpting.

14:44 Chopping techniques may be more friendly to zonules than typical divide and conquer.

14:50 I, with a larger rhexis, can often Popeye the lens out and get it out of the bag, which is generally weaker, to avoid, additional stress.

15:00 Cortical removal can be di- challenging.

15:03 Visco dissection can help cleave the cortex from the capsule.

15:06 And sometimes when you're, aspirating the cortex out, you can see the bag coming, coming with you, which you don't want.

15:13 And a little bit of viscoelastic in the capsular bag can help provide the countertraction you need to, aspirate the remaining cortex safely.

15:20 And this goes without saying, but always be prepared for more.

15:23 We've learned this weekend a lot of different techniques to save ourselves from, from zonular issues, and you should be mentally prepared at least for rings, segments, hooks, whenever you need to get through the case safely.

15:35 Landmine two, a small crowded eye.

15:39 We know, you know, these could be angle closure eyes, these could be nanophthalmic eyes, and we know that the, le- you know, that lens extraction can be therapeutic in these situations.

15:48 But there are some refractive issues.

15:51 Lenses that are over thirty diopters have a tolerated manufacturing variability of up to one diopter, which can lead to refractive surprises in the postoperative period just related to the IOL. Effective lens position is more impactful.

16:04 The lens is more powerful, and so a small ELP miss or change can result in a, a higher change in refraction. And whenever you have a myopic surprise in small eye, absolutely consider malignant glaucoma even in the setting of a normal eye pressure. It may not be a refractive issue.

16:20 It may really be glaucoma. These eyes tend to have posterior pressure, floppier iris, which is a fantastic combination.

16:27 And, you know, longer wounds can help.

16:30 Avoid things like blocks or tight speculum, which can make your, issues worse.

16:37 I have a low threshold for mannitol.

16:39 I've never regretted giving it, but certainly not giving it I have regretted in the past.

16:45 And this clicker is not advancing.

16:47 Okay, there we go. And again, counsel your patient.

16:49 This is not your neighbor's cataract surgery.

16:51 This is your surgery, and it is more challenging.

16:56 A high viscosity OVD is wonderful in these cases.

16:59 You can see in the video here, putting in a typical disperso of viscoelastic, Viscoat is shooting out of the eye with how much vis- with how much posterior pressure there is.

17:07 Healon 5, for example, can maintain the space, and it can flatten the lens, making capsulorhexis safer in a small eye.

17:14 If the eye is super tight, you don't have much space, you may have to use microincisions through a paracentesis to complete the capsulorhexis, as you can see here.

17:24 You want to You know, we mentioned ma-malignant glaucoma, choroidal effusions.

17:28 Limiting pressure fluctuations, not allowing the eye pressure to decline in the middle of a case can help decrease the risk of that happening intraoperatively.

17:36 So at the end of cortical removal, for, for example, when you're coming out of the eye, there's no viscoelastic in there.

17:41 Inject BSS through a paracentesis as you come out with irrigation, so the AC stays formed, reducing the risk of these issues.

17:48 And again, be prepared for more.

17:50 Scleral windows, IIH, all things to, get you out of a sticky situation, in these smaller eyes. The last two, prior filtering surgery, advanced glaucoma.Show the patient their visual field.

18:07 And I, I think this is important whenever there's less field loss than what's shown.

18:11 But the cataract surgery is, is going to help, but it does not remove all of the cloudiness.

18:16 And that is a difficult concept sometimes for patients with advanced glaucoma to understand.

18:22 They also have to understand that pressure issues can come up after surgery.

18:25 Their filtrat- you know, their filtering surgery may start working less well.

18:30 Some questions that are helpful in deciding your, you know, operative planning: number one, is the filtering surgery still working?

18:36 Number two, where does the IOP need to be, and are we where the IOP needs to be now, and is that with or without medications?

18:45 Those questions seem basic, but they can help determine the entire plan.

18:49 And often MIBS after filtering surgery can be very reasonable depending on the answers to these questions. We'll kind of speed through this for the sake of time. The main point here is bleb failure is possible after phacoemulsification, even after a clean cataract surgery.

19:06 And more frequent steroid use and prolonged steroid use or a steroid injection at the end of the case can help decrease the risk of failure.

19:13 Certainly, if there's a bleb, mitomycin C, 5-FU, or needling is on the table.

19:19 And if possible, after a bleb-forming procedure, waiting six to 12 months is ideal to help the bleb mature and decrease the risk of future failure.

19:28 Bleb-induced astigmatism can develop and change over the course of the first year a bleb forms. The morphology can continue to change.

19:36 And so if you're planning a toric lens, be mindful of that.

19:38 And a soft eye prior to filtering can have a smaller-- with prior filtering can have a smaller axial length. And let's say you do cataract surgery, and now their IOP is higher because the, filtering surgery has now failed.

19:50 Well, the axial length can increase, leading to a myopic surprise.

19:52 Just something to keep in mind. SNUF, I'm going to speed past this.

19:58 This is exceedingly rare, three in a million.

20:01 And so c- you know, we're in an interventional era, and cataract surgery that IG ecosystem.

20:11 Cataract surgery can help improve quality of life, but it can also create opportunities.

20:16 These are moments to take control back from the patient and the disease.

20:21 It gives access to MIBS, drug delivery, and minimally invasive filtering procedures.

20:27 So these are all moments and opportunities.

20:29 But remember, cataract surgery in these eyes can be tricky and, and not quite as routine.

20:36 Last landmine, patient education is not the same as patient comprehensive.

20:40 We spend a lot of time educating patients, and in an interventional world, that is obviously very important.

20:46 But sometimes what the patient hears is different, no matter how much chair time you give them.

20:53 In an interventional world, it is really important that patients understand what we're doing, especially when it comes to glaucoma surgery mingling with cataract surgery.

21:02 You know, they're, they're the same but different.

21:04 And of all the landmines that can make routine cataract surgery more challenging, misunderstood expectations are certainly sometimes some of the most frustrating.

21:15 And so we'll move on now to the, case.

21:18 So speaking of, you know, routine cases going, going awry, we'll present this video.

21:24 I will admit it is not glaucoma related, but I think it is a, a good one to see and talk about.

21:36 And so here we're just sculpting, sculpting.

21:38 That looks a little bit funny.

21:41 You know, what is all that milky stuff?

21:46 What is going on here? Is the phaco not working?

21:50 That is a dense lens.

21:57 And we come out of the eye because that was just too strange.

22:00 So I'll, I'll kind of pause here towards the end.

22:02 Oh, I'm so sorry. I gave everything away.

22:06 That is That was not supposed to happen.

22:09 Okay. All right.

22:12 Well, you know, I've given it away anyway.

22:13 So thoughts? I'd love to hear from audience, and if not, panel.

22:19 You know, how, how would you handle these situations?

22:21 You know, what, what would you be thinking about when you see this?

22:24 I'm gonna tell you what my professor, Dr.

22:27 Singh, used to say when we were training to do cataracts.

22:30 He would stand behind you and goes, "Okay, start.

22:33 Suck, suck. Stop. Stop.

22:35 Stop." So, my first thing is stop.

22:40 And I think you have some viscoelastic that it's actually trypan on the, on the tip of your phaco. Stop.

22:48 Come out. Do a little irrigation.

22:51 Do not let that milk If you see actually the tubing on the phaco, how it's increasing the temperature, those are, are- Yeah.

23:00 That's evaporation of the fluid from the heat in the cornea.

23:04 So just stop.

23:08 Absolutely. Recognition is the absolute most important thing. If you see this, that milky kind of fluid right at the tip of your phaco, please stop.

23:16 Do not continue.

23:17 It will make things worse.

23:18 And you can see, you know, in this case, we did not stop.

23:21 And so you have a clean-looking wound at the start, and by the time you come out of the eye, and even by the end of the case, you can see the, you know, irregular astigmatism and the striae, and, very difficult to kind of close this wound and get a watertight seal sometimes.

23:35 P-Pujan, what's the incidence of this?

23:37 I mean, I've been in practice thirty-five, thirty-six years.

23:41 I've never had one of those.

23:42 And I do a lot of cataracts.

23:44 And, um- Right what are the risk factors?

23:46 And, I can understand if someone's never seen it to not really recognize it and not know to stop.

23:53 So what are the risk factors, and how often does that happen?So, you know, based on data, you know, i-it's about one in a thousand, which seems actually higher than I would expect, you know.

24:03 You know, endophthalmitis is one in a couple thousand, and I certainly feel like we see that a little bit more often than I've-- than we would never see this.

24:10 And that was my main reason for choosing this case, is most people don't see this.

24:14 And if you don't see it, you may not recognize it very quickly.

24:17 So I think it's important just to know.

24:19 You know, if you see that milky fluid, obviously, if you see gaping wounds, difficult watertight closure, these are things to recognize and, stop phacoing, create a different wound, you know, a-and figure out why this is happening.

24:32 Is it a very dense lens?

24:34 Is there an irrigation problem?

24:37 And, is the tubing crimped?

24:40 Just reassess.

24:42 So, so I actually have a setting on my, phaco, system that is, a more aggressive, You know, it's kind of like an, It, it, it removes the viscoelastic before I start sculpting, you know, to, to, to avoid this.

25:02 And I'm, I'm with Tom.

25:03 I've not personally, you know, seen this, but I worry about it every time, especially a case like this. So I, I try to You know, as I say, I have this special setting that's a-an aggressive, removal of viscoelastic.

25:18 And, and super important, I don't know if you're gonna touch on this.

25:22 Trying to put radial sutures to close this will make this gape, and you're gonna end up with ten stitches, and you're still gonna have a leak.

25:32 The answer for this is to put a mattress- Mattress suture.

25:35 So I don't know if you're gonna go through it.

25:38 No, for the sake of time. But put a mattress suture.

25:40 If you co-manage, do not let people cut them out a week.

25:44 It will leak again.

25:46 So put a big note if you're co-managing.

25:49 Do not remove. Let your patient know it all heals.

25:53 It, it, it gets better, but if you take the stitch too early, it will leak.

25:57 And if you- I like that remove it early, even though they're gonna have more astigmatism, you're gonna end up into trouble.

26:06 Yeah. There was a case we had, Thankfully, it wasn't, it wasn't mine. It was one of my colleagues.

26:10 And they couldn't get it closed.

26:12 And they, they called over the, the cornea specialist. Yeah.

26:14 And they actually got a piece of donor cornea- Yes like a patch graft for tubes, shoved it in the wound, and then sutured it.

26:21 And that was the only way they were able to get it closed.

26:23 So sometimes they can be so big that you can't- Yeah.

26:26 You can't close them. And, and mattress.

26:27 Mattress suture is the answer.

26:30 I'm gonna call up, Dr.

26:31 Rosamena next to speak on sustained-optic capture drug delivery.

26:36 Whenever I've worried about that, um-- like I said, I've never had one-- is some of really dense lenses where you put some OVD to create an OVD cushion behind the really dense lens. So while I've put extra viscoelastic in for those, I've sometimes worried about this, watched for it, but I've, I've not seen it.

26:51 So but it's great to see the initial sign to recognize if it does happen.

26:56 Okay, let's get started.

26:59 So my main thing, and, and I think some of you have seen this slide before, is that we need to change the way we treat glaucoma.

27:06 We need to start doing drops as that in-between treatment, between treatments that actually will last for the patient.

27:15 And I got this argument the other day, I don't know if you guys have heard it, "But SLT is only gonna last two years." And my response was, "Drops last twenty-four hours." And I think the new movement for extended release and appropriate treatment will be able to prevent this from happening.

27:33 I wish I never had to get a referral with a nerve like that because we should catch these patients way earlier.

27:40 There's a vicious circle that happens when you have a patient with Glaukos.

27:45 You already said it. They don't understand it for cataract surgery.

27:48 For glaucoma, they understand a little less.

27:51 They think you're gonna cure them.

27:53 They think this is not progressive.

27:55 And our treatments usually are worse than the disease for the patient.

28:00 You know, the eyes get red, the vision fluctuates, and we end up in this vicious circle that is very hard to break, and that vicious circle leads to vision loss.

28:10 So once we break it, there's no way this patient is gonna be taking his drops.

28:15 He was quite afraid. I mean, he, he was using them.

28:18 We had to stop them.

28:20 Or sometimes the patient is using the drops.

28:23 But as you can see, that's number three, number four.

28:28 Here it goes. Eight, five.

28:30 Okay, some of it got in.

28:33 Seven, eight, nine, and she blinked the drop in.

28:38 So even if they're trying to be compliant- Wearing a mask.

28:41 Yeah even if the patient really wants to be part of the treatment, they may not be able to get there.

28:49 So extended release, to me, is part of that new generation of treatments.

28:54 It makes interventional glaucoma.

28:56 We're taking compliance of the patient's hand, and every single patient will benefit from it. And the way I think of it is head to toe.

29:07 And I'm trying to If you haven't started sustained release, my thought is start with the low-hanging fruit.

29:14 Anybody with dementia, anybody with any kind of cognitive and that needs a caregiver most likely is not getting their medication.

29:23 If I have to feed you, clothe you, bathe you, putting a drop is kind of in the last part.

29:29 So all of those patients are low-hanging fruit to start your journey through extended release.

29:35 Anybody with shoulder issues, I can tell you I had a rotator cuff.

29:40 It was really hard to even brush my hair.

29:43 Putting a drop would be really hard.

29:45 And then you go to all the ocular cosmesis and then compliance.

29:49 There's plenty of studies, plenty of companies going into this.

29:55 We only have two approved, but there's more than ten in the market.

29:59 We have different rods, plugs.Sprays.

30:04 We also have IOLs that are coming in with, extended-release medication.

30:09 We have multiple canisters with multiple medications in the works.

30:14 So this is like the new frontier in, on glaucoma at the moment.

30:18 Now, there's two approved devices, two approved drugs: bimatoprost sustained release that is placed in the office or in the operating room, and then you have travoprost in a canister. Now, bimatoprost SR is one drop of bimatoprost that you place inside the eye, and it will give you up to 18 months of treatment.

30:46 It's biodegradable.

30:48 It is one millimeter long.

30:50 It's non-preserved, and it comes preassembled in a 28 ga- gauge needle.

30:56 Now, when you prep the eye, you can have some hyperemia.

30:58 Multiple implants did show some damage to the endothelium, so it's approved for one implantation.

31:07 And, we are able to see results up to 18 months.

31:12 Now, 77% of patients to 18 months gives you a year and a half, almost two years of treatment without having to put drops in the eye, without requiring compliance.

31:26 And going back to your case, Tom, that patient most likely was not being very compliant if he was getting worse in four or five years.

31:35 So that would've been an option, and, and I would've actually jumped onto that.

31:41 I think it was before the times for this.

31:43 I do it in the office.

31:45 I do nasal and temporal if I'm doing bilateral, and I don't even use a speculum But this is one of the patients.

31:56 I do a double-click technique.

31:59 Do we have a pointer? I do a first click, a second click, and come out.

32:04 I'm zooming in. Usually, I aim inferiorly.

32:07 What you're seeing there is in order to be able to see the implant, you wanna go in two bevel lengths inside the anterior chamber, and there you see it come down.

32:18 As I said, I usually go superior or inferior and aim to the lower angle.

32:25 It's just hard to get a good video when you're doing that. Okay.

32:30 Now, the next implantation we have is the travoprost intracranial implant.

32:34 This is different. It doesn't disintegrate.

32:37 It's a travoprost honey that is inside this titanium canister that you can exchange at three years if you desire.

32:47 It measures 1.8 millimeters.

32:50 You're gonna have 1.2 millimeters of this canister in the intracameral.

32:55 It is preservative free, and this is around 40 drops of travoprost, but this will last 30-- I'm sorry, 30-- I'm sorry, three years.

33:06 I'm sorry. I was gonna try to math 36 .

33:10 Now, what are the advantages of all of this?

33:13 Well- Thanks you're not having compliance, and we already established compliance is the hardest thing.

33:21 My favorite lines from patients are like, "I am religious with my drop." I really like that one.

33:28 The other one I love is, "I just ran out last night." "I swear I did get it," but they haven't filled their prescription.

33:38 And the other one is like, "What color is your drop?" And they're like, "Uh." And you've been putting this every day of your life, and you don't know what color the cap is?

33:49 So compliance to me is the biggest issue, and being able to bypass compliance, to me, is what makes all of this pretty important.

33:59 Now, prostaglandins are the strongest medication we have in the market.

34:04 I expect all of this to work.

34:07 Side effects are the concerning part.

34:10 With the travoprost implant, they did not see any endothelial cell loss, which was very, very important to me.

34:18 And you get great results in IOP drop, with most of the patients being out of medication.

34:26 The placement of this device, it's in the operating room.

34:29 You got the canister.

34:30 If you compare it to the IStent, you're gonna push harder than what you push with the IStent when you're pushing on the iDose.

34:39 Once you embed that barb into the sclera, you're gonna check that it's not moving.

34:46 And with this- Don't go there I'm gonna go to issues that we can see, and I'm gonna be asking the audience. I have to say, it was hard to find issues with extended release.

34:59 Number one, okay, when you go in, you're gonna go two bevel lengths in.

35:06 But what happens if the patient moves and you end up with this?

35:12 Nate, what do you do if you end up with this?

35:16 It never happens. Yeah.

35:20 You call, you call a cornea surgeon.

35:22 Is it stuck inside the cornea?

35:24 It is-- The patient moved- Okay and the device was deployed inside the stroma of the cornea. Oh.

35:32 So- That's before and after, so patient had a great result, just FYI.

35:37 So, so, first of all, time is of the essence.

35:40 You don't wanna deal with this the next day after it starts swelling, right?

35:45 Could they push it back out from the inside through a separate paracentesis at the perfect angle? Well, I, I would say the opposite.

35:52 Anybody else has any other, thoughts?

35:56 This is intrastromal? Intrastromal.

36:01 Okay. I'd just go through the same- So I'm- same para and just push it inBut you can push it in.

36:06 So there's a couple of things that you wanna keep in mind.

36:10 If you're trying to go in with a needle, you're gonna take that implant and crack it, or you're gonna create another path.

36:17 They actually do have a little device that can help you push it through.

36:22 It's a blunt device that will push it in.

36:24 But- They usually can't find it. Correct.

36:26 If, if you're not- Or it's not sterile.

36:28 It's not sterile. But Dr. X actually went into the operating room and, and I didn't wanna disclose the name of the doctor, but they actually just irrigated it out. Yeah.

36:39 Kind of broke it apart because after it has swollen up, it's very hard to push it through.

36:44 Yeah. I know some people that have actually left it in, and there hasn't been an issue.

36:51 So just keep that in mind.

36:54 It is important to get the two bevel lengths in.

36:58 Now, another tip is that the device can be very sticky, so warm it up before.

37:04 It really helps if you take it out of the fridge, and I, I have them, I have my- my technician kind of walk around with it and warm it up because it does make a huge difference on how not sticky it is.

37:19 As we go through, this is Paul's video, and he's talking through this.

37:24 But he waits and waits, and he's still filming, and he waits, and the thing is still stuck. And he massages a little, so he just went in and pushed it out.

37:40 Now, reality is, if it's not in the wound, you can just let it be.

37:45 I usually leave my patients be, go see other patients, sit them outside, and then and see them.

37:52 But this next one is a patient of mine.

37:57 See, it ni- it dropped nicely.

37:59 This is a patient of mine.

38:01 This had been like 30 minutes after, and the thing was still in, so I just took a 30 gauge and tried to remove it.

38:09 But as you can tell, this is sticky.

38:12 This is very sticky. Okay, maybe if I rub it on the iris.

38:16 Let me see. Let me go in the pupil.

38:17 No, I'm gonna rub it down, all the way down, and the thing is just not coming out.

38:23 Well, roll it.

38:25 Oh, magic.

38:26 It's down, and it's gone.

38:28 And this is one of my favorite videos.

38:30 It's from Dr. Ayala. Take a look.

38:31 Wait, wait, wait. Oh.

38:34 Okay. Okay. What do you do?

38:36 Okay. Hold on. What do you do?

38:38 Guys, what do you do about this?

38:42 Leave it. Leave it.

38:43 Leave it, yeah. Wait it out.

38:45 I would leave it. Well, I am very happy that Ramesh actually waited it out, still recording.

38:52 Waited out.

38:54 Wait, wait, wait.

38:57 Oh. It is in.

39:03 And even if I tried to replicate this, I could not get this to happen.

39:08 I've tried to get my bubbles there, and it nicely settles at the inferior angle.

39:18 I mean, how I mean, impossible.

39:20 So what do you guys think is this?

39:23 I got a call for an emergency.

39:26 There's an Eydos in the IC and everything's swollen.

39:30 Then again, this, of course, most likely were maltracking residents.

39:33 They could not differentiate six millimeters from one millimeter.

39:39 Because this is not a one-millimeter implant.

39:43 This is actually for the retina guys in the room, an Ozurdex.

39:49 This is an Ozurdex that was in the vitreous.

39:52 Through that inferior PI, it pushed forward, and this is an emergency.

39:59 The Ozurdex will destroy the cornea.

40:01 It is an emergency.

40:03 You have to Popeye back, take it out.

40:05 We just popped it right back out and then put a stitch on that inferior PI.

40:11 But do remember, Ozurdex is an emergency.

40:14 You are supposed to have an Eydos in the IC. Decades.

40:17 How did you Popeye it out?

40:22 How did you Popeye it out? Did it scare him? Yeah.

40:25 We pushed it back in, and then we brought the patient back into the operating room and made the P. acnes smaller. This is another case.

40:35 I've heard of two, cases.

40:38 She just left it. So why do this happens?

40:41 Guys, do you tell your patients anything after any of these implants?

40:48 No? So I tell my patients Did we establish that patients are not compliant?

40:53 So I, when I put any of these devices, I tell the patient that they need to stay vertical, not watch their phone, because this is not vertical, for three hours, and I put it in a little paper that they get because I want that implant to settle in the inferior angle.

41:10 This patient went home and took a nap.

41:13 And that's why you have the implant in the IOL.

41:16 Now, this hasn't happened to me.

41:18 I would take a 30 gauge and wipe it off right there in the slit lamp.

41:22 You can try to YAG it or just leave it if it's not affecting vision, but this is because that patient did not follow instructions.

41:32 And why is this not moving?

41:34 All these are cases. And we're almost done.

41:36 Let me show you a couple of Eydoses.

41:41 So the Eydos is placed.

41:45 They already did a large goniotomy.

41:48 And oh, oh, why did this go back?

41:52 Hold on. Let me see.

41:55 I cannot, I cannot stop it.

41:58 Guys, can you help me out?

41:59 Can you play it? Pause the video? Yep.

42:02 And then pause.

42:03 Yep, keep going a little more.

42:05 Oh, I have the, I have the mouse.

42:06 Nope, the mouse doesn't work.

42:08 So what would you guys do once you have that?We can pause it a little more, a little more.

42:18 And nope.

42:19 Okay. We can pause it there.

42:21 What's the answer, guys?

42:24 Re-implant. Okay.

42:26 It popped out? I didn't see it.

42:28 So if you see the implant wiggle- it is not implanted correctly.

42:34 Just re-grab it, push it in.

42:37 You have to push harder than what you push for an stent.

42:41 And if you already unroofed the TM, you're not gonna have that support, so push a little bit harder.

42:49 You can play it again.

42:54 And that's exactly what they did.

42:56 Viscoelastic.

42:58 Do yours re-grasp.

43:01 Make sure you do not bump or fist bump that cap- because you can dislodge it and actually damage the membrane.

43:11 This is a patient from Dr.

43:12 Sarkissian, that had trauma, got hit in the eye, and it was time to explant it.

43:19 He was part of the studies.

43:20 And they just aligned it, grab it with some MIBS, and removed.

43:25 We do have a code for re-implantation after.

43:30 And, and the removal, as long as you keep it straight, is- Yeah.

43:33 I would, yeah pretty straightforward because this is what you see with the patients after.

43:39 One eye is red, inflamed.

43:41 This is a week out on this patient.

43:47 This is an eye on a different patient that had Look at the difference between the ectropion, the irritation in the eye, the way the patient feel in the eye that did not have the implant compared to the eye that had the implant the week after.

44:07 So it does change quality of life.

44:09 It does change the way the patients feel.

44:12 And just to recap, every single patient will benefit from extended release.

44:19 Thank you.

44:27 Great job. Thank you. Our next speaker, Dr.

44:29 Jelani from right here in Charleston, minim- minimally invasive filtration surgery.

44:34 Hi, everyone. Thank you for being here and spending some time with us on Saturday morning.

44:39 So let's go right into the these are my financial disclosures.

44:45 Audience question. We can just do a show of hands.

44:47 So what is the primary factor currently limiting your use of filtering surgery such as trabeculectomy?

44:54 Risk of hypotony or related complications, or burden of postop, postop, postop bleb management, operative time or surgical effort, variability and unpredictability of outcomes, or all of the above?

45:11 Yeah. Well, anyone who's doing filtering surgery, all of these are real. So how are, how are you currently using minimally invasive bleb-forming surgery in your practice?

45:22 A, early to moderate disease only, B, refractory post-failure cases, C, across the disease spectrum, D, I refer out, I don't wanna deal with the bleb, or E, I'm planning to learn more about these MIBS procedures and maybe adopt in the near future.

45:40 Well, so any of these, answers can be the correct answer.

45:45 So hopefully we'll be able to, answer confidently after this, presentation.

45:51 So even though we have so many different glaucoma procedures and in this era of interventional glaucoma, we still have to choose between safety and efficacy of glaucoma surgery.

46:04 Minimally invasive glaucoma surgery, the main advantage is really the safety, and it's so much so that now we are claiming that it is safer than drops.

46:13 Now we can use it as a first-line therapy for early glaucoma patients.

46:17 But we all know the limitation of minimally invasive glaucoma surgeries.

46:21 We can't achieve the IOP below episcleral venous pressure of that patient.

46:26 And anyone with a distal outflow pathway resistance, you just cannot lower the pressure below certain level.

46:33 And all these patients will end up needing more medication that we try to get away from, and eventually need a filtering surgery, which is still gold standard in achieving the lowest I- IOP. However, we all know it is still very invasive, higher complication rate, and post-op burden and variable outcomes, and that's what really limits our use of in our patients.

46:57 So to answer these challenges, this is a very, very simple solution.

47:03 It's just a twenty-two gauge needle with a reverse cutting edge on the left side.

47:08 It is implant free.

47:10 You can do it ab externo in a minimally invasive way.

47:12 You don't need any suturing.

47:14 You don't need to create a flap, and it is bleb forming.

47:19 So here's a bench top research, research that was done in, Utah in Morania Institute.

47:25 You can see that it what it showed is that it whenever you use this device to create a tunnel, it is very reproducible in creating a bleb.

47:33 And also size of the bleb, size of the tunnel can be modulated by the number of passes.

47:41 And most interesting finding from this bench top research is the fact that when the IOP is high, outflow increases, and when the IOP is low, it decreases, which means this tunnel that's created is not just a hole in the eye.

47:58 It works like a valve, natural valve system.

48:01 So it collapses as the IOP goes down, and that's how it protects the eye from hypotony.

48:08 So this is how we perform it.

48:10 This is a seventy-seven-year-old male on, you know, pressure is, mid-twenties on four class of medication. As you can see, the ocular surface is really irritated, and patient is not doing very well with the drop.

48:22 Here we are going to prep the eye.

48:25 We mark the eye two millimeter from the limbus.

48:27 That's where we're gonna start the tunneling. And then we'll inject lidocaine with epinephrine for local anesthesia and to prevent bleeding.

48:37 You don't wanna have a big bleb here 'cause, you won't- you don't wanna interfere the view, so we're just, massaging the eye to gently distribute it evenly.

48:48 And then we'll fill the eye with the viscoelastic.

48:52 Use a cohesive viscoelastic so that we can have a firm eye.

48:55 It's actually very important to have a firm eye to have a more predictable tunneling.

49:00 And then we start tunneling right at two millimeter from the limbus, and then you point towards the cornea. Now, this is the implant free, right?

49:09 So you don't have to be, like, s- close to the iris.

49:12 And then you lean towards where the reverse notch is, and we just pull it with conviction.

49:20 Here we go. Fancy. And once we remove the viscoelastic, you will see the bleb rising.

49:26 There we go. So this is another reason we wanna use a cohesive, because it's a lot easier to remove.

49:30 It's actually important that you remove most of your viscoelastic so that it doesn't block the ostium.

49:36 And here's a thirty gauge needle.

49:37 We're doing a primary needling here to prevent the tenon block- tenon blockage of external ostium. So just, gently sweeping.

49:46 And we have a mitomycin here, injecting it posteriorly.

49:50 Typically inject point one or point two CC of a, point two milligram per CC of a mitomycin.

49:58 And there you have it. It's very simple procedure.

50:02 And how are the results?

50:03 These are the earliest results, of, patients who have completed up to twenty-seven month follow-up.

50:09 Most of them completed one m- one year follow-up.

50:13 So twenty-six eyes, five of them had it in both eyes, eighteen of them as a standalone without phaco. We divided these groups into surgery naive versus those people who f- failed the prior filtering procedures.

50:25 Mean IOP was twenty on three classes of medication.

50:29 And at twelve months, with the Everyone had a one pass.

50:32 We kind of talked about if you do several passes, you can actually increase the, the, the IOP and also the T1 S1 size of the tunnel.

50:39 But with the one pass, we saw that most patients actually achieve the IOP of eighteen or lower.

50:46 But in patients with, who never had a surgery, or bleb forming procedure, most percent of patients achieved a fourteen or lower.

50:57 And medication as well, si- sixty, thirty, sixty-three percent of patients were med free, but in surgery naive eyes, eighty percent were medication free and still achieved the IOP target.

51:10 Needling rate is, I will say, slightly better than XENs, ab-external procedure, so thirty-eight percent overall and only nine percent in virgin eyes.

51:20 And this is what the bleb looks like.

51:21 It's barely visible, kind of similar to the XENs bleb.

51:26 It is posterior, it's diffuse and low, very comfortable for the patients.

51:30 I will say on day one, patient's vision is back to baseline already because it's not inducing those irregular astigmatism.

51:38 This is seventy-eight-year-old male.

51:39 At two months, IOP is twelve from twenty.

51:42 He's off medication.

51:43 At seven months, it looks exactly the same.

51:45 When you do the anterior segment OCT, you will see all those microcysts.

51:48 And you know, sometimes you can't see the bleb, but, but you know it's filtering because of the IOP. And our initial results of our own patients have been recently, presented at the AGS, and here my research fellow, dedicated research fellow, Dr. Irfan, is going to, present it in other conferences and also writing up the paper, so you will hear more about it.

52:12 Our Storm Eye is also doing the first human trial at the, in US.

52:17 And we are collecting our one-year data.

52:20 It's almost finished, so you will hear more about it soon.

52:23 So thank you.

52:30 And now we're going to what would you do?

52:34 Let's see. Can you just go back to the same presentation?

52:41 Okay, so this, I titled it as "Ibis that keeps on giving." So this is, we are doing the AquaLumen case. Here we go.

52:50 We just, pull it out with conviction.

52:52 I'm like, "Yeah, that was easy." All right, so let's have a look at the gonios.

52:56 I'm like, "Oh. Oh, sorry." Can we stop?

52:59 Let's, let's go back.

53:01 I'm, I'm, I'm, I'm- Go back to the same video.

53:06 I mean And then- Yes.

53:08 Yeah, we can advance to that point, and then we can stop.

53:11 So basically, the gonios was showing that iris was prolapsing into the internal ostium.

53:17 It's hard. So stop right there.

53:19 No, no, this is not- Okay. So we can go around the panel and what would you do? Personally, I, I, I don't know if you pre-treat with a miotic, but I would certainly do that to try to prevent it from happening.

53:31 But I would just do a, a para and, and just do a, a, a iris sweep- Okay.

53:36 Well- maneuver and, and use a miotic to keep preventing it from happening.

53:39 But I would also, worry that it's gonna happen again, post-operatively.

53:44 That's exactly what I did and what happened.

53:47 So let's play it.

53:50 We can play the video. Yeah.

53:52 So I was like, "Okay, great." This is a phaco patient, by the way.

53:57 Clear lens. So okay.

53:58 So I'm now using the m- Omidria.

54:01 Miocol works right away.

54:04 So kind of putting it underneath the viscoelastic before I remove the viscoelastic so that it doesn't collapse through the para, even though it actually still happened.

54:14 Here we go. And, the viscoelastic I used here was a Helon5, so it's a super cohesive.

54:19 Okay, so getting the iris out of the way, out of the ostium, and then here we go.

54:26 That worked. And yeah.

54:28 Okay, you can stop. Now what do you do, DURAVYU?

54:33 I think you just put him on your, cataract schedule.I wish I did the biometry.

54:40 This eye is asking for a surgical iridectomy.

54:43 Yep. Little paracentesis, pull it out, snip it off.

54:49 Or micro instruments if they have them handy.

54:51 I usually don't have the patience to wait for them to find them.

54:56 So you will do superior corneal incision- Yeah pull it out, and then do a paracentesis.

54:59 Small paracentesis, pull out the iris. Mm-hmm.

55:02 Make a little I mean, you can go through paras and just do it, with MS- Yeah instruments and, and ties and the scissors and, and, and- Mm-hmm do that without poking.

55:11 Well, I wish y- I had you as my advisors, but let's see what happen.

55:16 We can roll. So I'm like, "Okay, well, let's get the iris out of the way first." And then what I decide to do is like, "Hey, the reason that it keeps prolapsing is because it's too posterior, so let's make the lumen a little bit more anterior." So I'm going in, back in with the AquaLumen.

55:36 Now we are going to angle up higher so that ostium ends up slightly more superior to the previous one.

55:45 So let's see.

55:47 There we go. Stop right there. Okay.

55:49 Well, actually, let's roll. Keep rolling.

55:52 So I'm like, "Yeah. Okay.

55:54 We, we got this now." We're removing the viscoelastic.

56:00 And then now iris is coming towards that so that's why I made another to get the iris out of the way. I'm pre-hydrating so that that prevents the iris prolapse, and there we go.

56:12 That's really not aqueous.

56:13 That's gonna be caravan. Okay.

56:15 Hydrating really aggressively, so there we g- Ah. Ah.

56:19 Yeah. Now we got two. So we can stop there, or maybe I should've just done the iridectomy, but I was just, like, a little bit reluctant to do that because I'm like, "Oh, it's supposed to be minimally invasive.

56:28 Oh, this phakic patient." I'm like, "Ah." So what I d- ended up doing was actually putting a dollop of Visco, like a dispersive viscoelastic right on the top of where it was prolapsing, and then I kept the patient on Pilo.

56:42 So maybe we can roll.

56:43 It shows- Iris that here I'm coming in with the viscoelastic- This- Viscoat specifically, and then put it on the top of the iris.

56:55 It works well for phaco, iris during phaco as well if it keeps prolapsing the main one.

57:02 So I confirmed that there's no iris through the ostium, and then I left it at that.

57:08 And patient is actually doing well.

57:10 Maybe I was lucky, but that's something that you can consider in these kind of situations.

57:15 Well, thank you. Thank you.

57:21 Thank you, Jela. While Devinder comes up, and DURAVYU- Grover is our next speaker, who's gonna speak on uveoscleral outflow procedures.

57:31 I've added XENs, and, and this would qualify as well, as would suprachoroidal procedures, as things that can fail spectacularly.

57:40 They can work fantastic, but if they fail, they're not gonna fail gradually- Correct in some instances. And, and I add XENs to that because I had a case who had been doing great for, like, two years.

57:51 Beautiful bleb. She came in, pressure was, like, ten like it had been for years, and then she came in and it was, like, fifty- Mm-hmm, mm-hmm, mm-hmm and had significant progression. But she, she had been dilated, and, and just that excursion of the iris caused a little knuckle of iris to block it.

58:08 And so when I teach XENs, I say, you know, "You don't wanna be in the endothelium, but also I'd rather be, frankly, a little closer to the cornea than the iris with XENs for, for that reason, that particular case." So this, you know, you'd worry about, occlusion with iris with some of these, sclerostomy techniques, but, just a little thought there on, on that. Devinder. Excellent.

58:30 Well, thank you all for having me. Tom, great session, and everything's going really well. It's nice to have this conversation.

58:36 It's great to be here.

58:37 I'm gonna speak on super- the su- suprachoroidal space.

58:40 Pertinent financial disclosures are I do work with, Eydrk and iStar Medical, both of which I'll be speaking about today.

58:47 I wanna talk s- first about what this space is, and the surgeries that for this space, the problems with this space, the perceived problems with this space, and then what the future hopefully holds. So, you know, this is a virtual space, between the outer choroid and the inner sclera.

59:02 What makes it so desirable is that there's an inherent, pressure differential.

59:07 And, you know, Carol Torres showed that there was a, a good capacity for, to, for this space to handle aqueous. And actually, if you look at the, the capacity, it outperforms the eye's ability to make aqueous.

59:20 So we know this space, can handle, handle the surgery.

59:24 And what are the available options globally right now?

59:27 We can obviously make our own.

59:29 And then Miniject, is not available in the U.S., but it's available in Europe, and then AlloFlo.

59:34 But this goes all the way back to the 1900s, where when the first, cyclodialysis cleft was made by, Dr. Hein.

59:41 And it was actually one of the most common procedures done, early on.

59:44 And then in the, in the '60s, well, in the '50s, it went ab interno.

59:48 We have better imaging with, with some gonio prisms and thinking about inside the eye.

59:53 And then, and then come the '60s, that's when the optomes and the trabeculectomies kind of take-- took hold. And it wasn't until kind of, I guess, XEN came out in the, in the 2000s that, that we started having a renewed interest in this space.

01:00:05 And then there have been multiple attempts, at, at, you know, b- from different industries to, to get this something on the market, and none of which have really, come to well in the U.S.

01:00:16 Yet. And let's talk about Miniject.

01:00:19 So Miniject is this proprietary, silicone structure.

01:00:23 The vast majority of it is space.

01:00:26 And, it's about five millimeters in length, one point one millimeters wide, and about point six millimeters thick.

01:00:33 It was developed at University of Washington.

01:00:35 It's this soft, flexible thing.

01:00:36 And you see this, this green little strip.

01:00:38 That's what's supposed to be seen in the i- in the eye when it's implanted appropriately, right there. And-It's an ab interno approach, blood-free and, and you, you-- it creates a space and, they've done some, here's the-- this is from the FDA trial, that is no longer going on.

01:00:57 It's all these technologies basically have a sleeve that, that creates a cyclodialysis cleft- Yeah. -uh, and then the sleeve will retract and leave the structure in place ideally in the mo-- in a, in a, in a good place.

01:01:10 You do get some bleeding, and that's what you have to manage by just keeping the anterior chamber formed. And then you'll see this little wa-- the little green strip, coming out as the sleeve retracts.

01:01:21 And this is a little spongy. It's kinda hard to push in, but you can.

01:01:24 I, I manipulated it a little bit, but it's pretty hard to push in, and that's kinda the ideal, ideal place for it to be.

01:01:30 You can see that patient prior-- previously had a goniotomy.

01:01:34 Wound healing. We don't understand wound he-wound healing anywhere in glaucoma. We definitely don't understand wound healing in the suprachoroidal space.

01:01:40 This is a rabbit eye that showed that after about six months, you saw some infiltration of macrophages, and it was getting healed, but you can see how it gets infiltrated, by everything.

01:01:50 But they were still able to demonstrate that there was still some pretty decent flow intact in this structure. This is a meta-analysis of a bunch of different trials globally from all over the- -all over the country at different T1 sites with about two years of follow-up.

01:02:05 And, what, what you saw, and this is what you're seeing across the board, and again, when you look at a population level or large level, it doesn't give you the nuances of what happens in your clinic.

01:02:14 But you are seeing a significant and sustained drop in pressure, a significant and sustained drop in medication required, and a lot of patients did well.

01:02:21 You know, almost ninety percent had a greater than or equal to twenty percent reduction in IOP.

01:02:27 Almost a little bit more than a third were off all meds.

01:02:29 And then endothelial cell loss, plus or minus nine percent was, was about six.

01:02:34 And nobody had a significant amount of endothelial cell loss.

01:02:38 This is my AI-generated slide.

01:02:39 Couldn't help but have a few of those in here.

01:02:42 But you're seeing again, a-- what we're seeing patients o-- decrease drops, decrease meds, sorry, and IOP and, and pretty safe to the endothelium compared to CyPass.

01:02:53 And it says twenty percent on CyPass.

01:02:54 That was in those patients that had the longer, exposure of the CyPass.

01:02:59 IOP spikes are, you know, the, the elephant in the room.

01:03:03 Out of these, eighty eyes, ten patients had IOP spikes.

01:03:08 That's something you've gotta keep in mind when you're doing these in patients with advanced glaucoma.

01:03:13 But again, this is glaucoma surgery, so you, you-- there's no free lunch.

01:03:17 Now talking about AlloFlo, this is approved in the US.

01:03:20 Well, there's no appro-approval required because it's a, it's a tissue, not a device.

01:03:24 And you're gonna see the video on it.

01:03:25 You're creating a cyclodialysis cleft, and you're using these acellular scleral spacers kind of And, the, the company recommends putting in two kind of as bookends.

01:03:36 And these spacers are, about, five millimeters in length and about five hundred microns in, in, in width and hei- and height.

01:03:47 Same thing, putting a sleeve in.

01:03:49 The sleeve is retracting and leaving it in place.

01:03:51 The scleral's a little bit more, robust, and you can actually push it in a little more and manipulate it a little bit.

01:03:56 This is a, a great video.

01:03:57 Usually, you will see some bleeding, but this is a really great video.

01:04:01 All my videos are not this good.

01:04:03 And, but really nice control of, of heme.

01:04:06 And then you can see the cyclodialysis I've created, and then the spacers on, on the space in the middle and, a nice demonstration of what the, what the procedure, ideally should look like every time.

01:04:19 And these spacers ideally keep, keep the cleft open to prevent any kind of scar tissue from forming. Again, you're seeing similar, similar outcomes.

01:04:27 Again, a s-sustained release, a sustained drop in pressure, a sta-sustained decrease in medication, over time.

01:04:35 Safety-wise is there.

01:04:36 These are stan-- one of these are standalone, but some of these are in combined with cataract surgery with the CREST trial.

01:04:41 And, but, and then also, pretty good health on the endothelium, and I'll talk about that.

01:04:47 But let's talk about endothelial health in general.

01:04:49 You know, trabeculectomies give you damage to endothelium.

01:04:52 Tubes give you inevitably damage to epithelium.

01:04:55 The big s- thing that hit CyPass, was, was the damage to the epithelium.

01:05:00 And, you know, you see, some damage, to the epithelium with Miniject, some with AlloFlo.

01:05:06 There's not a lot of data published with, with AlloFlo.

01:05:09 This is an AGS poster, and then one, one paper that shows, endothelial cell health with, with AlloFlo.

01:05:15 But we're seeing similar numbers, right?

01:05:18 And, and this has, I think, been such a barrier to entry to the market, especially by the, by the FDA. The big picture is, and maybe you guys might disagree with me, but I mean, we can replace the endothelium, right?

01:05:30 That's not-- That's pretty, pretty safe.

01:05:32 We can't replace the nerve tissue.

01:05:34 And, and so I don't understand why there's such a big deal of being placed on this thing.

01:05:39 And, and also, you know, measuring the endothelial cell count is like the tonal pen of, of, you know, glaucoma.

01:05:44 You get a different measurement every time you do it.

01:05:47 But this is my, my approach to the suprachoroidal space.

01:05:50 I think it's gonna be not in the Phaco iStent type of patients.

01:05:54 These are patients that have real Glaukos.

01:05:56 So it's patients I think you can do in standalone.

01:05:59 Basically patients that are inadequately controlled likely after angle surgery- -maybe after a, a, a MIBS procedure and patients that you're really trying to avoid doing a trab and a tubin. And, you know, the-- what's the nice thing about the suprachoroidal space is that you don't lose real estate, so you can always or a tube or a MIBS later.

01:06:18 But, the surgical learning curve is pretty, pretty low, and you don't put the patient at lifelong risk for erosions or double vision or endophthalmitis.

01:06:26 The big problem is it is unpredictable.

01:06:28 We still don't understand it.

01:06:29 You can get some endothelial cell damage.

01:06:32 It can cause, hypotony, and we just don't understand this space well at all.

01:06:37 So I think it is a relatively safe and effective surgery, but there are some unexpected side effects we, we still need to learn to manage.

01:06:44 We need to understand this space.

01:06:46 We, we need this option in the US.Uh, and I think the FDA needs to understand, you know, having a rational pr-approach to the patients that would truly benefit from this space.

01:06:57 It's not the, the mild patients that need a cataract surgery that are, you know, healthy nerve and a pressure of twenty-one.

01:07:03 So thank you for your time.

01:07:10 Okay. So, this patient did come to me on April 1st.

01:07:14 No joke. So, and, and so don't let In fact, I was come up with a funny different titles, but don't let inflammation and angle closure f-make a fool of you or fool you.

01:07:23 So, this is a fifty-seven-year-old African-American female, comes to me from a, a cl- a cataract doc in town, after, uncomplicated cataract surgery two and a half weeks later. She's got a five-year history of, of diabetes, relatively decently controlled, but history of not being well-controlled.

01:07:41 Is on a bunch of meds for diabetes and high blood pressure.

01:07:44 The only, And she's on acetazolamide for the pressure being so high.

01:07:48 She's on dipyridamole and, and, diclofenac.

01:07:51 She's count fingers in her surgical eye, and, her pressure's forty-three.

01:07:56 She's flat, three sixty IK touch, has a, has some corneal edema, a fibrous, membrane, over the pupil, and, her left eye is, is phakic and, and is, is deep.

01:08:09 Gonio, she's closed, but the fellow eye, which is always important.

01:08:12 Anytime you're seeing a closure, right, you need to gonio the fellow eye to understand what the heck might be happening.

01:08:16 Angle is open. You know, a-average axial length.

01:08:20 She's myopic in her left eye.

01:08:22 Can't really obtain anything in her, in her surgical eye.

01:08:24 She does have an OCT that she came in with ha- that shows diabetic macular edema.

01:08:28 She has on her chart was d- history of, proliferative diabetic retinopathy.

01:08:33 And on UBM, she has some suprachoroidal.

01:08:36 So, just to show hands quickly, how many of you guys have seen this kind of situation after cataract surgery? Yeah.

01:08:44 And, you know, this is acute angle closure.

01:08:48 It's pupil block, right?

01:08:50 Is this primary angle closure?

01:08:52 No, 'cause we gonio'd the other eye and, and see that her other eye is open.

01:08:54 So it's not primary angle closure.

01:08:56 Could this be aqueous misdirection?

01:08:59 Yeah, maybe. But, but again, she has a fibrous membrane and she's, you know, slightly myopic in her fellow eye.

01:09:05 She's open. Usually, we'll see, aqueous misdirection in hyperopic eyes and, and so it's, it's unlikely, especially with the level of inflammation.

01:09:14 So, you know, how do, how do you treat?

01:09:15 And, you know, Jella had, talked about using pilo in, in, in that case with, with the, with the floppy iris. You know, do you use pilo?

01:09:23 Do you atropine? What do you, what do you, what do you do here?

01:09:25 Do you drain the suprachoroidals? Do you just refer to another, another doctor and wonder why, why this has happened to me on April Fools' Day?

01:09:32 Am I the, am I the fool?

01:09:34 So- DURAVYU, did you know that You couldn't see the suprachoroidal clinically, I guess.

01:09:38 It was just- No, I couldn't see anything.

01:09:39 There was a fibrous membrane- So, so until you got the UBM, you were a little bit more of a diagnostic quandary really, right?

01:09:45 Well, yeah. I mean, I just I did it just 'cause it was April Fools' Day and I was waiting to get kicked in the butt.

01:09:49 You know, talking about glau- you know, any kind of surgery- 'Cause it is an important, it is an important finding to help differentiate what's going on.

01:09:55 Yes. Yes. So, yeah.

01:09:57 And that also, I mean, it cinched the diagnosis that this was an aqueous misdirection, which I didn't think it was.

01:10:02 And, and so, you know, what do, what do you, what do you guys think?

01:10:06 I have a question. Was it Bombay?

01:10:08 If you have a pupillary membrane, I mean, at this point, you're having an acute angle closure. Yeah.

01:10:12 You just have to break that attack first.

01:10:14 I mean- Exactly. Exactly.

01:10:15 This is a thirty gauge.

01:10:17 Yeah. Take the membrane.

01:10:19 Well- Get the pressure down and then reassess to see what else you can do.

01:10:22 And that's my general approach to patients with angle closure, is you gotta do a paracentesis.

01:10:26 I almost got dinged on my oral boards 'cause that was my immediate answer and they're like- You wanna stick a needle in the eye first before you do anything?" And I was like, "Okay.

01:10:33 I'll put them on drops, and whenever the drops don't work, then I'll stick a needle eye." But yeah. But yeah, that was, that's what I usually do with my acute angle closure.

01:10:41 And this lady, the eye was still pretty steamy.

01:10:44 There was not a lot of space, but it was pretty classic Bombay.

01:10:48 So I actually, and I didn't get a picture on the day of.

01:10:53 I was distracted by April Fools' Day and my kids played a bunch of tricks on me.

01:10:57 But, but the key thing is this, is And this is inflammatory.

01:11:01 These patients are prone to inflammation.

01:11:03 The key thing is make more than one LPI.

01:11:05 So you can see I made one at, at nasal and one inferior.

01:11:09 This was three days later, because one of them is inevitably gonna close, right?

01:11:13 So just do a few because one's gonna inevitably close.

01:11:16 You atropinize the patient.

01:11:18 You can see the resolving membrane.

01:11:20 And then, this is what she looked like, twenty-six days after, the LPI.

01:11:26 You can see that membrane is d- is dissolving.

01:11:29 The eye is, is, is quiet.

01:11:30 It's deep. Both my PIs are actually open still.

01:11:34 And she's, she's really, she's really happy.

01:11:37 And, and, and now she doesn't wanna go back to that doctor for her other eye.

01:11:41 She wants me to do it. And, again, I'll probably do it on April Foo- on April Fools' Day. But the question really is, you know, what happened, right? So, you know, this is a large amount of inflammation.

01:11:51 These eyes are prone to inflammation.

01:11:53 You see this in patients that are, you know, poorly controlled diabetics, or patients with, with other inflammatory conditions.

01:12:00 And this is all the way back to, you know, the '80s, right?

01:12:02 When these were more Cataract surgery was early days of phaco.

01:12:06 Lenses, lenses were larger, a lot of inflammations.

01:12:08 Surgical iridectomies were the standard, right?

01:12:11 And, and, but now we don't see it as often.

01:12:15 But, but this was, an interesting article I found which showed, you know, how many patients had acute postoperative pupillary block.

01:12:22 Eleven eyes after 12,000 cataracts, were performed.

01:12:27 And of those 11 eyes, 10 of them had poorly controlled diabetes.

01:12:31 All right? And, so that's actually, that's, that's a real number. All right?

01:12:35 And so pupillary block occurred in 10 of the 1,700 eyes with diabetes.

01:12:40 That's not that bad.

01:12:41 But in patients with diabetic retinopathy, there was like a 3.5% incidence.

01:12:45 So that, it makes you think about things.

01:12:48 You know, according to the, preferred practice patterns of the, of the academy, it's not routine appropriate and, and, or indicated to do a preemptive PI in patients with diabetes.

01:12:59 But it is, I think, appropriate, and I've done that before in a patient that I got burned on previouslyUm, but I think it is important anytime you're operating on a diabetic to say, Hey, are we op- It's not an emergency," right?

01:13:11 So you have time to operate, to, to get the patient's diabetes controlled, get the eye controlled before you poke on it, 'cause you're gonna get burned.

01:13:18 And, and so, you know, you wanna aggressively manage the diabetes, aggressively manage this inflammation afterwards.

01:13:25 And so in her fellow eye, I'll probably do some, preaponeurotic steroids, pre-op NSAIDs even a pre-op anti-VEGF or an intracameral anti-VEGF treatment, atropine and triamcinolone afterwards.

01:13:35 So, so, what about, Triesence both, you know, at the time of surgery?

01:13:41 That's something I use in cases like this.

01:13:44 W- w- what? Say that again. Triesence.

01:13:47 Yeah. I, I'm not a big fan o- of, of that.

01:13:50 I, um- Why?

01:13:51 I think cost. Oh, the all right.

01:13:53 Well, cost- It's a costly- I mean, that's a- So And I think we can win with preaponeurotic, you know, dipyridamole- Yeah preoperative NSAIDs, intracameral, anti-VEGF and, and post-op atropine.

01:14:05 I think you can- Just, just I'm sorry.

01:14:07 Just one comment about the LPI.

01:14:09 So this is not a patient where you do the LPI and say, "Come back in three to four months." Over the first six to eight weeks, these can close up, and I've had several close over a six-week period. So follow these people frequently for the first two to three months. Thanks.

01:14:23 And compliance, compliance, compliance.

01:14:25 That patient was not really doing a lot of the steroids.

01:14:28 I would've injected that patient also with triamcinolone at the, after the PIs.

01:14:35 Our next speaker is Dr. Radcliffe.

01:14:37 I'm sorry. Take that back. Our next speaker is, Ray Brown, clinical outcomes of sustained release intraocular implants.

01:14:42 And, while Ray's coming up, Annalisa, you implied, I think, that you would do the You'd break the pupillary block with a needle- as opposed to a laser as your first step.

01:14:52 Yep. Tell us about that just real briefly.

01:14:55 So I, I, I think that the 30 gauge is underutilized in, in, in regular practice.

01:15:01 This patient has a All the discomfort of this patient is the buildup, and I would actually You can go in into the iris.

01:15:09 It's a ph- it's a pseudophakic patient.

01:15:12 And then with that same 30 gauge, like I showed in my case when I was moving the, the Durysta implant, you break that membrane.

01:15:20 Now, it's gonna never recur.

01:15:22 This is just to bring that pressure down, get the eye less painful, get the eye a little And then I would do a more permanent PI.

01:15:29 And the reason I had you elaborate on that is because, in this setting of an acute angle closure attack in a thick brown iris, laser can sometimes- It's diffi- make it worse because you're generating a lot of inflation.

01:15:42 If it's a really thick iris, it's hard to get through.

01:15:44 So if you can break it that way and then do the laser, uh- Yeah whenever the angle is not so narrow.

01:15:50 But I'd appreciate both argon and then a YAG.

01:15:52 That helps. And, and your view is pretty bad if you have corneal edema, count fingers vision. Mm-hmm.

01:15:56 You're not seeing enough to get that laser sometimes.

01:15:59 So 30 gauge right through the, through the limbus, self-seals, swipe that membrane, poke at the iris.

01:16:08 Yeah. Okay. All right.

01:16:09 And then in 30 minutes, you come in and do that P. acnes Yeah and, and, and everything- a- is happier. It's a rare clinic day where I don't stick a needle in an eye. Yeah. Yeah. 30 gauge.

01:16:19 A hundred very rare. And surprisingly, patients are very okay with it.

01:16:23 I, I mean, at the beginning, people are like, "Oh." But if you do something in the clinic, it's not a complication.

01:16:31 Yeah. If you take it down to the OR, there was a problem.

01:16:35 I usually hide the needle and I'm like, "Oh, I'm gonna just, gonna take a little bit of fluid out of the eye." And then after I do it- Exactly I'm like, "Hey, just to let you know, I did just stick a needle in your eye." And I say, "This because it's the one thing that is steroid." All right. We're, we're gonna have to Yeah. We're gonna have to move on. It's great to have Ray back.

01:16:47 Hey, Ray. Ray's one of the original KIWA glaucoma day guys.

01:16:50 Uh- Tom, Tom, thank you very much.

01:16:53 I've been coming here for 15 plus years, and it's always a fun meeting and connecting with people like, Tom and all, all the great, people who come here.

01:17:03 So thank you very much.

01:17:04 All right. This is gonna be, again about, compliance and iDose.

01:17:11 I have no disclosures.

01:17:12 Interventional glaucoma has become an increasingly, popular treatment strategy.

01:17:18 Surgery instead of eye drops.

01:17:20 This means working inside the eye.

01:17:24 There's audio with the next, slide.

01:17:29 I go back with this a long way.

01:17:33 Oh. Hey. Oh.

01:17:38 Anyway, I said that, now with this new technology, we can now do surgery inside the eye.

01:17:43 That's 1990.

01:17:45 So I was- and, and here I'm quoted in 2009, "Glaucoma surgery," I'm o- obviously overly optimistic.

01:17:54 Glaukos surgery, or glaucoma should be a surgical disease, but that can only be true whenever we have safe and effective procedures. But I believe this since 1990 ahead of your time is indistinguishable from being wrong.

01:18:10 Which is the place I've been for most of my career.

01:18:13 Uh- A- and Ray, this won't come off your time either, but I One of the first glaucoma meetings I attended after finishing fellowship was at KIWA.

01:18:21 Your surgical meeting- Right KI and I think 1991 or two.

01:18:24 To nine- '92. Yeah.

01:18:26 So- Really. And then I, I was still- And it was all about this, so. I was still delusional, and, and I'm still delusional really. Uh- Your time has come.

01:18:33 But, anyway, it's finally coming true.

01:18:36 The, case for surgery and IIH really begins with the hard reality that, there's so many problems with medical therapy.

01:18:43 We've, we've heard a lot about non-compliance.

01:18:46 I heard a podcast, really just the other day, where the person was talking about compliance in general, and he was saying that, it's horrible.

01:18:55 And he wasn't talking about eye drops.

01:18:57 He, he But he said that we're much better at giving our pets their medicines.

01:19:02 You know, we'll go to the ends of the earth, and we'll fight to get the drops in the dog, but we won't take our own medicines.

01:19:08 The, the other thing is theThe, side effects, which are very common, and they're often only noticeable in patients, who are taking them in one eye.

01:19:19 This is a more dramatic example.

01:19:21 Surgery in the right eye, medical treatment in the left eye.

01:19:24 But if both, of this patient's eyes looked like the left eye and the pressures were good, w-we would consider that a success.

01:19:34 We would say, "Mr. Smith, you're doing great." The newest entrant in the, IG space is iDose.

01:19:44 This is a tiny canister that's, placed into the angle and releases travoprost.

01:19:52 FDA trials have shown a ninety-two percent success rate at one year and sixty-nine percent at three years.

01:20:03 And it's a little bit amazing.

01:20:04 This little tiny canister, is compared here to a single eye drop.

01:20:11 It's almost magical.

01:20:13 And I, I don't have a relationship with Glaucoma, so I'm, I'm just, impressed with this on my own.

01:20:20 Two or three years of efficacy, seven hundred eye drops in that little tiny canister compared with this single drop.

01:20:30 What about comparing iDose with MIBS?

01:20:34 There are four MIBS devices that have been approved in large, pivotal trials.

01:20:39 These are all washout studies.

01:20:44 The total pressure reduction for the MIBS devices plus cataract surgery, even though they're very different devices, has been in a relatively narrow range of 7.4 to seven point seven.

01:20:58 But iDose plus cataract surgery, by contrast, lowers pressure T1 millimeters at twelve months.

01:21:07 So this means that cataract surgery plus iDose lowers pressure better than MIBS.

01:21:14 In, in fairness, these studies are not perfectly comparable, but we forget the IOP lowering power of, PGAs.

01:21:23 What about safety? I've left this side blank because there really isn't much to say.

01:21:31 A-and again, I, I, I have no, relationship.

01:21:38 But it's still intraocular surgery, and so infection is a, potential problem.

01:21:45 And in stand-alone cases, if you're aggressive with irrigation and the capsule is open, you can have vitreous prolapse.

01:21:52 This is Arkady Yagdorov, who's a good friend and is in Atlanta doing an essentially perfect, im-im-implantation.

01:22:01 And you've seen Annalisa, showing cases.

01:22:05 And, there's a little barb at the end, so you have to kind of wiggle it through the incision.

01:22:11 And he's got a great view, which is, always critical.

01:22:15 There's a little barb at the end that's gonna be, placed into the angle, and then he's gonna let go. You have to be a little bit careful at this point 'cause you often jostle it as, as he's doing it, but then he taps it on each side, to make sure it's in place.

01:22:36 We've needs-- needed surgical options to bridge the surgical, chasm.

01:22:42 Patients who, don't do well enough with laser and medical therapy, but a trab or a tube is too risky. And that's been MIBS.

01:22:53 But it doesn't have to be MIGS versus iDose, it can be MIGS and iDose.

01:22:59 These are a couple of examples in stand-alone cases.

01:23:03 An Alzheimer's patient with uncertain compliance and a seventy-year-old who I followed for a long time, but the pressure suddenly get into the thirties on max treatment.

01:23:13 And in both cases, I did iDose with the Canaloplasty goniotomy, and they have done very well. And I, I, I have many other patients in my practice where I've done this.

01:23:24 So in conclusion, iDose, can be the antidote to non-compliance.

01:23:29 We, we, we know compliance is terrible.

01:23:32 Meds may not be enough, and laser, and Durysta may not be enough, but we have options.

01:23:38 Cataract surgery plus iDose can lower pressure T1 millimeters, or we can bridge the surgical chasm with the MIBS of your choice plus iDose.

01:23:50 Thank you very much.

01:23:57 Okay, I wanna go on to my case.

01:24:01 My, my case is a musical, case.

01:24:04 So, it'll be a little different.

01:24:06 I don't think I have anything else for you, sir.

01:24:11 I, I dropped it- Ray, while they're looking, I have a question from the audience about how do you know whenever the, sustained release canister stops working?

01:24:22 And, do you worry about iris color change and inflammation and some of the other issues that you might get with topical PGs?

01:24:31 You know, I, I haven't even thought about it, but now that you mention it, I probably should think about it. Did, did, did you find the, uh- I have.

01:24:41 It's on. I, I, I dropped it off yesterday.

01:24:42 It, it's a- Oh.

01:24:45 It's a, um- I, I- It's, it, it's in a, presentation.

01:24:50 There, there are two slides that have, two, two videos.

01:24:55 There are.

01:24:56 Well- So- While we talk, I think that it's important when you're doing iDose com-- with a con-- with a goniotomy to place your goniotomy in the spot you do not want your IOLs to go.

01:25:10 So I sometimes go with whenever is easier.

01:25:12 If it's a right eye, it ends up on the top.

01:25:14 If it's a left eye, it ends up in the bottom for my goniotomy.

01:25:17 But whenever I'm doing a combined, I try to plan it.

01:25:20 I like to put my IOLs in a spot that has still TM.

01:25:23 One- So just to push back on that a little bit- And you know what?

01:25:25 I just- I, I think the scl- I, I use the sclera really to anchor my IOLs- Yeah not the inner wall of TM. Oh, right.

01:25:32 So I, I, I push pretty hard 'cause I don't want what, y- you know- I, I was- the case that you showed. Nate? Well, yes.

01:25:38 So it's, it's some it gets kind of tricky.

01:25:39 Like, I did a hydrus once in a right eye, with an IOLs.

01:25:43 And, you know, usually- All right I like to put the hydrus kind of, you know, going up towards the, you know, superonasal quadrant, but that's where I wanted to put the, the IOLs.

01:25:51 I, I'm even putting the IOLs- The, That gets trickier with hydrus, for sure. Yeah.

01:25:54 The, the other thing to worry about is blood, and so I've, I've started doing the IOLs first, and then I do, the, the goniotomy, never.

01:26:02 Yep. So any- anyway, here we go.

01:26:07 I think here we go. Now use the clicker. Okay.

01:26:11 Yeah. I'm, I'm trying to use the trypan mouse.

01:26:15 That can help. There we go. All right.

01:26:17 This has audio.

01:26:21 A very experienced cataract surgeon was performing routine cataract surgery, but it became very complicated.

01:26:29 We've all been there, and all you can say is this Sometimes we feel like that.

01:26:40 Sometimes. Yeah, we feel like that. Sometimes.

01:26:42 Yeah, we feel like that. You, you, you saw this problem.

01:26:46 Post-op, she developed UGH syndrome with vitreous- Oh optic capture, high pressure, and inflammation.

01:26:56 Five weeks later, in the same practice, a retina surgeon performed a pars plana vitrectomy and a lens repositioning.

01:27:04 But post-op, she was no better.

01:27:06 She was followed with topical treatment for the next five months.

01:27:11 She was referred to me at six months, and the basic question was, "Why is this happening?" Tell me why.

01:27:20 Tell me why ain't nothing but a mistake.

01:27:28 So the lens is upside down, and the first goal has to be to flip it.

01:27:35 Something's going on.

01:27:37 You must flip it.

01:27:41 You must flip it.

01:27:42 Something's going on.

01:27:43 You must flip it.

01:27:46 Now flip it.

01:27:48 Shake it. Shake.

01:27:49 Shake it up. Get it straight.

01:27:52 Go for it. Move ahead.

01:27:55 Got to protect it.

01:27:57 It's up to you. So I wanted to, do optic capture, but I thought the capsule rhexis was just too small and fibrotic.

01:28:07 I thought I would tear something.

01:28:09 First, do no harm, and I thought that proper placement in the sulcus would be enough.

01:28:15 And for the next year, she did very well.

01:28:20 But at two years- it all came back.

01:28:26 She was referred to a uveitis specialist, who recommended removing the lens and doing a mymani.

01:28:33 She returned to me, and I said Sometimes.

01:28:52 Sometimes. Sometimes. Okay.

01:28:54 So, that's where we are.

01:28:56 Sh- What, what do we do?

01:28:58 The, It's UGH syndrome.

01:29:03 W- what's the next step?

01:29:05 Probably UBM to see what is irritating the iris.

01:29:10 Oh, okay. Well I didn't, I didn't have one.

01:29:17 I think, I think, I, I- Just- I think I know what's irritating the iris.

01:29:21 It's the lens. Do you have any 30-gauge needles, Ray?

01:29:26 What, what? What, what's that?

01:29:28 Do you have any 30-gauge needles?

01:29:30 Well, you can actually move the iris- You could, you could optic capture that at the slit lamp with a 30-gauge needle. Yeah.

01:29:35 Oh, yeah, yeah. Oh, yeah, yeah, yeah.

01:29:36 No, no. I just rotate it in the toroid. I, I do that all the time in, in the clinic.

01:29:38 What's her, what's her nerve?

01:29:40 What's, I mean, is she bad?

01:29:42 You know, she's, she's, she's developing Yeah.

01:29:45 It, it's not, it's not bad, but the- It's not a total- the big problem is the six months that she was half in front of the iris, half behind the iris.

01:29:53 She has huge pigment dispersion in the- cornea, which is, I mean, y- you wonder, like, how did people follow this for six months?

01:30:03 But, the nerve is, okay.

01:30:07 You know, I, I, I think the field is nearly normal.

01:30:10 I, I, I should've included that.

01:30:11 W- what's the issue right now?

01:30:12 Is she, is she getting recurrent hyphema?

01:30:14 Is she getting inflammation? Is she getting high pressures? Yeah.

01:30:16 What, what's- High pressure.

01:30:17 High pressure. Inflammation.

01:30:21 Chronic steroid use.

01:30:22 Vision isn't as good as it should be.

01:30:26 Is the lens moving, or is it a haptic that's not in the right place?

01:30:29 No, no. The lens is in the right place. Mm-hmm.

01:30:31 It's, it's just, still irritating the iris.

01:30:34 It's, it's still Adhesis. Okay.

01:30:36 So Well, and- Go ahead.

01:30:38 Have we beaten it to Well, I, I, I, I, I- Well, you probably know what I did I know, I think, the answer, so I don't want to say anything.

01:30:44 But if, but you probably should just bring us home.

01:30:46 We gotta have a meeting. Yeah.

01:30:47 To speak as well. Can you go to the next, No, no.

01:30:51 The There's another Oh, okay.

01:30:53 My recommendation was to use a tractor to widen the rhexis and then do optic capture.

01:31:35 So now it's optic capture.

01:31:36 For the past few years, she has done great with excellent vision, controlled pressure, and no inflammation.

01:31:45 So that's the, uh- Ray, was it a square-edged haptic?

01:31:48 Was it a- Yes. Yes. Was it optic capture that shouldn't in the sulcus in the first place?

01:31:52 Do you know? Uh- I mean, you may not know, but, but that would solve- No, it, it, it was, it was a three-piece.

01:31:57 Yeah. It was a three 'Cause, 'cause it was a complicated- Sure.

01:32:00 You know, it, it's, it's like the, You know, as the three-piece comes out, you know, it kind of spins around. You really have to- Sure pay attention to what's- So just getting rid of the contact obviously solved it, so. Yeah. Yeah. Yeah.

01:32:12 Or you can just go in, just cut the haptic.

01:32:15 Usually it is a haptic that's causing the problem.

01:32:18 Well, this was not as clear-cut.

01:32:20 It was not You know, there are some haptics where you have like a little, transillumination defect right over the haptic. Mm-hmm.

01:32:27 And, and those are usually three-piece.

01:32:29 I mean, single piece, but this was a three-piece. Mm-hmm.

01:32:33 Any- anyway, that's what I- Great case, Ray.

01:32:34 I, I have to admit, a couple times I looked over to see if you were dancing once I was watching you. Yeah.

01:32:39 To my disappointment, you were not, but- I don't know why I did it this way.

01:32:42 I just did. Anyway, thank you.

01:32:49 All right. Our, our closer, Dr.

01:32:52 Radcliffe, is gonna bring us home.

01:32:53 Canaloplasty devices and procedures for IOP control.

01:33:00 All right. One thing that never surprises me is how few people will do just a Canaloplasty with a minimal, say, less than millimeter goniotomy, for example, for a patient on just one drop.

01:33:13 Any- anyone? Just me?

01:33:15 No, I do- This wouldn't be the first time I'm the only one.

01:33:17 No, no, no. I do. I do. Yeah.

01:33:19 But, but it's not You know, most people feel like you've got to do sizable- You think more should do more. Yeah.

01:33:23 Sizable goniotomy. Or you think people should use that more.

01:33:25 Okay. I tend to think you limit high fema and, and can get pretty good efficacy with it. Yeah.

01:33:31 And so I'll try to convince you why, why that might make sense.

01:33:36 I actually have been showing this slide for, for years, and I just recently put Ray's name on it, but, he did give me this picture.

01:33:43 You recognize this? Yes, I do. Okay.

01:33:47 So, so the, You know, the canals is the anatomy is a little bit variable and, you know, seeing this picture, was really eye-opening for me because, it, it immediately correlated with some of the obstructions and problems I have.

01:34:00 I just don't think you're always gonna get three sixty in every canal.

01:34:03 You have strictures and just abnormal anatomy.

01:34:07 But, you know, as you can see, there's also area for intervention here.

01:34:15 I, I generally refer to myself as a hernia surgeon.

01:34:18 And it turns out I am because the collector channels are apparently getting, quite a few hernias.

01:34:24 And I think this is an important, you know, part to understand the potential value for Canaloplasty.

01:34:31 And, you know, if you think of just many, many cases, for, for me, the IOP that cannot be controlled after multiple Avastin, procedures, you know, could it be that the canal is collapsing, that the meshwork is getting stuck in the collector channels and you're know, limiting the n- options for outflow?

01:34:51 And if that's the case, could it be that simply reestablishing the normal anatomy could be, a valuable way to, address this?

01:34:58 So, patients with glaucoma, have quite a few of these or, or more patients have them, whenever you look on the pathology.

01:35:08 But apparently some normal people get them too.

01:35:12 But, you know, it's, it's part of the, the disease pathology.

01:35:15 You know, could this explain why laser trabeculoplasty, doesn't work that well, for example, in some patients who've had glaucoma, for a longer period of time?

01:35:24 Are we collecting these hernias, over time?

01:35:28 So, you know, just a fairly straightforward, Canaloplasty, being done here. And I, I just show this to make the point, you know, I don't always go for a ninety-degree, you know, goniotomy.

01:35:43 Sometimes I do. I think if a patient's on two or three drops, you know, I try to make the goniotomy a little bit bigger.

01:35:50 Generally speaking, though, I'm, I'm personally not a three sixty, goniotomy surgeon.

01:35:57 Yeah, and, and, you know, I do kind of feel like here I'm making a second small otomy.

01:36:01 It's a little bit easier to sort of enter, the second, pass through, you know, sort of virgin meshwork rather than going in through your, your prior small goniotomy.

01:36:11 But I don't think I've opened up more than a clockwork, you know, clock hour of, angle here, in this video. This is, this, this was sort of, a meaningful observation that I had in clinic.

01:36:26 The second image on the bottom, was up on the screen when I walked into the room for follow-up patient. And I just, you know, I thought to myself like, That, that is a big canal we've got there.

01:36:36 Any chance that I've done Canaloplasty on this patient?" Now, th- that image on the the temporal, cornea.

01:36:44 So this is a hundred and eighty degrees away.

01:36:46 And in fact, the patient had had Canaloplasty two years earlier.

01:36:50 And I found the baseline, angle image, which you see up top, which is prior to the procedure, also of the, same eye and temporal cornea.

01:36:58 So, you know, you can have lasting anatomical changes, that expand, the size of the canal, several years after, just Canaloplasty.

01:37:09 Canaloplasty, of course, has been done ab externo and ab interno. And, you know, we p-probably reasonably familiar, with, the data, but you can get significant IOP reduction.

01:37:21 Although you'll often see the pressures kind of bottoming out in the mid-teens, which I think most of us, have mirrored that, in, in our clinic experience.

01:37:32 And the ab interno seems to deliver very similar efficacy as, ab externo Canaloplasty.

01:37:39 This came up a few years ago when we were having some reimbursement struggles.

01:37:41 We really do need a prospective comparative, study, you know, comparing, say, for example, goniotomy and Canaloplasty or stents.

01:37:51 I, you know, I was part of this thirty-six month, Iris study, which was, you know, kind of fun to play around with big data, two hundred patients, just Canaloplasty out to three years, phakic and pseudo phakic.

01:38:04 And really just kind of showing a similar, type of pressure reduction, twenty-two down to fifteen.

01:38:09 Meds just about cut in half, but stable effect out to three months.

01:38:15 Streamline, is just another, of the, the different options we have.

01:38:21 This one I happened to capture really good fluid wave going through the canal.

01:38:26 And, it's kind of a fun video.

01:38:36 Yeah. I did not know that had yeah, there we go.

01:38:42 So, you know, you don't always get that though with the fluid wave.

01:38:46 And one of the things, I did how did I do that?

01:38:57 Trying to get to my next slide here.

01:39:08 The next slide. Yeah.

01:39:13 I did play around with the instrumentation a little bit, much to my friend Malik Khok, who's involved in the creation of Streamline, by just removing the blue tip, so I could see the, the microcatheter a little bit better.

01:39:24 A-and I found it was a much more reliable way to really get inside of the canal and get that fluid wave that I was looking for.

01:39:32 Interestingly, New World Medical has now made a clear tip that you-- where you can see-- clear plastic tip, where you can see things much better.

01:39:41 One thing you'll notice when you do this type of Canaloplasty is that the meshwork will sort of bow down, inferiorly, and that's just as the canaloplasty expands, that the meshwork of, take much more of an angle.

01:39:53 I think we'll see it maybe here.

01:40:00 But with the, with the tip visible like this, I just found it so much easier to get right inside of the canaloplasty and to be confident you're there.

01:40:08 The other thing you can do with Streamline after you've done your Canaloplasty is you can just wiggle back and forth a little bit, perform a little bit of a larger goniotomy, and just confirm that you are, in the tissue or in the tissue plane or inside of the canal like you wanna be. So that's Canaloplasty and, y-you know, I think it's, it's interesting the way it, addresses the different areas that are obstructing outflow, the meshwork, the canal, and even the collector channels.

01:40:35 Trabecular herniations are real, and we could probably use slightly better prospective data.

01:40:41 Nate, ha- showing that Streamline the way you just did is a little reminiscent of anticipate with the, excimer laser sclerostomy with Elios perhaps later this year.

01:40:50 Do you, do you see something, useful for that?

01:40:55 I mean, how what are your thoughts where that's gonna fit in? Yeah.

01:40:58 Excimer laser. Yeah. So, you know, this is, this is interesting. I, you know, the-- one of the things you can do with the ELT laser, which, which causes little microablations or microgoniotomies, if you will, or trabeculostomies, is you will occasionally see a pneumo canaloplasty, where the, vaporization bubble created by the, the laser will actually go through the canal and then theoretically, cause some expansion in there.

01:41:24 I think that that procedure, you know, patients, patients like the sound of laser when you're talking about going to the operating room.

01:41:31 They don't always love it when you're talking about their drops.

01:41:34 But it's, it's an appealing, therapy.

01:41:37 I think it will appeal to patients and the safety data that's been provided, seems to be consistent with it feeling like a, a, a laser procedure to patients, so.

01:41:46 Just for the audience, they just submitted-- B&L just submitted the, uh- Yeah FDA- Yeah submission for, approval. Yeah.

01:41:55 All right. Case? Yeah. Yeah.

01:41:57 I think we have, we have just- Few minutes, so- Yeah.

01:41:59 This won't take long.

01:42:01 You know, talking to colleagues, getting phone calls from colleagues, seems like hyphema is, I wouldn't say it's a heavily medically impactful long-term problem for glaucoma patients, but boy, whenever someone's in that early post-op period and they have their eye, no one's happy.

01:42:17 And so, you know, I thought it would be worth just taking a second to kind of look.

01:42:20 Now, this was an Ahmed valve, that had a hyphema and, you know, the, the number one thing that kind of helps with this situation is having mentioned the bleeding risk, ahead of the surgery. And I'd say with, with tubes as well as with MIGS, just letting patients know that, you know, you might have bleeding.

01:42:37 If you do, you'll probably not be happy with me.

01:42:40 But in the long run, you know, you'll be fine.

01:42:44 It is just super helpful.

01:42:46 As you kind of get through these hyphemas, I think the thing that really thwarts a lot of hyphema removals, and I'd say about a week is, is a fine time to approach these.

01:42:55 I think if you wait longer, you start to get into, you know, corneal blood staining.

01:42:58 Anyone have any preferred timelines on, on big hyphemas?

01:43:04 I meant to do a week is about right.

01:43:05 Depends on what's going on in their other eye. Yeah. Yeah.

01:43:09 So you know, you get the blood out, you're feeling pretty good.

01:43:12 You just have to consider whenever there's spillover vitreous hemorrhage.

01:43:15 Cause that, you know, taking out a, an anterior chamber hyphema, but leaving blood in the vit just isn't gonna be helpful.

01:43:21 And I, I don't think you need a retina surgeon in all cases to come in.

01:43:25 And I think partially removing the vitreous will speed, the body's rate of, of reabsorption.

01:43:30 So, you know, I just make a mil-- take a one-millimeter blade, three millimeters posterior to the limbus. I irrigate through the intracameral and just, collect what I can from the, anterior vitrectomy.

01:43:43 And this is how I do almost any vitrectomy, whenever it's, you know, with cataract surgery, you know, some complication.

01:43:49 It, you know, I think it does a great job of keeping vitreous strands and all that out anterior chamber.

01:43:54 What gauge, Nate?

01:43:57 Vitrectomy? Yeah.

01:43:58 Twenty-five? Yeah.

01:44:00 Yeah. Just antovitrectomy. Twenty-five. Yeah.

01:44:01 It's the Alcon. Yeah.

01:44:02 It's antovitrectomy. Yeah. Yeah.

01:44:05 But you know, I, I'd rather make an attempt and get rid of, the anterior vitrectomy if there's any question it's spillover because, you know, the patients are obviously miserable, and you took them to the OR already once, so.

01:44:15 And that's my pearl. Okay. Okay.

01:44:17 Terrific.

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