Fall 2017 Newsletter

Follow our latest updates in our Fall 2017 Newsletter

Fall 2017 Newsletter
7th Residency Announcement

Exciting Residency Announcement!

ACGME approves seventh resident complement; first increase in over 30 years!

Grand Rounds

Grand Rounds and Case Studies

Check out our weekly presentations

OTEP

OTEP

Ophthalmic Technician Education Program

LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: When You Have Reached an Impasse

Zaman Reznik
Presenter: Arman Zaman, MD Discussant: Alena Reznik, MD
 

History

  • 72-year-old female, POW#1 s/p cataract surgery with CyPass OS
  • Complains of mild blurry vision and difficulty reading
  • No associated, pain, headaches, nausea, vomiting

Exam Findings

  • VA: 20/50 OD, 20/40 OS
  • IOP: 15 OD, 26 OS
  • Pupils: Surgical, irregular OD, RR OS
  • EOM full OU
  • SLE OS:
Figure 1: Slit-lamp examination of the left eye reveals partially extruded CyPass implant nasally in the anterior chamber. There is no corneal edema and the anterior chamber is deep and quiet.
Figure 1: Slit-lamp examination of the left eye reveals partially extruded CyPass implant nasally in the anterior chamber. There is no corneal edema and the anterior chamber is deep and quiet.
  • Dilated Fundus Examination: ON: 0.8 with superior/inferior thinning OD, 0.4 sharp pink OS. Macula, vessels, periphery WNL OU.

Differential Diagnosis

  • Elevated IOP after Cataract Surgery with CyPass Implant
    • Suprachoroidal hemorrhage
    • Aqueous Misdirection
    • Choroidal effusion
    • Pupillary block
    • Steroid response
    • IOP spike from extruded CyPass implant

Additional Investigations

Figure 2: UBM of left eye. CyPass implant visible in the suprachoroidal space with partial extrusion into the anterior chamber. The anterior chamber is deep with no anterior rotation of the lens-iris diaphragm.
Figure 2: UBM of left eye. CyPass implant visible in the suprachoroidal space with partial extrusion into the anterior chamber. The anterior chamber is deep with no anterior rotation of the lens-iris diaphragm.

 

Diagnosis

  • CyPass Implant Extrusion with Elevated Intraocular Pressure

Pathophysiology

  • The CyPass Implant can be classified under the new wave of Minimally Invasive Glaucoma Surgery (MIGS). It is FDA approved for concurrent use during cataract surgery for patients with mild to moderate glaucoma and is placed in the suprachoroidal space between the ciliary body and scleral spur using an ab-interno approach to enhance uveoscleral outflow of aqueous humor.
  • The COMPASS Trial was a two-year interventional study randomizing patients to phacoemulsification alone and phacoemulsification with CyPass microstent at 1:3 ratio. The study found that 72.5 percent of CyPass achieved a >20 percent reduction in IOP at two years and that CyPass eyes achieved a nearly 2 mmHg additional IOP reduction from baseline compared to cataract surgery alone. The most common complications in the CyPass group was hypotony (2.9 percent), iritis (8.6 percent), IOP spike > 10 mmHg over baseline (4.3 percent), and implant extrusion (1-2 percent).

Treatment

  • Control intraocular pressure by restarting IOP-lowering drops
  • Use steroid drops to treat any resulting iritis
  • Can attempt repositioning of CyPass implant or explantation of current microstent, which carries high risk of IOP spike due to closure of the cyclodialysis cleft. Patients will often need additional surgical intervention for IOP control.

Prognosis and Future Directions

  • MIGS is a useful tool for managing patients with mild to moderate glaucoma and CyPass has been shown to provide increased IOP reduction compared to cataract surgery alone
  • Although MIGS is considered relatively safe with less side effects compared to traditional glaucoma surgery, post-operative patients still need to be monitored carefully for potential complications
  • More time and research will give us a better understanding of the safety profile and efficacy of these newer MIGS devices

References

  • Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. Combined iStent Trabecular Micro-Bypass Stent Implantation and Phacoemulsification for Co-Existent Open-Angle Glaucoma and Cataract: A Long-Term Study. Br J Ophthalmol. 2012;96(5):645
  • Craven ER, Katz LJ, Wells JM, Giamporcaro JE, iStent Study Group. Cataract Surgery with Trabecular Micro-Bypass Stent Implantation in Patients with Mild-to-Moderate Open-Angle Glaucoma and Cataract: Two-Year Follow-Up. J Cataract Refract Surg. 2012; 38(8): 1339-1345.
  • Distelhorst JS, Hughes GM. Open-Angle Glaucoma. Am Fam Physician. 2003; 67(9):1937-44.
  • Francis BA, Minckler D, Dustin L, et al. Combined Cataract Extraction and Trabeculotomy by the Internal Approach for Co-Existing Cataract and Open-Angle Glaucoma: Initial Results. J Cataract Refract Surg; 34(7). 1096-1103.
  • Francis BA, Singh K, Lin SC, Hodapp E, Jampel HD, Samples JR, Smith SD, Novel Glaucoma Procedures: A Report by the American Academy of Ophthalmology. Ophthalmology, Volume 118, Issue 7, July 2011, Pages 1466-1480.
  • Grover DS, Godfrey DG, Smith O, et al. Outcomes of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes with Prior Incisional Glaucoma Surgery. J Glaucoma 2017; 26: 41-45.
  • Helmut H, Ahmed IK, Grisanti S, et al. Early Postoperative Safety and Surgical Outcomes After Implantation of a Suprachoroidal Micro-Stent for the Treatment of Open-Angle Glaucoma Concomitant with Cataract Surgery. J Cataract Refract Surg. 2013;39(3):431-437.
  • Maeda M, Watanabe M, Ichikawa K. Evaluation of Trabectome in Open-Angle Glaucoma. J Glaucoma. 2013;22(3):205-8. 10.
  • Okeke CO, Quigley HA, Jampel HD, et al. Adherence with Topical Glaucoma Medication Monitored Electronically the Travatan Dosing Aid Study. Ophthalmology 2009;116:191-9.
  • Pfeiffer N, Lorenz K, Ramirez M, et al. 6 Month Results from a Prospective, Multicenter Study of a Nickel-Titanium Schlemm’s Canal Scaffold for IOP Reduction After Cataract Surgery in Open-Angle Glaucoma. American Glaucoma Society Annual Meeting. New York, NY. March 1-4 2012.
  • Quigley HA, Broman AT. The Number of People with Glaucoma Worldwide in 2010 and 2020. Br J Ophthalmol. 2006; 90(3):262-7.
  • Samples JR, Singh K, Lin SC, et al. Laser Trabeculoplasty for Open-Angle Glaucoma: A Report by the American Academy of Ophthalmology. Ophthalmology. 2011; 118(7):2296-2302.
  • Vold, S. D. Micro-Invasive Stent Implanted During Phaco-Cataract Surgery Achieves Sustained IOP Lower Effect in Glaucomatous Eyes at 12 Months. Presented at 11/13/12 AAO Conference, Chicago, IL.

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Produced by: Monica Chavez, John Daniel and Dr. Vivek Patel
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