Supplement to Early Spring 2011

New Advances
in Glaucoma Surgery:
Alternatives
to Standard
Trabeculectomy
Material from the 2010 ICGS Symposium
in New Delhi, India.

S p o n s o re d by A l co n L a b o r ato r i e s , I n c .
New Advances in Glaucoma Surgery

A New Filtration Device

The EX-PRESS Glaucoma Filtration
Device (Alcon Laboratories, Inc., Fort
Worth, TX; Figure 1) represents an alter-
native approach to trabeculectomy that
may provide glaucoma patients fewer postopera-
tive complications and a quicker visual recovery.
Although clinical experience with the EX-PRESS
device is still accumulating, it is showing promis-
ing results in several recently published studies, as
described herein.
At the International Congress on Glaucoma
Surgery symposium held in New Delhi in late
2010, noted clinicians described their use of the
EX-PRESS device as well as additional strategies to
enhance outcomes in some patients undergoing
filtration surgery after failed medical and laser
procedures. We hope you find this monograph
informative and relevant to your daily practice.

Malik Y. Kahook, MD
Associate Professor & Director of Research
Figure 1. The EX-PRESS Glaucoma Filtration Device.
University of Colorado Hospital Eye Center

CONTENTS

3 THE HOW AND THE WHOM OF THE EX-PRESS DEVICE

By Robert D. Fechtner, MD

6 CONJUNCTIVA-INDEPENDENT GLAUCOMA SURGERY

By Tarek Shaarawy, MD

8 CATARACT WITH GLAUCOMA: SURGICAL OPTIONS

By Tanuj Dada, MD

11 SURGICAL MANAGEMENT OF ANGLE-CLOSURE GLAUCOMA

By Prin Rojanapongpun, MD

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 New Advances in Glaucoma Surgery

The Howand the Whom

of the EX-PRESS Device
Pearls for choosing the best candidates and surgical techniques for the EX-PRESS device.
BY ROBERT D. FECHTNER, MD

When we evaluate glaucoma patients' candi-

dacy for surgery, it is useful to classify them The EX-PRESS Glaucoma Filtration
according to their disease, underlying medical Device is useful in making a portion of
conditions, and their estimated life expectancy. the surgery more predictable and
This information helps us decide whether to
perform surgery, what type of surgery to perform, and avoiding certain complications.
when.
Trabeculectomy has traditionally been glaucoma sur- device provides an opening of approximately 50 m to
geons' surgical standard; it is a continuously evolving pro- somewhat regulate outflow. Additionally, the EX-PRESS
cedure that we each execute slightly differently. During device has demonstrated IOP-lowering efficiency similar
my career, I have seen several important advancements in to trabeculectomy, and it can reduce certain intraoper-
trabeculectomy surgery, including fornix-based limbal ative complications and offer alternatives for postopera-
conjunctiva incisions, standard wound-management tive care.
techniques, and releasable or laserable flap-suture tech- No single type of glaucoma surgery is right for all
niques. These innovations have helped me immeasurably patients, and the EX-PRESS device may not be suitable
to improve outcomes and avoid complications. for all eyes that need surgical reduction of IOP. The cost
When considering using the EX-PRESS Glaucoma associated with this procedure has also been cited as a
Filtration Device (Alcon Laboratories, Inc., Fort Worth, drawback compared with trabeculectomy.
Texas), I think it is essential that we understand both
the how of the surgical technique and the whom of IOP CONTROL: A RETROSPECTIVE STUDY
patient selection. An early indicator of the usefulness of the EX-PRESS
Glaucoma Filtration Device was a retrospective study of
THE EX-PRESS DEVICE: WHAT IS IT? IOP control that compared the device with trabeculecto-
The EX-PRESS Glaucoma Filtration Device is a small, my. This report by Maris et al1 showed that by 6 months,
stainless steel implant less than 3 mm in size (Figure 1). It the pressure control was identical between trabeculecto-
has a channel that diverts aqueous from the anterior my patients and EX-PRESS device patients. There was a
chamber under a scleral flap. The version of the EX-PRESS higher mean IOP in the EX-PRESS device group in the
device I currently use (the P-50 model) has one port at
the tip that faces into the eye, and another port that
faces anteriorly toward the cornea. The anterior port
helps avoid occlusion of the tip; even if some of the iris
should touch the tip, there is a slot in the footplate that
directs aqueous posteriorly and helps the surgeon cor-
rectly orient the device.

ADVANTAGES AND DISADVANTAGES

Why not just continue performing trabeculectomy in
every glaucomatous patient? Many glaucoma surgeons
have found several aspects of trabeculectomy surgery
to be problematic. The EX-PRESS Glaucoma Filtration
Device is useful in making a portion of the surgery more Figure 1. The EX-PRESS Glaucoma Filtration Device as seen at
predictable and avoiding certain complications. The the slit lamp after implantation.

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New Advances in Glaucoma Surgery

early postoperative period. The success rate between the

two groups was virtually identical, however.

PREOPERATIVE CONSIDERATIONS
How can we successfully use the EX-PRESS Glaucoma
Filtration Device? My first guideline for implanting this
device is to choose the right patients. My rule of thumb is
that individuals who are poor candidates for trabeculec-
tomy should not be considered for implantation with the
EX-PRESS device. For me, these include patients with
uveitis, neovascular glaucoma, or severe dry eye.
Preoperative gonioscopy is essential to effectively
using the EX-PRESS device; you must know what is going Figure 2. The EX-PRESS Glaucoma Filtration Device comes
on in the superior angle before you an attempt an im- with its own inserter. The author positions his finger over the
plantation. Narrow angles can make placement of the injectors trigger button and then applies downward pres-
EX-PRESS device difficult. sure for a soft release.

CONJUNCTIVAL INCISION, ANTIFIBROSIS is to recreate that space to allow for easy insertion of the
AGENTS device. I suggest creating a paracentesis similar to that
When making the conjunctival incision, I use the same used in trabeculectomy; it may be helpful to use an oph-
approach as for trabeculectomy, provided that the inci- thalmic viscoelastic device for the first several cases.
sion is large enough to accommodate the delivery of
standard wound management techniques and suturing ENTRY UNDER THE SCLERAL FLAP
of the flap. A fornix-based limbal incision maximizes Inserting the EX-PRESS Glaucoma Filtration Device
exposure. I use my same wound-management techniques under the scleral flap is an important aspect of per-
as with trabeculectomy. forming the EX-PRESS device procedure. In my opinion, a
25-gauge needle is more than sufficiently large for this
purpose. A 27-gauge needle is too small, unless you
enlarge the opening. Some surgeons who desire a tighter
These are quiet eyes that do not have fit may use a smaller needle, but for early cases, I think a
the same spectrum of postoperative 25-gauge needle is suitable. Because the plate has an
complications as their trabeculectomy anterior portion, it is important to leave space between
the entry site and the anterior hinge of the flapI prefer
counterparts. 1 mm from the hinge.

INSERTION AND FLAP CLOSURE

THE SCLERAL FLAP The EX-PRESS device inserter (Figure 2) is quite easy to
It is very important to create a properly sized scleral use. It features a wire and an injector trigger button.
flap for the EX-PRESS device procedure. One common Pressing on the release point causes the wire to with-
technical error is to make the flap too small and leave draw, leaving the EX-PRESS device behind (Figures 3 and
part of the implant exposed. A depth of 3 x 3 mm is suffi- 4). Prior to entry, I keep the inserter in my hand, with my
cient to provide good coverage. Leave the sclera thick finger positioned over the injector trigger to allow for
enough to cover the device on top and to support it from easy release.
underneath; I consider 300- to 400-m flap thickness to Flap closure with the EX-PRESS device is slightly differ-
be a good starting point in a normal eye. I encourage my ent than with trabeculectomy, because the former great-
colleagues to be cautious implanting the EX-PRESS device ly slows the flow of fluid, and if the surgeon does not
in eyes with thin sclera, such as high myopes, because achieve a secure flap closure, he or she may see hypotony
they may not have enough scleral thickness to adequately in the early postoperative period. When starting out with
support and cover the device. the EX-PRESS device, I suggest suturing the flap securely
and then releasing sutures postoperatively.
ROLE OF THE PARACENTESIS
The paracentesis plays an important role in terms of CONJUNCTIVAL CLOSURE
deepening the chamber prior to inserting the EX-PRESS AND POSTOPERATIVE CARE
device. Making the paracentesis can cause some aqueous Conjunctival closure and postoperative care are largely
to escape and induce the iris to move forward. Our goal the same with the EX-PRESS device as they are with

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 New Advances in Glaucoma Surgery

Figure 3. The author places the EX-PRESS device under the Figure 4. The EX-PRESS device in position before the author
scleral flap via the inserter. closes the scleral flap.

trabeculectomy. I recommend using topical steroids and

antibiotics and performing cycloplegia if necessary. I find
that many surgeons who implant the EX-PRESS device are
comfortable releasing more sutures earlier, either with
planned suture lysis or releasable sutures, starting at 4 to
7 days postoperatively. In general, these are quiet eyes that
do not have the same spectrum of postoperative compli-
cations as their trabeculectomy counterparts (Figure 5).

EX-PRESS DEVICE PATIENT PROFILE

Once we understand the intricacies of the procedure, it
is important to recognize the type of patient who is an
appropriate candidate for the EX-PRESS device. Specifically,
the device may be indicated for patients who are poor
candidates for iridotomy due to risk of bleeding or inflam-
mation. There is very little bleeding with the EX-PRESS Figure 5. The EX-PRESS Glaucoma Filtration Device as seen
device procedure. The EX-PRESS device may also be desir- at the slit lamp 2 months after implantation. Note the tra-
able when there is a need to avoid low intra- and postop- becular meshwork pigment band confirming the correct
erative IOP, such as in cases where there has been a supra- insertion site.
choroidal hemorrhage in the fellow eye. The EX-PRESS
device does not need to cause the intraocular drop in IOP ensure the greatest chance for success with the EX-PRESS
that trabeculectomy does, where the chamber shallows device. I find the EX-PRESS device procedure to be an
and the pressure goes to zero. attractive alternative to trabeculectomy for appropriate
patients, being that it is more controlled, requires less
OTHER CONSIDERATIONS postoperative care, and produces results similar to tra-
Patients with anatomic considerations, such as eyes beculectomy. I feel that the EX-PRESS device is a valuable
with a compromised angle, would not be suitable candi- tool in our battle against glaucoma.
dates for an EX-PRESS device. I also would not perform
this surgery on patients with active uveitic glaucoma or Robert D. Fechtner, MD, is the director of the Glaucoma
those who are poor candidates for trabeculectomy due Division at the University of Medicine and Dentistry, New
to conjunctival scarring or scleral problems. Jersey, and he is a professor of ophthalmology at the
Institute of Ophthalmology, both at New Jersey Medical
SUMMARY School in Newark. He is a consultant to and has received
I would characterize the ideal first patient for implan- research support from Alcon Laboratories, Inc., and
tation with the EX-PRESS device as someone who meets Allergan, Inc. Dr. Fechtner may be reached at (973) 972-
the surgeon's standards for trabeculectomy, is pseudo- 2030; [email protected].
phakic, has open-angle glaucoma with a wide open angle,
and has had no previous conjunctival surgery. In my 1. Maris PJ Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-PRESS minia-
opinion, this is an excellent place to start in order to ture glaucoma device implanted under scleral flap. J Glaucoma. 2007;16 (1):14-19.

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New Advances in Glaucoma Surgery

Conjunctiva-Independent
Glaucoma Surgery
An ab interno, minimally invasive surgical option.
BY TAREK SHAARAWY, MD

It is mandatory that we glaucoma surgeons eval-

uate the ocular surface and the health of the Ab interno approaches can be per-
conjunctiva. A conjunctiva that is scarred from
years of exposure to topical medications can formed quickly, do not damage the
make the surgical procedure long and difficult. conjunctiva, and appear to be safe.
Because the tissue is more susceptible to postoperative scar-
ring, it can compromise surgical outcomes. Since the ad-
verse effects of antiglaucoma medications and benzalkoni- up to 5% of cases.1 Such a risk can be lessened by placing a
um chloride (the most commonly used preservative) is dose tube in a tunnel to protect it, creating a deep trench in
dependent, each additional eye drop decreases the chances which to bury the tube, and using a large envelope flap (9 x
of success with conventional glaucoma surgical procedures. 5 mm; Figure 1). Conjunctival scarring remains a determi-
Thus, we need to judiciously choose between the potentially nant of surgical success, however.
deleterious effects of exposing the eye to multiple antiglau- Therefore, we must consider other options that circum-
coma medications versus the risks and benefits of surgery. vent the conjunctiva. Conjunctiva-independent surgery is
The current surgical options for glaucoma surgery in- essentially an ab interno approach, which has the potential
clude trabeculectomy (which is the gold standard), tube to drastically influence the results of glaucoma surgery.
shunts, nonpenetrating glaucoma surgery, cyclophotocoag-
ulation, and conjunctiva-independent surgery. Conjunctiva-
independent surgery is considered the new kid on the
block among the current surgical interventions for glauco-
ma. According to the available evidence based on limited
experience, these ab interno approaches can be performed
quickly, do not damage the conjunctiva, and appear to be
safe. Their main advantage is that they do not rely on the
conjunctiva for surgical success, leaving it unaffected and
available for later use in case of surgical failure. Three
established conjunctiva-independent approaches include
conjunctiva-independent Trabectome surgery (NeoMedix,
Inc., Tustin, CA), the trabecular microstent (the iStent; Figure 1. The author creates a scleral envelope and deep
Glaukos Corp., Laguna Hills, CA; not available in the United trench for implanting the Ahmed Glaucoma Valve (New
States), and the CyPass implant (Transcend Medical, Inc., World Medical, Inc., Rancho Cucamonga, CA).
Menlo Park, CA; not available in the United States).

TRABECULECTOMY, TUBES
Nonpenetrating glaucoma surgery and trabeculectomy
both essentially depend on the limbal conjunctiva for suc-
cess and thus are contraindicated in a scarred limbal con-
junctiva. A potential course of action in these eyes is a tube,
which shunts the aqueous to an area posterior to the lim-
bus and thus bypasses the limbal conjunctiva. This proce-
dure is not without significant complications, however.
Extrusions are particularly problematic, according to the Figure 2. The iStent trabecular microstent is the fraction of
Tube Versus Trabeculectomy (TVT) study, and they occur in the size of a 1-cent coin.

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 New Advances in Glaucoma Surgery

The microstent is implanted under gonioscopic guidance

using an applicator introduced via an anterior chamber
paracentesis.
Most clinical studies of the iStent have been encourag-
ing, showing decreased medication requirements postop-
eratively and reduced IOP to an average of approximately
17 mm Hg after iStent instillation. Complications have
been infrequent, with the most common being malposi-
tioning of the iStent presumed to lead to clinical failure.
Reflux bleeding from Schlemm's canal after viscoelastic
removal intraoperatively has been common.
Figure 3. The CyPass supraciliary device targets aqueous out-
flow through the supraciliary space. THE CYPASS MICROSTENT
The final ab interno approach is the CyPass supraciliary
device (Figure 3). Unlike other tubes, it does not target the
conventional pathways such as the trabecular meshwork
and Schlemm's canal system. Again, the surgeon creates a
paracentesis by injecting viscoelastic into the anterior cham-
ber under the guidance of a gonioscopy lens (Figure 4).
After inserting the CyPass, the goal is to target the aqueous
outflow through the supraciliary space by positioning the
outlet of the tube between the sclera and the ciliary body,
almost like a surgical prostaglandin. This approach taps into
the eye's strategic reserves of uveoscleral outflow. The first
time I attempted this procedure, I was skeptical about how
easy it would be to properly place the CyPass. I found that
the sclera's rigidity guides the tube into the space between
the ciliary body and the sclera. The procedure is quite
Figure 4. The author creates the anterior chamber paracente- straightforward and is not particularly challenging for the
sis to implant the CyPass. trained surgeon. Long-term follow-up results are necessary.

AB INTERNO TRABECULECTOMY ADVANTAGES OF CONJUNCTIVA-SPARING

One of the more widely accepted conjunctiva-independ- PROCEDURES
ent surgeries is ab interno trabeculectomy with the I am interested in conjunctiva-sparing procedures for
Trabectome. The procedure involves an electrocautery abla- glaucoma therapy, because they are fast and relatively safe,
tion of the trabecular meshwork and inner wall of based on the data thus far. However, these modalities
Schlemm's canal through a paracentesis incision under need more long-term data on their safety and ability to
gonioscopic guidance. I was privileged to participate in the lower IOP. Nevertheless, they appear to offer viable
early clinical trial of the first 101 cases of ab interno tra- options for driving IOP below critical levels without dam-
beculectomy with George Baerveldt, MD, and Donald S. aging the conjunctiva, which leaves those tissues available
Minckler, MD, both at the University of California, Irvine.2 for conventional filtration procedures if and when
Our early results showed that the procedure spared the required. Controlled, randomized, head-to-head compar-
conjunctiva and was minimally invasive. IOP outcomes to isons with trabeculectomy are essential before these
date in our clinical case series have been in the mid-to-low devices can gain widespread use.
teens, so the procedure may not be appropriate for eyes in
which a very low IOP goal is deemed necessary. As with any Tarek Shaarawy, MD, is head of glaucoma in the
new glaucoma surgery, patient selection should take into Ophthalmology Service, Department of Clinical
account the expected IOP outcome. Neurosciences, Geneva University Hospitals, Switzerland. He
acknowledged no financial interest in the products or com-
MICROSTENT SURGERY panies mentioned herein. Dr. Shaarawy may be reached at
The rationale for using a trabecular microstent (the iStent; [email protected].
Figure 2) is that it provides a channel for direct transtrabec-
ular aqueous outflow from the anterior chamber to collec- 1. Gedde SJ, Schiffman JC, Feuer WJ, et al. Three-year follow-up of the tube versus trabeculectomy
study. Am J Ophthlamol. 2009;148(5):670-684.
tor channels. The device is self-retaining, constructed of 2. Minckler D, Baerveldt G, Remierez MA, et al. Clinical results with the trabectome, a novel surgical
implant-grade titanium (6AL4V), and coated with heparin. device for the treatment of open angle glaucoma. Trans Am Ophthalmol Soc. 2006:104:40-50.

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New Advances in Glaucoma Surgery

Cataract With Glaucoma:

Surgical Options
When is combined or sequential surgery indicated for these coexisting conditions?
BY TANUJ DADA, MD

The coexistence of glaucoma and cataract is a

common occurrence that requires insight into
the diagnosis and management of both con-
ditions. The presence of a cataract can affect
the ability to detect glaucoma, and cataract
surgery can affect both IOP control and the effectiveness
of previously performed glaucoma surgery.
The management of coexistent glaucoma and cataract is
a complex issue with several therapeutic options, and there
is currently a dearth of clear guidelines based on the evi- Figure 1. GDx VCC parameters pre- and postcataract surgery.3
dence from the literature. When deciding how to manage
patients with coexisting cataract and glaucoma, we must
consider the impact of each condition on the diagnosis and
treatment of the other as well as the indications for a com-
bined surgery versus cataract or glaucoma surgery alone.

THE IMPACT OF CATARACT ON THE EVALUATION

OF GLAUCOMA
First, we must consider the extent to which the pres-
ence of a cataract may compromise the evaluation of
the glaucomatous eye. The development of a cataract
worsens the mean deviation across all tests of the visual
field, including standard automated perimetry, frequency
doubling perimetry, and short-wavelength automated
perimetry. For this reason, visual field analyses are not
considered reliable in cases of coexisting glaucoma and Figure 2. A GDx VCC printout shows increased thickness of the
cataract. Also, some studies have indicated that the retinal nerve fiber layer after cataract surgery.
presence of a cataract may affect the visual field index/
glaucoma progression index as well as the characteriza- progression may, in cases of coexisting cataract, be due
tion of scotomas.1 Therefore, the presentation of a instead to artifact from advancing cataract.
cataract may affect the decision to monitor versus oper- In another study, colleagues and I assessed the meas-
ate on the glaucomatous eye. urement of the RNFL using the GDx scanning laser
The existence of a cataract may also obfuscate the perimeter (Carl Zeiss Meditec, Inc., Dublin, CA) in
evaluation of optic nerve structures and the retinal patients before and after they underwent cataract sur-
nerve fiber layer (RNFL). The use of optical coherence gery.3 We found a definite increase in the RNFL thickness
tomography (OCT) in assessing the RNFL of patients after cataract surgery, and we concluded that the cat-
with cataracts can cause an underestimation of the aract was retarding the signal and leading to an underes-
thickness of the RNFL and may lead to a false detection timation of the parameters of the RNFL (Figures 1 and
of progression with OCT due to the cataract. According 2). Therefore, in the presence of a cataract, there may be
to a study conducted by Mwanza and colleagues at the a false underestimation of the thickness of the peripapil-
Bascom Palmer Eye Institute,2 thinning of the peripapil- lary RNFL, primarily due to a decrease in the signal-to-
lary RNFL that is typically characteristic of glaucomatous noise ratio.

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 New Advances in Glaucoma Surgery

Figure 3. Setting the target IOP in glaucomatous eyes with a Figure 4. Decision tree for treating a glaucomatous eye with
cataract. a cataract.

EFFECT OF TRABECULECTOMY ON proceed with surgery, I have three options: cataract sur-
CATARACTOGENESIS gery alone, combined cataract and glaucoma surgery, or
Another important consideration is the potential two-phased surgery (glaucoma surgery followed by
effect of trabeculectomy on accelerating cataract devel- cataract surgery, or vice versa) (Figure 4).
opment in glaucomatous eyes. The Advanced Glaucoma Cataract surgery alone may be sufficient in cases of
Intervention Study (AGIS) clearly showed a 78% in- elevated glaucoma or ocular hypertension or when the
creased risk of cataract in patients who have undergone IOP is well controlled with a single drug. It is important
a first trabeculectomy.4 This heightened risk was deter- to remember, however, that cataract surgery in such eyes
mined in AGIS eyes after adjusting for age and diabetes, requires pharmaceutical control of the IOP postopera-
and it was especially pronounced in eyes with a shallow tively. To control the IOP in these eyes as well as possi-
anterior chamber or a history of uveitis following ble, I thoroughly remove all viscoelastic at the conclu-
cataract surgery. sion of cataract surgery, and I administer a drop of timo-
lol immediately after surgery before patching the eye in
EFFECT OF CATARACT SURGERY ON IOP the postoperative period.
According to a review by Shrivastava and Singh pub- Trabeculectomy surgery alone is indicated in eyes that
lished in Current Opinion in Ophthalmology,5 there may need to achieve a very low target IOP. The procedure is
be a modest, long-lasting decrease in IOP following pha- also appropriate for patients who are poor candidates
coemulsification in some eyes with open-angle glauco- for combined surgery, including those with
ma and ocular hypertension. We must also consider the advanced glaucomatous optic neuropathy
impact of cataract surgery on eyes that already have a a very high IOP that is not controlled medically
filtering bleb. The literature shows that phacoemulsifica- a poor prognosis for trabeculectomy, due either to
tion has an adverse effect on bleb function, even in sur- excessive conjunctival scarring or secondary glaucoma
geries that avoid the area of the bleb, such as temporal such as uveitic or neovascular glaucoma
clear corneal phacoemulsification. pseudoexfoliation or a subluxated lens with anticipat-
ed vitreous loss
SURGICAL OPTIONS AND INDICATIONS
In deciding when to perform combined phacoemulsi- Combined surgery may be warranted for
fication and trabeculectomy surgery, I think it is wise to patients with early-to-moderate glaucoma
consider the extent of glaucomatous damage, the type patients with IOP above or at the required target on
of patient, the surgeon's individual expertise, and the multiple medications
number of topical medicines the patient is taking. When noncompliant patients or those experiencing side
evaluating the severity of glaucoma, the surgeon must effects of medications
look at the target pressure that is required for the indi- patients whose geographic locations preclude return-
vidual case (Figure 3). Most glaucoma patients I see pres- ing for a second surgery
ent at a moderate-to-advanced stage and require an IOP One important factor to consider is the IOP-lowering
below 15 mm Hg. After assessing an individuals IOP, I potential of combined surgery versus trabeculectomy
consider whether he or she is compliant with topical alone. This has been addressed in several studies, which
medications and whether his or her geographic location have found that the IOP-lowering capability of trabecu-
is conducive to a two-phased surgery. Once I decide to lectomy alone is far superior to that of combined

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New Advances in Glaucoma Surgery

phacoemulsification and trabeculectomy. There is an

unmet need for developing a surgical technique for There is an unmet need for
combined cataract and glaucoma surgery with IOP- developing a surgical technique for
lowering efficacy similar to trabeculectomy. New
microsurgical shunts like the EX-PRESS Glaucoma combined cataract and glaucoma
Filtration Device (Alcon Laboratories, Inc., Fort Worth, surgery with IOP-lowering efficacy
TX) may offer some advantages in terms of lowering similar to trabeculectomy.
complication rates as compared to standard trabeculec-
tomy, but they need to be evaluated in terms of long-
term IOP control when used in combination with CONCLUSION
phacoemulsification. We have learned that trabeculectomy leads to the
progression of a cataract and a worsening of visual acu-
TECHNIQUE RECOMMENDATIONS ity (and therefore patients quality of life), and that
According to an evidence-based review published in cataract surgery can complicate the control of IOP after
Ophthalmology,6 there are three important points to trabeculectomy. Moreover, the IOP-lowering capability
remember when considering the surgical technique for of combined surgery is inferior to that of trabeculectomy
glaucomatous eyes: alone. In most cases, then, it is prudent to perform a
In all combined surgery, the use of standard wound- staged procedure: cataract surgery alone (IOP control
management techniques will provide a 2- to 4-mm Hg with topical ocular hypotensive therapy), establish a new
benefit baseline of IOP, verify the structure and function of the
Two-site surgery is superior to single-site surgery as far optic nerve, and then perform a second-stage trabecu-
as IOP reduction is concerned lectomy with standard wound-management techniques
Performing cataract surgery after trabeculectomy may if required (if the target IOP was not reached with med-
compromise bleb function ical therapy or there is evidence of progression).
My preferred approach for most glaucomatous eyes
with cataract is first to perform temporal clear corneal Tanuj Dada, MD, specializes in glaucoma and phacoemul-
phacoemulsification and strictly monitor the patient sification at the RP Centre for Ophthalmic Sciences in the
postoperatively to prevent and treat any spikes in IOP. All India Institute of Medical Sciences in New Delhi, India.
After the cataract has been removed, I re-evaluate the He acknowledged no financial interest in any product or
eyes IOP and the structure and function of the optic company mentioned herein. Dr. Dada may be reached at
nerve to set a new baseline and try to reach the desired +91 98 733 36315; [email protected].
target IOP with topical medical therapy. If the eyes IOP 1. Ang GS, Shunmugam M, Azuara-Blanco A, et al. Effect of cataract extraction on the glau-
is not at the desired level despite medical therapy (a coma progression index (GPI) in glaucoma patients. J Glaucoma. 2010;194:275-278.
2. Mwanza JC, Bhorade AM, Sekhon N, et al. Effect of cataract and its removal on signal
maximum of three medications as three eye drops in strength and peripapillary retinal nerve fiber layer optical coherence tomography measure-
24 hours), I plan a second-stage trabeculectomy with ments. J Glaucoma. 2011;20(1):37-43.
3. Dada T, Behera G, Agarwal A, et al. Effect of cataract surgery on retinal nerve fiber layer
my standard wound-management technique. This way, thickness parameters using scanning laser polarimetry (GDxVCC). Indian J Ophthalmol.
2010;58(5):389-394.
both procedures are standard eye surgeries with pre- 4. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open-angle glaucoma in Australia.
dictable outcomes, and I do not need to change my The Blue Mountains Eye Study. Ophthalmology. 1999;106:2144-2153.
5. Shrivastava A, Singh K. The effect of cataract extraction on intraocular pressure. Curr Opin
surgical technique. Additionally, performing trabeculec- Ophthalmol. 2010;21(2):118-122.
tomy is much easier in a pseudophakic eye with a deep 6. Jampel HD, Friedman DS, Lubomski LH, et al. Effect of technique on intraocular pressure
after combined cataract and glaucoma surgery: an evidence-based review. Ophthalmology.
anterior chamber. 2002;109(12):2215-2224.

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 New Advances in Glaucoma Surgery

Surgical Management of
Angle-Closure Glaucoma
Consider patient subgroups.
BY PRIN ROJANAPONGPUN, MD

For glaucoma specialists, the question of

whether angle-closure glaucoma is a surgical
disease is an important one, and in my opin-
ion, the answer to this question is 'yes.'
Surgical options for angle-closure glaucoma
are different than those for open-angle glaucoma and
depend upon such factors as the extent of IOP control
with medications and the presence of coexisting
cataract. Our choice of surgical intervention needs to
take these factors into account.
Eyes with angle-closure glaucoma progress from
potential angle closure to angle closure with or without
peripheral anterior synechiae (PAS), followed by an
acute or chronic rise in IOP, and finally glaucomatous
optic neuropathy (Figure 1). My colleagues and I are Figure 1. The angle-closure glaucoma cascade.
focused on this last stage of angle-closure glaucoma,
which has already induced structural and functional mizing changes in the optic disc and visual field (Figure 2).
changes of the optic disc. Options for correcting this condition generally include
laser or surgical peripheral iridotomy, iridoplasty, topical
CONSULTING THE GUIDELINES pilocarpine, and removal of the crystalline lens. Unfor-
The treatment guidelines for angle-closure glaucoma tunately, according to a study published by Aung and
are derived through consensus by glaucoma experts colleagues,3 nearly 60% of primary angle-closure glauco-
based on the best available evidence. I helped to develop ma patients demonstrate increased IOP and damage to
the Asia Pacific Glaucoma Guidelines.1 When we the optic nerve head after successful laser peripheral iri-
released the second edition in 2008, the information on dotomy upon long-term follow-up. We may opt to use
angle-closure glaucoma was incomplete, particularly additional treatments such as laser iridoplasty or gonio-
regarding the surgical aspect of this disease. A more synechialysis to reopen the angle after a peripheral irido-
recent publication comes from the American Academy tomy. Goniosynechialysis may improve aqueous outflow,
of Ophthalmology's Preferred Practice Patterns,2 which particularly when it is performed within 6 months after
was released in October 2010. These guidelines address an acute attack.
the goals of managing a patient with primary angle-closure
glaucoma: IS LENS REMOVAL NECESSARY?
to reverse or prevent the angle-closure process We know that the crystalline lens contributes signifi-
to control IOP cantly to the mechanism of primary angle closure, par-
to prevent damage to the optic nerve ticularly in the Asian population. Do we therefore need
Iridotomy is indicated in all eyes with primary angle- to remove the lens?
closure glaucoma. According to one series published by Sihota and col-
leagues,4 more than one-fourth (35%) of primary angle-
MANAGEMENT PRINCIPLES closure glaucoma patients needed some kind of surgical
The management of primary angle-closure glaucoma intervention to control IOP at the 6-year follow-up. Al-
focuses on correcting the problem by modifying the though various surgical options are available, treatment
angle-closure configurations, controlling IOP, and mini- for this condition is more complex than for open-angle

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New Advances in Glaucoma Surgery

Figure 2. The authors basic principles for managing angle-

closure glaucoma. Figure 3. The lens mechanism in eyes with angle-closure
glaucoma is difficult to assess.
glaucoma, because the lens is involved. We must decide
whether to remove the lens with or without performing cations. If we adjust for the seven reported cases of hy-
goniosynechialysis or to do a combined surgery. potony in the combined phacoemulsification and tra-
The outcomes of trabeculectomy to treat angle closure beculectomy group, the outcomes of the two groups are
seem to be less favorable than for open-angle glaucoma, very similar. Thus, for patients with medically controlled
with a higher risk of filtration failure. Trabeculectomy also angle-closure glaucoma and cataract, the benefit of
increases the chance of further shallowing of the anterior combined phacoemulsification and trabeculectomy is
chamber, the risk of developing malignant glaucoma, and not sufficient to justify the additional complications. For
the risk of cataract formation. Although a study by Maris this reason, phacoemulsification alone may be indicated
et al5 showed significantly lower complication rates with in such a group.
the EX-PRESS Glaucoma Filtration Device (Alcon
Laboratories, Inc., Fort Worth, TX) versus trabeculectomy Uncontrolled Angle-Closure Glaucoma With Cataract
in patients with primary open-angle glaucoma, experience When considering the best procedure for medically
with this approach in these patients is still limited and uncontrolled angle-closure glaucoma with cataract, we
subject to potential future studies. can consult a smaller series of Tham's randomized trial.7
The study also found that combined phacoemulsification
SUBCATEGORIZING PATIENT POPULATIONS and trabeculectomy generated a greater IOP-lowering
Deciding Between a Single or Combined Therapy effect (1.97 mm Hg) than phacoemulsification alone, and
In terms of clinical approach, we can divide angle-closure the combination therapy enabled patients to reduce their
glaucoma patients by those with coexisting cataract and medications. Again, however, combined phacoemulsifica-
those without. We can subcategorize these groups into tion and trabeculectomy was found to produce signifi-
individuals with medically controlled versus uncontrolled cantly more complications, and I therefore recommend
angle-closure glaucoma. Within these subcategories, we phaco surgery alone for patients who are at higher risk for
need to consider whether to simply perform phacoemul- trabeculectomy complications as well as for those who
sification surgery or a combined phacoemulsification and are not willing to accept the higher risk of complications. I
trabeculectomy procedure. would advise a combined procedure for patients with
poor compliance, drug allergy, or a lack of access to drugs.
Medically Controlled Angle-Closure Glaucoma With
Cataract Angle-Closure Glaucoma in Eyes Without Cataract
A prospective, randomized trial conducted by Tham In considering angle-closure glaucoma in eyes without
and colleagues in Hong Kong6 evaluated 35 eyes with cataracts, we can once again subdivide these patients
medically controlled angle-closure glaucoma that under- into those whose condition is medically controlled or
went phacoemulsification alone and 37 eyes that had not. For medically controlled angle-closure glaucoma, I
combined phacoemulsification and trabeculectomy sur- think it is fairly easy to maintain the medication regimen,
gery. The phacoemulsification-only group experienced a unless the patient expresses a desire to discontinue it.
9.82% reduction of IOP, and 59.2% decreased their use of For uncontrolled angle-closure glaucoma, I feel the cur-
medications. rent evidence is insufficient to correctly identify the lens
Although the combined phacoemulsification and tra- mechanism. Therefore, I feel a reserved approach is war-
beculectomy procedure appeared to deliver slightly bet- ranted and that we must address this group similarly to
ter results, this group also had significantly more compli- eyes with primary open-angle glaucoma. Remember,

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 New Advances in Glaucoma Surgery

be indicated. For angle-closure glaucoma patients with-

out coexisting cataract, I advise continuing a regimen of
medication as long as it can control the IOP. For uncon-
trolled angle-closure glaucoma without cataract, tra-
beculectomy may be a better option, and lens removal
must be reserved for those eyes whose lens component
can be correctly documented.

Prin Rojanapongpun, MD, is chairman of the Department

of Ophthalmology at Chulalongkorn University, Bangkok,
Thailand. He acknowledged no financial interest in the prod-
ucts or companies described herein. Dr. Rojanapongpun may
be reached at +(66) 2-256-4421; [email protected].
Figure 4. Conclusions.
1. South East Asia Glaucoma Interest Group. Asia Pacific Glaucoma Guidelines, 2nd ed.
Scientific Communications International, 208:1-117.
cataract extraction alone may yield substantial IOP reduc- 2. Preferred Practice Patterns, Primary Angle Closure, American Academy of Ophthalmology,
tion in selected angle-closure cases. Oct. 2010
3. Aung T, Ang LP, Chan SP, Chew PT. Acute primary angle closure: long term intraocular
pressure outcome in Asian eyes. Am J Ophthalmol. 2001;131(1):7-12.
CONCLUSION 4. Sihota R, Sood A, Gupta V, et al. A prospective longterm study of primary chronic angle
closure glaucoma. Acta Ophthalmol Scand. 2004;82(2):209-213.
I think angle-closure glaucoma is indeed a surgical dis- 5. Maris PJ Jr, Ishida K, Netland PA. Comparison of trabeculectomy with Ex-PRESS miniature
ease that has treatment options distinct from those glaucoma device implanted under scleral flap. J Glaucoma. 2007;16 (1):14-19.
6. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification versus combined phacotra-
used in primary open-angle glaucoma with coexisting beculectomy in medically controlled chronic angle closure glaucoma with cataract.
cataract. If the IOP is controlled with medications, we Ophthalmology. 2008;115(12)2167-2173.
7. Tham CC, Kwong YY, Leung DY, et al. Phacoemulsification versus combined phacotra-
can perform phacoemulsification alone; if not, then beculectomy in medically uncontrolled chronic angle closure glaucoma with cataracts.
combined phacoemulsification and trabeculectomy may Ophthalmology. 2009 Apr;116(4):725-31

EARLY SPRING 2011 I SUPPLEMENT TO GLAUCOMA TODAY I 13

New Advances in Glaucoma Surgery

EX-PRESS Glaucoma Filtration Device

CAUTION: Federal law restricts this device to sale by or on the order of a physician.

INDICATION: The EX-PRESS Glaucoma Filtration Device is intended to reduce intraocular

pressure in glaucoma patients where medical and conventional surgical treatments have
failed.

CLINICAL STUDY INFORMATION: A clinical study was performed with the EX-PRESS
Glaucoma Filtration Device versions R-30 and R-50. The study was a prospective, open-
label multi-center study of 113 open angle glaucoma patients with a follow-up period of
one year. Results indicated an 80.4% overall success for the per-protocol cohort (R-30 and
R-50, n=58) at one year, where overall success was defined as an IOP reduction greater
than 20% from baseline with or without medications. Results indicated a 75.9% overall
success for the per-protocol cohort (R-30 and R-50, n=58) at one year, where overall suc-
cess was defined as an IOP of less than 21 mmHg with or without medications. The mean
IOP reduction at one year was 33.8%. The percentage reduction from baseline was greater
than 28% for the R-30 version and greater than 40% for the R-50 version.

The overall average number of glaucoma medications dropped significantly from 1.55 pre-
operative to 0.52 medications at one-year postoperative.

The clinical study was not designed to compare between the various versions of the EX-
PRESS Glaucoma Filtration Device. The selection of the appropriate version is according
to the doctor's discretion.

The most commonly reported adverse events included the need for further filtering sur-
gery, device explantation, bleb revision and iris touch. Reasons for device explantation
included flat anterior chamber with hypotony, device exposure from erosion, and poor
efficacy. Other adverse events such as, but not limited to, corneal and retinal complica-
tions, uveitis, and significant reduction in visual acuity, may occur as well.

CONTRAINDICATIONS: The use of this device is contraindicated if one or more of the

following conditions exist: Presence of ocular disease such as uveitis, ocular infection,
severe dry eye, severe blepharitis; pre-existing ocular or systemic pathology that, in the
opinion of the surgeon, is likely to cause postoperative complications following implanta-
tion of the device or patients diagnosed with angle closure glaucoma.

WARNINGS/PRECAUTIONS: The surgeon should be familiar with the instructions for use.
The integrity of the package should be examined prior to use and the device should not
be used if the package is damaged and sterility is compromised. This device is for single use
only. MRI of the head is permitted, however not recommended, in the first two weeks
post implantation.

ATTENTION: Reference the Directions for Use labeling for a complete listing of indica-
tions, warnings and precautions.

14 I SUPPLEMENT TO GLAUCOMA TODAY I EARLY SPRING 2011

EXP10582JS