BLOG: Hey doc, you should see the view from here

BySavak Sev Teymoorian, MD, MBA

Whether ophthalmologists are ready or not, there will be a large increase in the number of glaucoma patients in the near future. There are two major factors driving this fact. First, the average length of time glaucoma patients need to be treated is expanding because they are being diagnosed earlier yet living longer. Second, the number of older patients, representing the subclass most likely to develop glaucoma, is increasing as baby boomers are entering that age category. Someone will need to help with this drastic need for care that can’t be sustained with our current level of glaucoma specialists. The centerpiece of this will involve how these patients will be cared for surgically. The natural source of aid will come from anterior segment surgeons, given that they already perform cataract surgery.

We are fortunate to be in the MIGS era that within the next few years will include more options in addition to the first-generation iStent (Glaukos). The ability for providers to successful integrate these procedures will rely heavily on obtaining surgical proficiencies in angle surgery, including mastering the use of a gonioprism. In MIGS surgery, the quality of the view of the angle makes a significant difference in how efficiently and effectively the surgeon can place the stent. The example I give to colleagues learning angle surgery about the importance of a good view is like the difference in performing phacoemulsification in a well-dilated eye vs. a small pupil. It is much easier looking through an open door into a room than through a keyhole.

Luckily, the mastery (or re-mastery for some) of gonioscopic views for surgeons has been aided in part by industry itself. As first movers in the MIGS arena, Glaukos has provided time and resources to aid in the acquisition of these skills. However, no matter how good the skill level for any surgeon, there is room for improvement, which leaves an opportunity for even further innovation. One recently released item the company developed to help surgeons is an adaptive clip that can placed on the gonioprism to further facilitate viewing of the angle during surgery. It is a disposable plastic clip with three prongs that each individually have three small teeth. When placed on the eye, the teeth gently engage the limbus without interfering with the view from the prism. It can help not only the early adapter of MIGS obtain a proper view but also enhance the skills of a more mature user.

The addition of this innovation to the surgeon’s armamentarium provides three major benefits:

1. Reduces (or in some cases eliminates) the difficulty surgeons can have when trying to use the gonioprism in the nondominant hand by not pushing down too hard and creating corneal striations that interfere with the view.

2. Provides surgeons the ability to move the eye as needed to obtain a better view in topical patients having difficulty fixating and blocked patients having secondary eccentric fixation.

3. Helps maintain adequate spacing between the gonioprism and the clear corneal incision that prevents difficulty surgeons can have with the iStent shooter lifting up the prism and diminishing the view when engaged in the eye.

These improvements during surgery using the clip can lead to better and more controlled views of the angle. This allows for more reliable iStent positioning that can enhance IOP reduction while doing so in shorter surgical times. The final effect is improved outcomes for patients and most importantly their quality of life while making happier surgeons.

Remember to stay patient and keep practicing your gonioscopic exam — if you practice it, the aqueous will come.

Disclosure: Teymoorian reports he is a consultant for Glaukos.