This lecture will discuss some Minimally Invasive Glaucoma Surgeries (MIGS) including iStents, Hydrus, and Xen gel stents. Why choose one over the other? The pros and cons of each procedure will be presented as well as surgery videos and case presentations to help attendees understand MIGS.

AMEN 2021: While It Is Day

<p>This lecture will discuss some Minimally Invasive Glaucoma Surgeries (MIGS) including iStents, Hydrus, and Xen gel stents. Why choose one over the other? The pros and cons of each procedure will be presented as well as surgery videos and case presentations to help attendees understand MIGS.</p>

<p>Free sharing permitted under the Creative Commons <a rel="license" href="http://creativecommons.org/licenses/by-nc-nd/3.0/us/">BY-NC-ND 3.0 (US)</a> license.</p>

Adventist Medical Evangelism Network (AMEN)

Optical

Peter Blackburn

Small Differences with Big Consequences: A Story of Underrated Maladies

I think this is the I room, the ophthalmology, optometry sort of tract.

Augustine a couple of years ago, the last time we met, which seems like a long, long time ago as to what we've been through since then.

But so today, 1 caveat, I never really know, this is such an interesting group because it's such a mixture of people.

So there's some eye stuff in here and some general medical stuff and then some spiritual stuff because I just don't know how to handle that completely.

So I think there's a little bit for everybody.

It's a compilation of talks and you'll probably see the division in there.

And so we're talking about small things that have a large effect.

That's the theme sort of for the the next hour or so.

So maybe we can say a word of prayer before we get started.

Father, I just thank you so much over the last couple of weeks as I've done some study and some preparation, I thank you for the message that you gave me, and I pray that you might give me the ability to communicate that message in a way that is communicated and what you meant to say to everybody.

I'm an ophthalmologist there in Lexington.

Somehow I miss Loma Linda, and I just don't know how that happened, but I did somehow.

So I've trained, did my last bit of my fellowship here at UK, and have worked there ever since.

So to get started, these are my siblings, my sister and my brother Craig.

And Craig is about 10 years older than me.

And So this is at a wedding a few weeks ago in Colorado.

And when he was about 20 and I was about 10, he was home from college and really kind of wasn't feeling very well.

Sort of lethargic and tired and just not doing great.

Well my mom makes this amazing cake that is sort of a combination between chocolate cake and brownies and it's kind of this fudgy thing and we love it.

And so 1 weekend she made this for me and my brother and we kind of ate the whole thing in a very short period of time.

Well, later that night, my brother just, he kind of got worse.

And so my mom would wake him up, and he would stay awake for about a minute, and then he would just fall back asleep.

My mom's a nurse, and so she knew something wasn't right.

And so we went to the emergency room, and it turned out that his blood sugar was about 800.

And so he was in the ICU for a few days, and it was my and our family's first introduction to diabetes.

And so our life kind of changed after that.

And so he was defined at that point as a type 1 diabetic.

Now he probably would be a tweener between type 1 and type 2, but in about 1980, that's what he was, was a type 1 diabetic.

And so, so our life kind of changed at that point in my life and it kind of got me interested in diabetes.

Well, fast forward about 10 or 15 years, or interested in medicine.

Fast forward about 10 or 15 years, and suddenly he's had the disease for 15 years, and I was in my mid-20s, and interested in medicine, and actually in medical school, and he started having some eye complaints.

So he'd see these floaters, and sort of blurred vision, missing part of his vision.

And so I got to go to the eye doctor with him, and it turns out that he had something called proliferative diabetic retinopathy.

He's a very brittle diabetic, really hard to control his sugars.

And so his disease progressed relatively quickly.

And so after going to the ophthalmologist, we then went to the retina doctor, and I got to sit in on laser for him getting PRP laser, pan-retinal photocoagulation, which is 1 of the ways that we treat that.

And I actually, it's a funny, there's lots of funny stories from this, but my family, we have this thing where we pass out at the smallest thing.

And so my job was to put my hand on my brother's head behind the laser and hold him in place in case he passed out.

Mu Young was a wonderful retina doctor in Denver at the time.

And so that's kinda got me interested in ophthalmology and in retina in particular.

And so that's kinda what we're gonna talk today about.

So my other love for ophthalmology is you actually get to see pathophysiology.

And so in other fields, you kinda study about it and you learn about all these mechanisms, these things that happen, and then you can get lab values and you can play with medicines and see what happens.

But in ophthalmology and optometry, you get to actually see pathophysiology.

And I just thought that was the coolest thing ever.

So we're gonna spend just a little bit about on blood as we kind of introduce the I part of this talk.

So blood in the Bible sort of represents life.

And you know, the wages of sin is death, and for forgiveness we have to have the spilling of blood.

So blood represents life, and we have this whole sacrificial system that represents Jesus giving his blood for us for the forgiveness of our sins.

Well today we're going to actually talk about blood, and real blood, and not symbolically, but actual blood.

So when I gave this talk at church, I actually asked them this, and I won't do that to you because I'm assuming everybody has a little bit of medical knowledge, but blood contains all sorts of things, right?

Contains, it's mostly water, but it contains enzymes and cells and white blood cells and red blood cells and all sorts of stuff.

You have to have energy for cells to survive.

1 of the other thing that blood contains is the regulatory hormone, insulin.

We've talked a little bit about that already, but insulin helps us to control our blood glucose level.

And so there's different ways that you can measure glucose.

You can take just a blood glucose level, whether it be fasting or just random and see what it is.

Or you can check something called a hemoglobin A1c, which is glycosylated hemoglobin.

And so that gives you an average of what someone's blood glucose is for the last 3 months.

And so it's very helpful in seeing over the long term how patients are controlling their blood sugars.

So a normal hemoglobin A1c is less than 5.7.

A pre-diabetic or suggestive diabetes is between 5.7 and 6.4, and a diabetic is a hemoglobin A1C of greater than 6.5.

So relatively small differences in that number can mean that you're a diabetic or you're not a diabetic.

But then the result of those differences, if you have diabetes or carry that diagnosis, you can have these big, huge consequences from that.

And so I asked my church, I said, okay, so what are some of the complications of diabetes?

Heart disease, kidney disease, peripheral neuropathy, and eye disease.

So those are big organ systems that can take a hit from having such a small number change.

So why does an elevated sugar level cause diabetic retinopathy, which is the thing that happens when you have, in the eyes, when you have diabetes?

So don't get nervous about it, because we're not going to really talk about the details of this.

But suffice to say, hyperglycemia, or elevated blood glucose levels, give you these elevated growth factors.

Paul Chung

Understanding the Changing Options with MIGS Part 1

I need God to help me, so let's pray before we start.

Heavenly Father, thank you for this opportunity to share about your wonderful creation, the eye, and some of the diseases that people can get and how we can treat it.

And I pray that you'll give me wisdom to say the right things and help it to be understandable and meaningful to our audience.

Well, I think probably less than half the audience here are actual eye care providers, but maybe some of the rest of you might be interested in ophthalmology or just want to learn more about the eye.

Okay, so I was going to talk about MIGS, minimally invasive glaucoma surgery.

But probably I need to explain what's glaucoma.

Glaucoma is an eye disease where you slowly go blind.

But basically you start losing your peripheral vision and then towards the end you get tunnel vision and then you can lose that completely.

It's usually caused by elevated eye pressures, but there are some people who just have weak optic nerves and even though their eye pressures are normal, they still develop glaucoma.

Their optic nerves get damaged and they can still go blind.

In 2010, there were 2.7 million people with glaucoma.

There's probably an equal number of undiagnosed glaucoma patients, because the early stages of glaucoma, patients can't tell that they have it.

So that's why it's important that you get eye exams, especially as you get older, Because they can check to see if you have glaucoma or not and treat it so you don't go blind.

By 2050 there may be 7.3 million patients with glaucoma.

All right, so you know in 40 years there may be 270% increase in the incidence of glaucoma.

You know when patients come to the eye doctor and they just most of the time they They're there because they need glasses and they want to see better.

And then you tell them, sorry, you have glaucoma and that's why you can't see.

That's why you have these black spots in your vision, and there's nothing we can do to reverse that.

Yeah, I think whenever you give a bad diagnosis to a patient, you have to give them hope.

We can treat glaucoma so you don't lose more vision.

The goal is to keep you seeing as long as you're living.

So if a 30 year old came in with an elevated eye pressure of 30 or 40, normal eye pressure is between 10 and 21 millimeters of mercury.

So if a 30 year old came in with elevated pressure, we're going to be a lot more aggressive in treating them because they've got many more years to live.

But if an 80 year old came in and they've got some early glaucoma, we tell them, well, we look at them and try to figure out how many more years are they gonna live.

And then we tell them, yeah, you have glaucoma, but it's okay.

Maybe we'll put you on 1 eye drop, but you're not going to go blind anytime in the next 2 to 3 years.

If you have an idea how much longer you're going to live, let me know and then we'll be more aggressive in treating.

But usually we start with topical eye drops and then there's laser trabeculoplasty, which can be performed to lower the pressure.

And then there's these minimally invasive glaucoma devices.

If patients have mild to moderate glaucoma, we can use any combination of these 3.

For more advanced glaucoma, sometimes we'll go into more aggressive treatment.

This is what happens when you have glaucoma.

100% when it gets to this line that means you're blind.

Let's say this is birth and this is your death.

A lot of people, even if they don't have glaucoma, their visual function does go down a little bit with age, but never to the point where they're affected by it.

With glaucoma, you basically have to lose more than 90% of your vision to really be affected.

Because you know even though we look straight ahead and we can see over here, we can see over here, even if it came out to about half that, you're still seeing well enough.

If 1 eye sees this much and the other eye sees that much, they overlap.

So if you have glaucoma, you can start losing vision faster.

And so if you intervene early, then you can slow down that rate so it's not a steep drop.

But some patients, it's amazing how I have patients that have never covered 1 eye and realized they couldn't see out of the other eye.

You see the optometrist there nodding their head.

Some people are just not aware of their health conditions.

But We have patients that come in at this point, and then if you can intervene, then maybe we can keep them seeing longer.

But if you don't intervene, their last few years of their life, they're blind.

I remember it was in the 80s when I visited Korea.

I think this was in the middle of my medical school years.

There was an American missionary who had actually been born in Korea.

Then he came back to America, but he often went to Korea.

I didn't know anything about ophthalmology.

But we did a bunch of things together and I've maintained a relationship with him.

Well, you know, 10 years later when I'm a glaucoma specialist he comes in as a patient of mine.

And I said, I didn't know you had glaucoma.

And he said, yeah, even in the 80s when I had glaucoma I was supposed to be taking eye drops, but got busy and ignored it.

And unfortunately by the time I was treating him, he barely had vision.

But I think the last 5 years of his life, he couldn't see anything out of his eyes.

So I told him, well, you just live too long.

Or if you had treated the glaucoma earlier, then you would still have your vision.

So some of the challenges of treating glaucoma is that because it's asymptomatic, patients don't even think they have a problem.

But then they're constantly told they have to use these eye drops.

Sometimes medications are very expensive.

Some of the branded medications, I mean patients tell me they spent 2 or 300 dollars for a little 2.5 milliliter bottle that's supposed to last them a month.

So then I checked their pressure and take them off the medicine and see what the pressure goes up to and then put them back on and see what it comes down to.

That only drops your pressure by 2 or 3 millimeters.

And the eye drops sometimes cause irritation, red eyes.

And so then sometimes we end up doing surgery, then they don't have to use the drops as much.

But surgery has its own problems with complications.

Trabeculectomy has been the most common glaucoma procedure done for the past 20 or 30 years, but it has a lot of its own problems.

So, that's why surgeries that have less risk, even if they're not as effective, have become more popular.

That's why we're talking about minimally invasive glaucoma procedures.

We're going to quickly go over these things because talking about non-compliance.

Yeah, non-compliance is the number 1 reason people go blind from glaucoma.

When I see patients that are worried about going blind, I tell them, look, the only people that go blind from glaucoma are those that either don't follow the treatment plan, like they don't use their eye drops, or they don't follow up with the doctor.

Because as long as they're following up, we can see how they're progressing.

We can explain to them, show the visual fields and say, okay, this is how much vision you had last year, this is how much you have now.

And then we can institute the treatment that's necessary so that we can sort of flatten the curve rather than having them continue losing vision.

So the advantages of minimally invasive glaucoma surgeries is sometimes we can get them off of some medication, so that saves them money.

Understanding the Changing Options with MIGS Part 2

I did want to mention to the optometrists in this group that even though this is not, my lecture here is not COPE approved, so you can't get credit for it.

But this is a series of lectures, This is just 2 hours of lecture in a six-hour series that Pacific Cataract and Laser Institute did for optometrists in Oregon, Washington, Idaho, Montana.

But I don't think it's available yet, but our PR person said that within a month it'll be available.

So you could go online and choose that lecture and just go to the end and you'll be able to answer the questions from what I told you.

So I don't know if you saw my email address at the beginning, But it's basically my first name dot last name at PCLI.com.

And if you email me, then I can send you the information when it's available.

So you can actually get credit for this lecture.

And it looks like we drove out all the non-I related people.

I don't know what you do with eye care, but I figured out who everyone else was.

Okay, so we'll continue on with our minimally effective glaucoma procedures, but it's actually minimally invasive glaucoma procedures because XenGel stents, I think, does work really well.

I started doing xangel stents probably 4 or 5 years ago.

I've been a glaucoma specialist for 25 years now.

Trabeculectomy was the main surgery I was doing.

I know there's some people who prefer tubes over traps, But I find that I get good results with my traps.

But it's very tedious surgery, time-consuming, and there's also potential for complications.

And the Zen gel stent can give you the same bleb and low pressure.

I mean less than 10 minutes if everything goes well.

So the Zen gel stent basically goes in through just either through TM or just above it.

This arrow should be higher and then into the sub-conjunctival space.

So when it was first FDA approved, it was approved as an ad internal approach.

So, you have to go in through peripheral corneal incision and then come out to the superior angle and find the area just anterior to the iris with this inserter that's basically a needle, 23 gauge needle I believe.

Once you're in the subconjunctival space, there's a slider that pushes the xangel stent out.

It's a stiff porcine collagen stent that gets pushed in the subconjunctival space so that a millimeter of it stays in the anterior chamber, 2 millimeters in the sclera, and then 3 millimeters in the subconjunctival space.

But as soon as it gets wet, it becomes like a wet noodle.

So this is basically the end result of it.

Sometimes you can see the anterior chamber portion on slit lamp exam.

Other times you have to gonio them if the sclera or the limbus is further anterior.

It's a 6 millimeter gelatin tube with a lumen diameter of 45 microns.

This 1 is a little more posterior than it should be.

When you go to posterior, when you stick it in, you can hit the blood vessel and they can bleed.

So that's why you want to go either through TM or more corneal.

I think this might have been 1 of my earlier ones.

So in the subconj area you can see this sort of yellowish stent and this looks pretty flat.

So it started off FDA approved as ab internal, but some surgeons came up with another idea thinking okay, why don't we do it, try going ab external, coming in from the outside.

I found it to be much easier doing it this way, than going ab internal, where you make an incision down here, go across, and then going to insert it somewhere here.

I put a corneal traction suture and this is caliper set at 3 millimeters so I'm trying to figure out where 3 millimeters is here and then another 3 and then another 3 because I want to go in around 7 or 8 millimeters back so that the stent will end up here, but my needle hole will be way back here, so it's not going to leak out through the needle hole.

I was just checking to make sure that there is a stent there before I go in.

So I expressed the stent out a little bit, and then I just pushed it back into the needle.

So now I rotate the eye down, and I'm trying to find the area where there aren't too many blood vessels.

Initially I want to go into tinons, but then I want to become more superficial.

It's sort of hard to do, to figure out exactly what level you're in.

But once you get about 2 to 3 millimeters from the limbus, you inject Pierce Disclera and you want to try to stay parallel with the iris and that needle tip should end up between the iris and the cornea, preferably right in the middle, bisecting that angle.

And so as soon as I can see the needle tip, then I advance the slider forward and I'll see the stent coming out.

Series

Optical

Understanding the Changing Options with MIGS Part 2

Transcript

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