Mayer_EU_OphthalReview 22/01/2010 11:07 Page 44
Glaucoma Surgery
New Technologies for Treating Glaucoma in
Patients Undergoing Cataract Surgery
Joseph L Lin
1
and Hylton R Mayer
2
1. Ophthalmology Resident; 2. Assistant Professor, Department of Ophthalmology and Visual Science, Yale University School of Medicine
Abstract
New surgical technologies, such as the ExPRESS™ shunt, iCath™ canaloplasty, Trabectome™ and endoscopic cyclophotocoagulation (ECP),
have been developed to provide safe and effective control of intraocular pressure (IOP) while avoiding many of the complications associated
with trabeculectomies or traditional glaucoma drainage implants. A benefit of some of the newer technologies, especially for patients for whom
traditional glaucoma surgeries may not previously have been considered, is that they can be readily performed at the time of cataract extraction.
Many surgeons are combining these new surgical techniques with cataract surgery because of the low rate of serious complications, limited
manipulation of ocular tissue (especially the conjunctiva) and/or faster visual recovery than traditional glaucoma surgeries.
Keywords
ExPRESS™ shunt, iCath™ canaloplasty, Trabectome™, endoscopic cyclophotocoagulation (ECP), iStent
®
, SOLX
®
Gold Shunt, Aquashunt™,
glaucoma surgery
Disclosure: The authors have no conflicts of interest to declare.
Received: 26 August 2009 Accepted: 21 September 2009
Correspondence: Hylton R Mayer, Department of Ophthalmology and Visual Science, Yale University School of Medicine, 40 Temple Street, 3rd Floor, New Haven,
CT 06510-2715, US. E:
hylton.mayer@yale.edu
The development of a visually significant cataract in a patient with maculopathy, bleb leaks, blebitis and bleb-related endophthalmitis,
glaucoma is a common and often expected event. The decision- bleb dysesthesia, ciliochoroidal effusions, peripheral anterior
making process regarding the timing and type of surgery offered for a synechiae formation, posterior synechiae, scleral melt and relatively
patient with a visually significant cataract and glaucoma is complex, high rates of long-term clinical failure.
4,5
The placement of tube-shunt
and depends on factors such as vision, visual potential, intraocular devices (e.g. Ahmed, Molteno, Baerveldt) shares many of the same
pressure (IOP) control, medication use and tolerance, optic nerve complications associated with trabeculectomy, as well as tube–
damage, visual field loss and the aetiology of the patient’s glaucoma. cornea touch, obstruction or migration of the tube, valve malfunction
Typically, traditional glaucoma surgery (a trabeculectomy or tube and/or erosion of the conjunctiva over the tube or plate.
6,7
shunt) has been performed in combination with cataract surgery for
patients with poorly controlled IOP or progressive visual field loss, As previously mentioned, the decision to perform incisional glaucoma
and/or for patients with good to marginal IOP control on multiple surgery requires the consideration of multiple factors. In general,
IOP-lowering drops. Newer surgical technologies, such as the many of the newer surgical techniques are indicated for the same
ExPRESS™ shunt, iCath™ canaloplasty, Trabectome™ and types of patient who traditionally would have been considered
endoscopic cyclophotocoagulation (ECP), have been developed to candidates for selective laser trabeculoplasty (SLT) or trabeculectomy.
provide safe and effective IOP control while avoiding many of the Due to their low rate of serious complications and limited destruction
complications associated with trabeculectomies or traditional or manipulation of ocular tissue (especially the conjunctiva), many of
glaucoma drainage implants. A benefit of some of the newer the newer surgeries, such as Trabectome or ECP, are considered
technologies, especially for patients for whom traditional glaucoma earlier in the course of treatment than traditional glaucoma surgeries.
surgeries may not have been considered, is that they can be readily In addition, failure of a newer surgery to obtain a desired IOP often
performed at the time of cataract extraction. does not limit the successful implementation of a traditional surgery.
Current mainstays for the surgical treatment of glaucoma are ExPRESS Shunt
trabeculectomy and first-generation glaucoma drainage implants. As The ExPRESS mini glaucoma shunt (Optonol Ltd, Neve Ilan, Israel) is a
demonstrated by numerous retrospective and prospective studies, small (~3mm-long) stainless steel tube-like device with an anchoring
traditional surgical therapies for glaucoma can successfully control footplate (see Figure 1). The ExPRESS shunt diverts aqueous from the
IOP and limit glaucomatous vision loss.
1–3
However, limitations to these anterior chamber through its 50 or 200µ lumen. When the ExPRESS
traditional IOP-lowering surgeries have been well documented. shunt was first introduced, the recommended technique involved
Complications of trabeculectomy with adjunctive 5-fluorouracil or insertion of the device at the limbus, directly under the conjunctiva, in
mitomycin C include cataractogenesis, hypotony and hypotony the belief that the small lumen size would restrict flow and prevent
44 © TOUCH BRIEFINGS 2009
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