Mix and match
At times, I mix and match procedures depending on the patients’ disease stage, IOP, and appearance of the drainage angle. Furthermore, I use endocyclophotocoagulation as an adjunct to the aforementioned procedures. All of these techniques work very well.
Many glaucoma specialists experience an additive effect by mixing and matching different MIGS procedures. I have recently starting using the dual blade with ABiC in my patients with more severe glaucoma, as this ensures that aqueous fluid has a direct route into Schlemm’s canal.
In primary open-angle glaucoma, there is a fusion of trabecular lamallae, increased extracellular matrix proteins, juxtacanalicular tissue, and loss of intra- and intercellular micropores—all of which increase resistance to outflow and potentially reduce the effective filtration area. Adding a focal goniotomy produces an additive effect and makes me feel more confident that aqueous will reach the newly dilated canal and distal system.
All existing glaucoma treatments have a place in the management of the disease, but MIGS have undoubtedly increased the options. Its ability to remove all potential ocular outflow pathway blockages—with or without cataract surgery—ensures that ABiC has the potential to become the go-to treatment option for most types of glaucoma.
1. Battista SA, Lu Z, Hofmann S, Freddo TF, Overby DR, Gong H. Reduction of the available area for Aqueous humor outflow and increase in meshwork herniations into collector channels following acute IOP elevation in bovine eyes. Invest Ophthalmol Vis Sci. 2008;49:5346-5352.
2. Cha ED, Xu J, Gong H. Variations in active areas of aqueous humor outflow through the trabecular outflow pathway. Presented at ARVO 2015.