Surgeon outlines benefits of new glaucoma procedures

NEPTUNE, N.J. – Vipul Lakhani, MD, urged attendees here at a New Jersey Academy of Optometry meeting to consider surgery earlier in the glaucoma treatment paradigm.

He said his favorite procedure is ab interno canaloplasty.

Lakhani
Vipul Lakhani

“It takes 10 minutes to perform, addresses the site of greatest resistance and results in an average 35% drop in intraocular pressure,” Lakhani, of Tom’s River, N.J., said at the meeting.

He said he performs this procedure, which he noted is similar to angioplasty, in patients with uncontrolled moderate to advanced glaucoma.

“The first week or two you have to wait for the viscoelastic to work its way out,” he noted. “The pressure will be elevated until then.”

The CyPass Micro-Stent (Alcon), a recently approved minimally invasive glaucoma surgery (MIGS) performed during cataract surgery, involves stenting into the suprachoroidal space to improve uveoscleral outflow, Lakhani continued.

“I’m doing my first case Friday,” he said.

The CyPass has been shown to result in a 20% reduction (from baseline) in IOP for 73% of patients at 2 years when combined with cataract surgery.

Lakhani said he is also seeing good results with the iStent (Glaukos).

“My results are much better now than 2 years ago,” he said. “Placement of iStent is the key.”

He noted that dual punch iStent is being evaluated, with a target of 30% reduction in IOP.

“In Canada they use a second and third iStent if necessary,” he added.

“Xen Gel Stent (AqueSys), which is a bypass procedure from within, is similar to trabeculectomy, but does not have all the same side effects,” Lakhani said.

“In patients where the trabecular meshwork can’t be rescued, the Xen Gel Stent’s soft material is injected into the subconjunctival space, bypassing the trabecular meshwork,” he continued.

Early transient hypotony is seen in some patients, he noted, but the complication rate is low. Patients will have a postoperative bleb.

A study of 865 patients showed that at 3 years there was a 50% IOP reduction and 74% decrease in medications, he said.

The procedure is indicated for failed medical therapy but is not yet FDA approved, Lakhani noted.

An attendee asked how an optometrist can tell if a patient has undergone a MIGS procedure.

“Use the gonioprism and look nasally; it will look white,” Lakhani said. “There is no trabecular meshwork; it’s hard to miss.

“With ab interno canaloplasty, you can’t tell,” he continued. “With CyPass, you’ll see the stent. The Xen Gel Stent creates an opening that the aqueous humor will go through, and a bleb will be present.”

Lakhani spoke to Primary Care Optometry News prior to his presentation.

Treating glaucoma today is drastically different than a few years ago,” he told PCON. “For a long time we had very limited options and treated most of our glaucoma patients the same.

“This is an exciting time for our patients because we now have surgical procedures that are less invasive, with fewer complications and provide many of the same benefits that our traditional procedures have,” he continued.

“We should consider glaucoma surgery earlier in our treatment paradigm,” Lakhani said. – by Nancy Hemphill, ELS, FAAO

Reference:

Lakhani V. Modern medical and surgical management of glaucoma. Presented at: New Jersey Academy of Optometry Dinner Lecture, Neptune, N.J. March 22, 2017.

Disclosure: Lakhani reported no relevant financial disclosures.

NEPTUNE, N.J. – Vipul Lakhani, MD, urged attendees here at a New Jersey Academy of Optometry meeting to consider surgery earlier in the glaucoma treatment paradigm.

He said his favorite procedure is ab interno canaloplasty.

Lakhani
Vipul Lakhani

“It takes 10 minutes to perform, addresses the site of greatest resistance and results in an average 35% drop in intraocular pressure,” Lakhani, of Tom’s River, N.J., said at the meeting.

He said he performs this procedure, which he noted is similar to angioplasty, in patients with uncontrolled moderate to advanced glaucoma.

“The first week or two you have to wait for the viscoelastic to work its way out,” he noted. “The pressure will be elevated until then.”

The CyPass Micro-Stent (Alcon), a recently approved minimally invasive glaucoma surgery (MIGS) performed during cataract surgery, involves stenting into the suprachoroidal space to improve uveoscleral outflow, Lakhani continued.

“I’m doing my first case Friday,” he said.

The CyPass has been shown to result in a 20% reduction (from baseline) in IOP for 73% of patients at 2 years when combined with cataract surgery.

Lakhani said he is also seeing good results with the iStent (Glaukos).

“My results are much better now than 2 years ago,” he said. “Placement of iStent is the key.”

He noted that dual punch iStent is being evaluated, with a target of 30% reduction in IOP.

“In Canada they use a second and third iStent if necessary,” he added.

“Xen Gel Stent (AqueSys), which is a bypass procedure from within, is similar to trabeculectomy, but does not have all the same side effects,” Lakhani said.

“In patients where the trabecular meshwork can’t be rescued, the Xen Gel Stent’s soft material is injected into the subconjunctival space, bypassing the trabecular meshwork,” he continued.

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Early transient hypotony is seen in some patients, he noted, but the complication rate is low. Patients will have a postoperative bleb.

A study of 865 patients showed that at 3 years there was a 50% IOP reduction and 74% decrease in medications, he said.

The procedure is indicated for failed medical therapy but is not yet FDA approved, Lakhani noted.

An attendee asked how an optometrist can tell if a patient has undergone a MIGS procedure.

“Use the gonioprism and look nasally; it will look white,” Lakhani said. “There is no trabecular meshwork; it’s hard to miss.

“With ab interno canaloplasty, you can’t tell,” he continued. “With CyPass, you’ll see the stent. The Xen Gel Stent creates an opening that the aqueous humor will go through, and a bleb will be present.”

Lakhani spoke to Primary Care Optometry News prior to his presentation.

Treating glaucoma today is drastically different than a few years ago,” he told PCON. “For a long time we had very limited options and treated most of our glaucoma patients the same.

“This is an exciting time for our patients because we now have surgical procedures that are less invasive, with fewer complications and provide many of the same benefits that our traditional procedures have,” he continued.

“We should consider glaucoma surgery earlier in our treatment paradigm,” Lakhani said. – by Nancy Hemphill, ELS, FAAO

Reference:

Lakhani V. Modern medical and surgical management of glaucoma. Presented at: New Jersey Academy of Optometry Dinner Lecture, Neptune, N.J. March 22, 2017.

Disclosure: Lakhani reported no relevant financial disclosures.