Trabectome Surgery: Techniques and New...
Transcript of Trabectome Surgery: Techniques and New...
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Trabectome Surgery: Techniques and New Indications
Nils Loewen, MD, PhD Director, Glaucoma and Cataract Service
Associate Professor of Ophthalmology
University of Pittsburgh School of Medicine
UPMC CHANGING LIFE
MEDICINE
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disclosures: NL - trabectome trainer
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1) Background
2) Technique + Postop Care
3) Outcomes
4) Case Presentations
5) Wet Lab
Overview
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TRABECTOME TECHNIQUE + POSTOP CARE
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MIGS vs Trabs/Tubes?
Trabectome Technique + Postop Care
Overview
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MINIMALLY INVASIVE GLAUCOMA SURGERIES (MIGS) VS TRABS/TUBES
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Problems with Hardware and MMC
up to 9%
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MIGS
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*Rosenquist et al. Curr Eye Res PMID: 2627793
240° versus 60° Single access point devices: - achieve only 2 clock hours of outflow segment access.
Canalography courtesy of UPMC’s
Glaucoma Imaging Group
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Outflow Tract Anatomy sagittal view
frontal view
schematic view
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Trabectome Surgical System
new, tapered sleeve
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Plasma Surgery: Bipolar 550 kHz Ablation of Trabecular Meshwork
● selective removal of primary pathology ● 200 micron plasma, pico-lightning ● no heat transfer, protective footplate
1.2o C
Very hot Very short (1ms) Low duty cycle
continuous aspiration
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Location of Collector Orifices
courtesy of Doug Johnson
proximity to anterior and posterior lips may explain high failure rate of goniotomy in adults
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Challenges with Microstents
Fibrosis + Compression of Collector Channels
courtesy of Ivantis Inc., Irvine, CA
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Angle Surgery: What Glaucomas?
POAG Pseudoexfoliation Steroid induced Anti-VEGF agents-induced Acute angle closure Chronic angle closure Low pressure 30%
TM
pat
ho
logy
Success 90-70%
Working collector drainage system necessary. Currently no function test available.
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5 Year Complications MIGS ● early 10 mmHg IOP
elevation that resolves o trabectome: 3-10%
● hyphema that resolves o more Schlemm's canal
access = more hyphema o trabectome > hydrus >
iStent
Trab/Tube (TVT Study) ● "manipulation needed"
o trabs: 74% o tubes: 27%
● early + late, vision threatening o trabs: 39 + 38 = 77% o tubes: 22 + 36 = 58%
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Cost Effective Treatment Algorithm *Iordanous Y et al. J Glaucoma. 2013.
BAT 20/50,
wants to improve vision,
has OHTN to advanced glaucoma
CEIOL + trabectome
toric lens
bypass surgery
(tube, trab, suprachoroidal devices)
SLT
PGAs + CAIs
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TRABECTOME TECHNIQUE + POSTOP CARE
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Key Surgical Steps
1.Visualization - excellent microscope (xenon, large tilt)
- no visco at start
- hypotony, identify
1.Technique - anterior, flared incision
- no outward push
- near 180o ablation
1.Reducing hyphema - viscoelastic tamponade: after ablation + after phaco
- pressurize well
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VISUALIZATION
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Large Tilt, Xenon Light
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Impact of Microscope Quality ● high end, xenon light ● large tilt
● insufficient tilt: requires patient rotation
● yellow light: hard to see lacy tissue
✓ STOP
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No Viscoelastic Prior to Trabectome
Because viscoelastic: ● traps plasma gas bubbles ● creates blurr from density interfaces ● makes it harder to induce hypotony
to identify Schlemm's canal
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SURGICAL STEPS
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2 mm Anterior, Flared Incision
● extend reach, no striae ● prevent iris prolapse
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Induce Hypotony to Identify TM
gape incision SC
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tip parallel hard to engage
pointed at TM easy to engage
Easier Engagement Towards Left
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Engaging the TM
1. just anterior to spur: engage
pointing up
2. advance strictly parallel,
no outward push
TM removal: careful with outward push as if you were peeling an epiretinal membrane
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Engaging the TM
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180o Ablation
90o ablation 90o ablation
go
nio
: h
eel u
p g
on
io: h
ee
l up
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Larger Arc = More Collectors
● Marginally significant correlation between:
o Ablation arc size vs final IOP (P=0.06)
o Ablation arc size vs final number of medications (P=0.07)
IOP = 20.5 - 0.053(Arc size)
n=29; R=0.351; P=0.06
A. Sit, 2011
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After Trabectome
1. Tamponade trabectome ablation with DisCoVisc
2. Enlarge same incision with keratome heel down
(self sealing)
3. Phaco
4. Tamponade ablation
again with DisCoVisc
5. IOL (+ CTR for torics if phacodonesis)
6. Leave visco in distal
half of AC (no hyphema)
up to 30% AC filling
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Incision Enlargement for CEIOL
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Post-Op
● "Changing blurriness for days“,
blurry = outflow system present!
● POV 1 day, 1 week, month 1, 2, 3 o Pilo QID x 1 month, TID 1 month, BID 1 month
o Pred Forte QID tapered one drop per week
o discontinue some glaucoma drops
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Summary: Key Surgical Steps
1. Visualization - excellent microscope (xenon, large tilt)
- no visco at start
- hypotony, identify
2. Technique - anterior, flared incision
- no outward push
- near 180o ablation
3. Reducing hyphema - viscoelastic tamponade: after ablation + after phaco
- pressurize well
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First Trainee Cases
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OUTCOMES
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Global Outcomes Phaco-Trabectome
# Medications # Medications
Baseline 2.3±1.2 2.8±1.3
6M 1.6±1.3 2.3±1.4
36M 1.9±1.2 (p=0.1) 2.0±1.4 (p<0.01)
Trabectome-only
N = 15 N = 58 N = 1873 N = 1401
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Global Outcomes
Trabectome alone 64.9%
Trabectome and PCE 86.9%
Success definition: No additional glaucoma surgery and
IOP reduction ≥20% from pre-op and IOP <21 mmHg last 2 follow ups, after 3 months post-op
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Trabectome-Only Results
Authors
Study Type # of pts pre-sx IOP % decrease meds decrease
months
Minckler 2005
Pro
37 28 40 % 0.9 13
Minckler, 2006 Pro 101 28 40 % n/a
30
Minckler, 2008 Retro 738 26 35 % 1.1 60
Ting, 2012 Pro 450 26 34 % 0.6 12
Ting,2012 Pro 67 29 44 % 0.9 12
Jea, 2012 Retro 115 28 41 % 1 30 Minckler, 2012 Retro 1151 26 36 % 1.7 60
Mosaed, 2011 Retro 538 26 31 % 0.8 12
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Phaco-Trabectome Results Authors
Study Type # of pts pre-sx IOP % decrease meds
decrease months
Minckler 2008 retro 366 20 20 % 1.2 60
Francis, 2008 Pro 304 20 25 % 1.2 21
Francis, 2011 Pro 89 22 27 % 1 12
Ting, 2012 Pro 263 20 22 % 0.7 12
Ting,2012 Pro 45 22 35 % 0.9 12 Minckler, 2011 retro 681 20 21 % 0.9 36
Mosaed, 2011 retro 290 20 18 % 0.8 12
Kaplowitz,
Loewen * retro 192 20 28 % 0.8 24
* including ACG, NVG, uveitic, secondary procedures
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6 Year Outcomes IOP (mmHg)
Glaucoma Medication Use
n = 3445
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Trabectome vs. Trabeculectomy (Dr. Brian Francis)
N = 58
Major complications: Trabectome-phaco group including subsequent trabeculectomy & tube = 4 Major complications: Trabeculectomy-phaco group including repeat trabeculectomy & tube = 16
Brian A. Francis; Jonathan Winarko; Clinical & Surgical Ophthalmology 29:2/3, 2011
N = 89 N = 23
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N = 58
Trabectome vs. Trabeculectomy (Brian Francis)
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Trabectome AFTER Trabeculectomy
Bussel II, Kaplowitz K, Schuman JS, Loewen NA
Outcomes of ab interno trabeculectomy with the trabectome after
failed trabeculectomy.
Br J Ophthalmol. 2014 Aug 28.
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Trabectome AFTER Trabeculectomy
Phaco-Trabectome
# Medications # Medications
Baseline 2.5±1.5 2.8±1.2
6M 1.8±1.5 2±1.3
12M 1.6±1.4 (p=0.1) 2±1.3 (p<0.01)
Trabectome-only
N = 15 N = 58
Bussel, II et al. BJO (2014)
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Trabectome by Degree of Angle Opening
Bussel II, Kaplowitz K, Schuman JS, Loewen NA
Outcomes of ab interno trabeculectomy with the trabectome by degree of
angle opening.
Br J Ophthalmol. 2014 Oct 21.
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N = 15
Trabectome by Degree of Angle Opening
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N = 15
Trabectome by Degree of Angle Opening
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N = 15
Trabectome Matched to Ahmed Valves
N=32 per group
*
T, A: 3 drops T: 1.9 drops
A: 4.1 drops
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Outcome by Type of Glaucoma
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POAG + Pseudoexfoliation p
seu
do
exfo
liati
on
N=481
PO
AG
N=2828
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Uveitic + Steroid Glaucoma u
veit
ic
ster
oid
N=69
N=49
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Infantile Glaucoma
Phaco-Trabectome Trabectome only
N=18 N=10
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Highly Complex, Mixed Mechanism Glaucomas
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Trabectome with glued, tied Baerveldt
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Wet Lab
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WET LAB
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Skills Transfer Course
Wet Lab Introduction
Brian Francis MD, MS Associate Professor of Ophthalmology Doheny-USC, Los Angeles, California
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Trabectome Surgical System
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Unique Key Features
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Human Corneal-Scleral Rim Setup
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Human Corneal-Scleral Rim Setup
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Handpiece Grip Technique
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Trabecular Meshwork Removal
George Baerveldt, MD, University of California, Irvine
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CASE PRESENTATIONS
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Case Representations ● Sjogren + Steroids
● Corneal Synechiae, Angle Closure
● Pseudoexfoliation
Historical Cases ● phaco-trabectome in POAG
● phaco-trabectome in PXG
Overview
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CASE 1:
SJOGREN + STEROID GLC
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●73-year-old Caucasian woman ●35 mmHg on 3 gtts ●Severe Sjogren’s Syndrome oSevere DES oFilamentary keratitis oErosions oXerostomia
HPI
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●Prednisone 4 mg QD, KCl 20 mEq QD, Alendronate, Calcium with vitamin D
●Steroid-induced glaucoma OU o50 mmHg max oUnnoticed by PMD x 6 months
HPI
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Exam OD OS
VA (cc) 20/50 20/200
Lens 3+ NS, +1 PSC
Disc 0.9 C/D
Severe inf, moderate sup
thinning
0.95 C/D
Severe inf + sup thinning
Cornea filaments
Lids severe crusting
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Phaco-Trabectome
OD ●POD #1: VA 20/25-2, IOP 10. ●POM #12: VA 20/25+, IOP 12. No gtts
for IOP OS ●POV: 10 mm Hg x 5 months ●POM #18: 14 mm Hg (added Travatan Z)
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CASE 2:
CORNEAL SYNECHIAE = ACG
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● 81-year-old Caucasian woman ● Deaf mute ● 20 mmHg on 3 gtts + oral CAI ● DSAEK OS years ago
○ 180 corneal-iris touch ○ drops affecting transplant ○ difficult med adherence
HPI
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Exam OD OS
VA (cc) 20/70 20/150
Lens sulcus PCIOL
Disc 0.4 C/D 0.7 C/D
Inf thinning
cornea DSAEK
Iris 180o iridocorneal adhesions
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iridocorneal adhesion
DSAEK 12
6
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Dissection of Iridocorneal Adhesions
12
9
6
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Trabectome Goniosynechiolysis
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Trabectome Ablation
open Schlemm's trabectome
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Outcome ●POM#18: OS VA 20/60, IOP 12 ●timolol QAM
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Summary
MIGS vs Trabs/Tubes
Trabectome Technique + Postop Care
Outcomes
Case Presentations
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Thank you.
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optional:
COST CONTAINMENT IN
GLAUCOMA
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COST CONTAINMENT IN
GLAUCOMA
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Increasing Lifespan
The Cause of Glaucoma
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Persistence with Glaucoma
Medications
Kass MA, 1986, AJO. Granstrom PA, 1982, BJO Reardon G, 2004, AJO
Friedman et al, IOVS, 2007:
● 59% patients had opportunity to fill gtts at 12 months after initial prescription
● only 10% actually had medication available continuously
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●$138,000-150,000 USD/QALY ●But: sequence of SLT, gtts, trab is very cost effective
(instead of max gtts, SLT, trab):
savings would return
$2.50 for every $1.00 spent
Costs of Glaucoma Treatment Taylor HR, Ophth, 2009
Performing trabectome early might also keep costs down and improve vision (if done with CEIOL)