I’ve probably done 100 of them post-approval here. A different study looked at the Kahook Dual Blade. “I like the ability of those stents to be implanted in patients who might have a more crowded angle,” he continues. Their pressures come down, and everybody’s happy, but we don’t know how much of the pressure lowering is from the minimally-invasive glaucoma surgery and how much is from removing the cataract.
Study eyes were assigned randomly (1:1) to undergo standalone microinvasive glaucoma surgery (MIGS) consisting of one Hydrus or two iStents. Preop, the mean IOP was 17.1 ±4.7 mmHg and the mean number of glaucoma medications was 2.4 ±1.3. It’s a fairly straightforward procedure to teach my fellows. Saturday: 9:00AM–12:00PM, Address: (310) 482-1240. So, it’s a little bewildering, but each surgeon is doing his or her own empirical testing. All rights reserved. I choose it because I’ve had the most experience with it and it works best in my hands,” he explains. At three years postop, the mean IOP was reduced by 42 percent to 14.6 ±2.0 mmHg (p<0.0001) and 87.9 percent of eyes achieved an IOP reduction of ≥ 20 percent. There were no serious complications at any time point in the follow-up period. “It’s very empirical. The authors acknowledged the limitations of unmasked postoperative examinations but conclude that these findings suggest that trabecular MIGS devices may play an important role in managing IOP and reducing the need for hypotensive medication. Postop, mean IOP was 14.9 mmHg, 13.9 mmHg, 14.1 mmHg, 14.4 mmHg, and 14.7 mmHg at one, three, six, nine and 12 months follow-up, respectively (all p<0.004). New York, NY 10001, Hours (Glaukos funded the article processing and provided writing assistance for the study.). Download PDF. Monday—Friday: 9:00AM–5:00PM Atlanta’s Reay Brown, MD, says he’ll use devices or other approaches when appropriate. Adv Ther 2019;36:7:1606-1617. All eyes maintained or decreased their 36-month medication burden versus preoperative levels. But, I’m a MIGS optimist, so I still will use a device or do an Omni in essentially every case in which I’m doing cataract surgery on a patient who’s on glaucoma drugs. (The Allergan Xen was voluntarily recalled in October 2019, and surgeons were told not to implant more of them; there’s been no word when surgeons can purchase new ones to implant.). Monday—Friday: 9:00AM–5:00PM Hydrus Minimally Invasive Glaucoma Surgery (MIGS) This minimally invasive technique, the Hydrus stent is highly effective in reducing pressure in those with glaucoma. “The other big advancement in that same area has been the iStent inject because it’s a lot easier for people to put in and, with the two stents in, I think we’re seeing better pressure reduction,” Dr. Craven adds. Sutie F Category I codes, used for goniotomy (65820) or viscocanalostomy (66174), have more consistent reimbursement numbers. M inimally-invasive glaucoma surgery is intended to lower intraocular pressure with less tissue disruption than traditional glaucoma surgeries.
You can use it in different disease severities. Address: 31824 Village Center Rd. Outcomes of interest were between- and within-group differences in IOP and number of glaucoma medications at 12 months. “I’ve had good success with all of the blade procedures and goniotomy procedures in high myopes, especially if they have a moderately high IOP. “For example, I note if someone has a history of long-term steroid use or uveitis. Follow-up exams were performed on day 1, week 1, and months 1, 3, 6, and 12 following surgery. Then, I review the options and try to make a plan for the patient. The Hydrus also was associated with reduced need for glaucoma medication (p = .004); more Hydrus subjects were completely free of such medication by month 12 (p = .0057). 1. The safety profiles of the two devices were similar. Hydrus to the iStent used the original iStent, not the iStent inject. He says he leans towards these hybrid procedures in high myopes to avoid filtering procedures and tubes. The retrospective study from Texas included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016. Preoperative mean IOP was 25.3 ±6.0 mmHg on a mean of 2.98 ±0.88 medications, with three-quarters of the eyes on three to five medications (no eyes were medication-free). The technique has been shown in studies to reduce the need for taking glaucoma drops and the majority of patients are off drops altogether. Westlake Village, CA 91361 It used to be a discussion about iStent vs Trabectome,” says Malik Kahook, MD, a professor of ophthalmology at the University of Colorado School of Medicine. He adds that the value proposition for all angle-based procedures is enhanced safety compared to full-thickness procedures.
“If the Hydrus did better than the single iStent, that shouldn’t be a surprise; the Hydrus accesses at least 90 degrees of the canal, so its odds of accessing one or more outflow channels is much greater. “That’s a lot of work and explanation to patients for a relatively small change in pressure. In addition, 97 percent of eyes reached an IOP of ≤ 18 mmHg (vs. 9.1 percent preoperatively; p<0.0001) and 70 percent of eyes reached IOP ≤ 15 mmHg (vs. 2.3 percent preoperatively; p<0.0001).
• An overall safety profile that was similar to cataract surgery alone.3. Secondary glaucoma surgery was required for two eyes in the iStent group (3.9%) and none in the Hydrus group. I think the iStent inject will replace the original iStent very quickly.”, “On the other hand, many surgeons will like the Hydrus design, and the fact that you can directly verify that it’s exactly where you want it to be in the canal because you can see it through the translucent inner wall.”. Also, residency programs are increasingly training residents in MIGS, so new ophthalmologists are coming out of training more comfortable with doing an angle-based or MIGS procedure,” he adds. The researchers say there were “minimal” adverse events and CDVA was stable through 36 months. KDB goniotomy was combined with cataract surgery in 100 eyes.2 The main outcome measures were postop IOP and the number of IOP lowering medications. Two eyes treated with Hydrus and one treated with iStent had BCVA loss of 2 lines or more. Dr. Seibold believes that MIGS procedures will gain popularity. According to Dr. Kahook, a simple literature review shows that most angle devices, whether stent implants or goniotomy devices, produce essentially the same IOP lowering after long-term follow-up. “I think the innovation represented by these new devices and procedures has sort of outstripped our ability to fully assess the effects of each one,” says Leonard K. Seibold, MD, an associate professor of ophthalmology at the University of Colorado School of Medicine. “The data from the HORIZON trial, which is the pivotal U.S. trial for Hydrus, was tremendously favorable—probably the best MIGS data that we’ve seen to date, in terms of the important combination of sustained efficacy and safety. All eyes underwent ab interno iStent inject implantation as a sole procedure. “Ultimately, the device that surgeons favor may depend on what long-term data shows in a large population of patients.”, Conclusion “iStent inject is to be seen even easier than the Hydrus. That approach is kind of between a goniotomy/trabeculotomy, with the idea being that you remove the trabecular meshwork, expose the canal, and try to get the pressure down,” he explains. “For people who aren’t undergoing cataract surgery, but who have elevated IOP and for whom medications aren’t working, I look at their age, refractive status, angle anatomy and ocular history,” he says.
In the future, that might be an option for us, but in the meantime, we’re left with having to remove the trabecular meshwork either through a goniotomy with some kind of a blade procedure or ab interno trabeculectomy with a catheter. Two iStent inject stents were implanted in 44 consecutive eyes (POAG=38, PXG=4, appositional NAG=1, secondary neovascular glaucoma=1) of 31 patients, and 33 eyes had 36-month follow-up data. There’s room for more than one canal device, just as we have multiple IOL platforms and phaco machines. First, it provides a direct inlet into the canal because the tail end of the Hydrus resides in the anterior chamber. Eyes with a preoperative IOP >21 mmHg were significantly more likely to undergo reoperation (p=0.038). The study included 556 patients and spanned 38 centers in nine countries. “The data from the device studies show 1.6 and 2.2 as the delta vs. cataract surgery,” he says. 1 Current options include canal-based stenting (iStent by Glaukos and Hydrus by Ivantis), viscodilation devices (Omni by Sight Sciences and ABiC by Ellex), excisional goniotomy (Kahook Dual Blade by New World Medical), and a cautery device (Trabectome by MicroSurgical Technology). 2. Your email address will not be published. It doesn’t require leaving an implant in the eye, and it can be used for different types of glaucoma.”. Copyright © 2020 Jobson Medical Information LLC unless otherwise noted. At this point, the complete success rate was better for the Hydrus device compared to two iStents (30.1% vs. 9.3%; p < .001). Your email address will not be published. Hydrus vs iStent.
Required fields are marked *, Address 3-year HORIZON results. The prospective HORIZON trial, sponsored by Ivantis, analyzed the Hydrus device when used in conjunction with cataract surgery, with cataract surgery alone used as a control. Conclusion The Hydrus has a lot of potential,” says Dr. Samuelson. Here, glaucoma experts share their thoughts on how they use the available devices, and we take a look at some of the results the devices are capable of achieving. hypothesized that a single Hydrus microstent would result in lower intraocular pressure (IOP) and reduced need for glaucoma medication in patients with open-angle glaucoma (OAG) compared to a pair of iStent devices. “We’re trying different things and seeing what works best,” he notes. With a variety of options—and mechanisms of action—to choose from ophthalmologists can sometimes be hard-pressed to make sense of it all. For patients who undergo cataract surgery, Dr. Craven says he still can’t predict whether or not a trabecular bypass procedure is going to work. Kornmann H, Fellman R, Feuer W. Early results of goniotomy with the Kahook Dual Blade. Assessments over three years included IOP measurements, medications, corrected distance visual acuity and secondary glaucoma surgeries. 3. Hydrus Versus iStent as Standalone Treatment for OAG, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Practice Forms Library - Job Descriptions, MIPS Solo and Small Practice Survival Guide, 2020 MIPS Payments: Understanding Remittance Advice Codes, Final Checklist for EHR/Non-EHR 2019 MIPS Reporting, Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Global Programs and Resources for National Societies, International Society of Refractive Surgery, Dr. Richard Mills' Opinions, 2002 to 2016. “I had a chance to do that in Saudi Arabia where it’s approved. The mean number of IOP-lowering drugs was 0.8, 1.0, 1.0, 1.0, and 1.6 at one, three, six, nine and 12 months follow-up, respectively (all p<0.001). Ahmed et al. The data clearly show that cataract surgery alone improves physiologic function, so one might argue that it makes sense to disrupt the tissue as little as possible while augmenting outflow. Reproduction in whole or in part without permission is prohibited. “As we use each procedure, we’re learning more about it. However, hospital-based facility fees are relatively uniform across most angle procedures regardless of type. Since the evidence of the iStent inject is attaining better outflow via improved access to the collector channels, surgeons may wonder about the relative merits of the iStent inject compared to the Hydrus, which should provide even greater access to the channels, at least in theory.
I like the Hydrus, and I’ve implanted it on many continents.
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