Supraciliary Microstent Surgery
Steven D. Vold
Microincisional glaucoma surgery is quickly becoming a popular surgical option in the management of glaucoma. Ike Ahmed coined the acronym MIGS to describe what he termed micro-invasive (or minimally invasive) glaucoma surgery. Per his definition, MIGS has the following characteristics: (1) ab interno surgical approach; (2) minimal tissue trauma; (3) superior safety and low complication profile; (4) at least modest intraocular pressure (IOP) lowering efficacy; and (5) rapid patient recovery. Currently, the only FDA-approved supraciliary microstent surgery available to surgeons is the CyPass microstent (Alcon Laboratories, Fort Worth, TX) (Figs. 29-1, 29-2 and 29-3). In the near future, the iStent supra (Glaukos Corporation, Laguna Hills, CA) will potentially be another supraciliary device available to ophthalmic surgeons.
• Currently only FDA approved for treatment of mild to moderate primary open-angle glaucoma in the setting of cataract surgery
• Under evaluation as stand-alone procedure
• Secondary glaucomas
• Angle closure glaucomas
Instrumentation and Supplies
• Lidocaine 1% or tetracaine 0.5%
• Intraocular acetylcholine or carbachol
• Direct surgical gonioscope (modified Swan-Jacob, Hill or Alcon Vold goniolens)
• Ophthalmic viscosurgical device (OVD)
• CyPass loading and insertion devices
Procedure is generally performed after phacoemulsification.
Examine the anterior chamber angle carefully before bringing the patient to surgery. Understanding the patient’s angle anatomy is critical to CyPass surgical success.
Handle the loaded CyPass insertion device with care. Personally remove the
apparatus from the packaging and make a significant effort to avoid hitting the CyPass on the corneal wound.
Tilt the microscope toward you and the patient’s head away from you by approximately 30 to 45 degrees to allow for good angle visualization using a modified Swan-Jacob or Hill lens. The Transcend Vold goniolens is designed to reduce the need for microscope and patient head tilt to achieve proper angle visualization.
Before implantation of the CyPass, remove the cataract via phacoemulsification and consider injecting an intraocular acetacholine or carbachol to induce miosis. Hyperinflate the anterior chamber with a cohesive OVD to facilitate safe placement of the CyPass.
Enter the anterior chamber through the temporal clear cornea cataract incision holding the CyPass parallel to the iris to avoid having the CyPass catch on the corneal wound lip and to prevent CyPass touch of the iris and intraocular lens.
When the CyPass is fully within the anterior chamber, rotate the CyPass microstent into a position radial to the iris and trabecular meshwork. From an approximately 60-degree-angle approach, gently press the guidewire tip of the CyPass insertion device against the scleral spur and begin to guide the CyPass posteriorly into the supraciliary space (Fig. 29-4).
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