Manjool M. Shah, MD, moderated a panel addressing “Surgical Management of Glaucoma” on Saturday. Conducted in an entirely virtual format, the 30-minute, intermediate level session addressed questions participants sent in live feed for instructors Lorraine M. Provencher, MD, and Shivani S. Kamat, MD.
Questions included their most notable case of the week, which led to a discussion of suprachoroidal stents. Dr. Shah believed suprachoroidal stents will be “an interesting part of our toolkit that is emerging over the next year or couple of years. I think one of the challenges now with what we have and what we are about to have is, where does it fit?”
Dr. Provencher responded that she prefers to keep traditional outflow going for as long as possible with the stenting currently available or TM bypass excising procedures is, and then go suprachoroidal, with close study of the safety data.
Dr. Kamat would prefer to keep suprachoroidal stents for patients who are “out of options.” For refractory patients, she said suprachoroidals could “really change the game.”
Next, Dr. Shah introduced the topic of the “mild or moderate plus” glaucoma patient for discussion — those who might have relatively mild disease, but they have high pressures or high medication burdens. “Do you think those patients are still good conventional angle-based, TM-based candidates, or would you skip that in certain patients and go right to the supraciliary space?”
Another participant asked what the surgeons were most excited about in terms of coming innovations. For Dr. Kamat, it was drug delivery systems. “We just got iDose (Glaukos),” she noted. Dr. Provencher’s pick: “I can’t wait to get my DSLT [direct selective laser trabeculoplasty].”
“It’s exciting in general that we are trying to take control of the patient’s eye pressure back into our own hands, because for so long, we have been relying on the patient to do the job, and they don’t do it well, and that’s understandable,” Dr. Kamat said. “So, it’s nice that we are trying to shift the paradigm as a group and create consensus that we know there are other things that work better, and we need to start pushing for that.”
Participants naturally turned the subject to MIGS. If the surgeon is not in residency or fellowship anymore, how does the surgeon start? Both Drs. Provencher and Kamat advised to start by getting very comfortable with the angle in clinic, with performing frequent gonioscopy and understanding the angle structures before going into the OR.
The importance of gonioscopy cannot be overstated,” said Dr. Kamat. She tells her trainees to gonio every single patient in order to get comfortable with it. “Get comfortable with turning the head during cataract surgery, turning the scope, get comfortable with those motions.” And get comfortable working in the angle, as she thinks that is the most difficult part of MIGS.
The session ended with a discussion of the surgeons’ top surgical pearls. One shared by both: “Listen to your instinct: If something feels off, resist the temptation to ignore it,” Dr. Provencher said.