Which device for which patient
Dr. Vold said that in the future, patient-specific imaging and diagnostics will enable individualized surgical decision-making.
“It would be nice if we could optimize the results for each patient by determining if he or she would benefit most from a trabecular bypass procedure versus a supraciliary approach or subconjunctival surgery,” Dr. Vold said.
Until such guidance is available, Dr. Vold suggested that trabecular bypass procedures may be considered for patients with mild disease or who have not been on medications long-term, based on the expectation that they still have a functioning collector system.
Implantation of a supraciliary device could be considered an excellent option for patients with mild-to-moderate glaucoma. Considering the favorable safety profile of these surgeries, both trabecular bypass and supraciliary procedures are being considered for early glaucomatous disease.
Dr. Vold said the subconjunctival microshunts are a promise option for treating moderate-to-advanced glaucoma. Compared with the trabecular micro-stents and supraciliary implants, subconjunctival microshunt surgery may be less likely to be adopted by comprehensive ophthalmologists and cataract surgeons.
“My sense is that surgeons interested in implanting the subconjunctival devices will have previous experience dealing with filtration blebs,” he said.
Finally, the future may combine aqueous outflow implants with drug delivery to achieve the best long-term results.
“We need to think of glaucoma as not just a medical disease or just a surgical disease, but rather as an interventional disease, where even laser trabeculoplasty and micropulse cyclophotocoagulation will have roles for management earlier in the disease process than they have in the past,” Dr. Vold said.