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CONSULTATION SECTION: GLAUCOMA

Cataract, glaucoma, possible Marfan syndrome, and conception aspirations

Section Editor(s): Samuelson, Thomas W. MD

Author Information
Journal of Cataract & Refractive Surgery: January 2020 - Volume 46 - Issue 1 - p 154-161
doi: 10.1097/j.jcrs.0000000000000095
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Sameh Mosaed, MD

Irvine, California, USA

Treatment of advanced primary open-angle glaucoma (POAG) in a young patient, where the stakes are much higher than in the typical POAG patient, involves complex consideration. For this 36-year-old female, we must consider the fact that she already has severe disease encroaching on fixation in the right eye and involving fixation in the left eye. Prompt and consistent IOP control is imperative if she is to keep her remaining vision for her lifetime. Given that she is in her childbearing years, we also must consider methods to eliminate or reduce medication reliance.

She is presenting with progressive field loss despite IOP in the high teens. Typically, MIGS procedures will only lower IOP into the mid-teens, usually with continued medication reliance. Additionally, MIGS procedures often have a waning effect over time; hence, it may not represent an adequately robust or enduring alternative for this young patient. Because she does not have low-tension glaucoma and likely does not require IOP in the high single digits, I would defer a trabeculectomy or other bleb-reliant procedure at this time. A reasonable goal IOP would be somewhere in the low teens, and a reliable procedure to deliver this is the placement of a Baerveldt glaucoma implant (Johnson & Johnson Vision Care, Inc.). While medication reliance may still be necessary, it is typically lower than with valved tube shunts or with any of the MIGS procedures.

MIGS procedures are generally low-risk and it would not be unreasonable to offer them to this patient to ascertain her individual response. When deciding on the appropriateness of a MIGS procedure, I use the goal IOP as the determining factor: if the goal is in the mid-teens, then I think the MIGS procedures are appropriate, regardless of disease severity. The trabecular bypass procedures using the goniotomy code have broad indications and likely would all have a similar effect here, and one could not discriminate among them. There are many real-world studies showing that patients with advanced disease can benefit greatly from trabecular bypass surgeries, as they typically have profound IOP reductions into the mid-teens from a high baseline. In contrast, the Schlemm canal implants are indicated only for mild-to-moderate disease. However, if the target IOP is in the mid-teens, then I would consider off-label use as reasonable in patients with more advanced glaucoma.

Given the body habitus and ocular signs of possible Marfan syndrome, referral for workup would allow for earlier detection of potentially life-threatening aortic aneurysms and other cardiovascular abnormalities. It would also provide information to the patient for consideration for family planning.

While this patient represents a tough case for the clinician considering the high risks involved, I would opt for placement of the Baerveldt glaucoma implant 101 to 350 in each eye. This is more predictable, higher-yield, and definitive than MIGS, and would hopefully result in a one-and-done surgical intervention for this patient.

Disclosures: The author does not have a financial or proprietary interest in any material or method mentioned.

Jacob W. Brubaker, MD

Sacramento, California, USA

There are many key points in this case to consider. Since initially the zonular laxity was unknown, at consideration is a young patient with advanced glaucoma with bilateral cataract status post retinal detachment surgery. To complicate matters she wishes to conceive and thus a reduced medication burden would be ideal.

With increasing adjunctive glaucoma surgical options at the time of cataract surgery becoming available, more precisely tailoring therapy to individual patients is now a reality. Options for this patient include trabecular stenting, ablating, or bypass. When treating with stents we are often constrained by insurance coverage based on their labeling for mild-to-moderate glaucoma. In my practice, I have found success in using trabecular stents to reduce medication burden if patients are well controlled on medications. This is independent of the glaucoma stage. The case at hand, however, shows a patient that is not well controlled and is in fact progressing on multiple medications. In addition, this patient is quite young and likely has a component of juvenile open-angle glaucoma (JOAG). The primary dysgenesis in these patients is located at the trabecular meshwork. Therefore, similar to a recent paper by Grover et al., I have found that that 360-degree goniotomy in this demographic is quite successful.1 Alternatively one could consider a subconjunctival microstent. In this situation, however, I would reserve this as a future consideration. Given her uncontrolled glaucoma, likely diagnosis of JOAG, and high myopia, I would have discussed and elected to proceed with 360-degree goniotomy at the time of her cataract surgery.

The discovery of zonular laxity as well as consideration for Marfan syndrome does change the discussion considerably. From an ocular standpoint, her glaucoma mechanism would need to be more fully determined. One paper looking at the rate of glaucoma in patients with Marfan syndrome2 showed that nearly half of those that developed glaucoma had POAG, with the minority having acute angle closure due to lenticular subluxation. The other half had post-surgical glaucoma, either post lens extraction or scleral buckle. Since secondary pigmentary glaucoma can develop due to IOL laxity, proper scleral fixation would need to be ensured.

More importantly, the possibility of Marfan syndrome needs to be investigated due to the high rate of aortic aneurysms. Given her desire to conceive, she would need to be informed and monitored, not only due to the increased risk of aortic dissection during pregnancy but also so she can be informed about the risk of passing this condition to her offspring. Although mechanical valve replacement is becoming less common in these patients, the risk of requiring long-term anticoagulants could potentially persuade against the use of a 360-degree goniotomy. If this diagnosis were confirmed, after consulting with her cardiologist, I would consider a trabecular stent if future blood thinners may be warranted as I feel the risk of future blood reflux into the anterior chamber is less common with these devices.

Disclosures: Neither author has a financial or proprietary interest in any material or method mentioned.

1. Grover DS, Smith O, Fellman RL, Godfrey DG, Butler MR, Montes de Oca I, Feuer WJ. Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. Br J Ophthalmol 2015;99:1092–1096

2. Izquierdo NJ, Traboulsi EI, Enger C, Maumenee IH. Glaucoma in the Marfan syndrome. Trans Am Ophthalmol Soc 1992;90:111–122

Sarah Maki, MDChristine L. Larsen, MD

Minneapolis, Minnesota, USA

There are several factors that are noteworthy when evaluating further surgical intervention in this patient. In the context of this patient's young age, the severity of her glaucomatous loss is concerning. Under the assumption that the IOP measurements were similar over the last year to those at the time of referral, the visual fields demonstrate a clear worsening of deficits despite multiple topical medications and an IOP of 18 and 20 in the right eye and left eye, respectively. It is apparent that the patient requires additional pressure lowering from her current baseline, which is further complicated by the fact that topical therapeutic options may be limited in the near future due to her desired pregnancy. In additional, and not an inconsequential consideration, are her previous history of retinal detachment repairs, which may limit surgical options. Because of these aforementioned factors we recommend fairly aggressive IOP control.

Regarding her left eye, her visual field changes in addition to her OCT scan demonstrating little nerve fiber layer reserve, would classify the stage of her glaucoma as severe. In this case, we would recommend careful evaluation for MIGS procedures, such as goniotomy. One could consider assessment for a primary tube shunt; however, given the risk of hypotony maculopathy in this young, highly myopic female, we would recommend MIGS, which would provide a superior safety profile. We would advise a thorough discussion with the patient regarding the aforementioned risks, and the possibility of requiring some topical medications after surgery. It should be noted that some topical medications classified as category C could likely be continued during her pregnancy without consequence if adequate IOP control was not achieved with goniotomy alone. Although her glaucomatous damage would be classified as severe, this case makes an indisputable argument that use of MIGS is best assessed by clinical context and not stage severity.

In surgical planning for the patient's right eye, there is again progression of her visual field with significant glaucomatous loss shown on her OCT scan, although not to the degree of her left eye. In this situation, we would again consider the use of MIGS. Specifically, we would recommend the use of larger canal microstent devices and goniotomy/viscodilation procedures involving the trabecular meshwork. We feel confident that this would best mitigate the surgical risk of more invasive glaucoma procedures such as trabeculectomy or tube shunt in the setting of less advanced visual field changes.

An important final point is that the patient's ocular pathology, including retinal detachments, high myopia, zonulopathy, and glaucoma, in addition to body habitus, are worrisome for Marfan syndrome. Given the significant comorbidities associated with this diagnosis, most notable thoracic aortic aneurysm and dissection, we believe it is imperative to work in conjunction with the patient's primary care provider for further evaluation and workup of this disease.

Disclosures: Dr. Sheybani is a consultant for Allergan, Inc. The other author does not have a financial or proprietary interest in any material or method mentioned.

Erin Sieck MDArsham Sheybani MD

St. Louis, Missouri, USA

This case presents a difficult position for glaucoma providers while treating women of childbearing age. Brimonidine, an alpha agonist, is the only category B topical antiglaucoma medication approved for use in pregnant women by the U.S. Food and Drug Administration. All other glaucoma-directed medications are category C and pose a potential teratogen to the fetus.1 In addition to her currently taking 2 category C medications, she has clear progression in her IOP in both eyes over the last year on her Humphrey Visual Field test. Given the severity of impact and IOP progression, and her young age, she needs a surgical intervention that has the potential to achieve an IOP below episcleral venous pressure.

At the time of cataract surgery, one could still consider a trabecular meshwork procedure, but a canal-based procedure will likely not get her IOP into the low teens without medication. I do consider MIGS procedures for severe glaucoma if the patient is near their IOP goal, has multiple comorbidities, and/or is of advanced age. This is not the case for this patient. Although a 360-degree ab intero trabeculotomy might be very reasonable in a young patient who may have a patent distal outflow system, in this case, the post-vitrectomized eye and weak zonules may mean she is at increased risk for a hyphema that may spill into the posterior segment.

To obtain an ideal IOP without medication, the patient needs subconjunctival surgery. Given her high myopia and the long axial length, I would avoid a traditional trabeculectomy. A tube shunt is unlikely to achieve goal IOPs because of the starting presurgical IOP. At this time, I would recommend a subconjunctival microshunt, such as the XEN stent (Allergan, Inc.). The implant could be placed ab interno without dissecting conjunctiva, especially if the conjunctiva is thin, or ab externo placed below Tenon and conjunctiva after ensuring a broad posterior dissection. The gel stent implant offers the best chance for lowering the IOP but minimizes the chance of chronic hypotony, for which she is at high risk. If she were to need bleb needling during her pregnancy, we would discuss the risk and benefits of using an antimetabolite during that procedure.

I would not initiate a workup for Marfan syndrome if she had a negative family history unless she had classic systemic findings such as arachnodactyly, pectus excavatum, pectus carinatum, or scoliosis. Zonular pathology can be seen following vitrectomy with or without gas placement. In addition, high myopes may have zonulopathy either with a normal axial length (microspherophakia) or a long axial length (as in this case).

Disclosures: Dr. Sheybani is a consultant for Allergan, Inc. The other author does not have a financial or proprietary interest in any material or method mentioned.

1. Razeghinejad MR. Glacuoma medications in pregnancy. Oman J Ophthalmol 2018;11:195–199

Antonio Maria Fea, MD, PhD

Torino, Italy

This case presents several challenges: the patient has glaucoma, high myopia, a monolateral cataract, and progressive visual field damage despite maximal medical therapy, and an IOP in the high teens. Furthermore, she is contact lens–intolerant and the future use of medications may be limited due to her desire to conceive a child.

Considering her progression and her myopia, a lower-target IOP may be advisable; the need for maximal reduction of medical therapy excludes the option of a combined surgery with a trabecular/Schlemm canal procedure. Potential alternatives are phaco-trabeculectomy, phaco-sclerectomy or phacoemulsification combined with a subconjunctival MIGS device (ie, XEN stent, PreserFlo microshunt [Santen]). I would certainly opt for a combined MIGS procedure. Phaco-trabeculectomy, even with lower or no mitomycin-C, may carry a significant risk of early postoperative hypotony, and both phaco-trabeculectomy and sclerectomy would limit future potential options. Either phaco-MIGS procedure may be advisable, but I would probably opt for a phacoemulsification combined with the Preserflo microshunt, because this may result in a lower final pressure and definitely in a lower number of adjunctive procedures. I would implant in the nasal quadrant in order to have the temporal and possibly the superior quadrant untouched in case surgery may be necessary in the future. For an IOL, I would probably choose a monovision option.

The findings of bilateral loose zonules and Marfan syndrome habitus would certainly suggest more investigation, specifically genetic and cardiological workups.

I do not limit the use of MIGS to mild-to-moderate glaucoma. The variables I take into consideration are the age, general health, and tolerance of topical therapy of the patient. Elderly patients with precarious health conditions are certainly included in my MIGS scenario; the choice between trabecular/Schlemm canal procedures vs subconjunctival procedures will mainly depend on the opportunity of adding topical therapy after the surgical procedure if needed. Another factor that plays a role in the decision-making is the starting IOP, the pharmaceutical load, and the need to combine with cataract surgery. In elderly patients with reasonable medical therapy (1 to 2 compounds), with moderately elevated IOP and with concomitant, combo trabecular/Schlemm canal surgery would certainly be an option. I would also consider MIGS in cases with previous complicated glaucoma surgery in the fellow eye; these patients, due to their previous unlucky experience, frequently refuse any further surgery but the offer of a less invasive surgery can be accepted and sometimes open the road for further surgery if necessary. I do use a MIGS device in severe glaucoma cases.

Disclosures: The author does not have a financial or proprietary interest in any material or method mentioned.

Manjool Shah, MD

Ann Arbor, Michigan, USA

There are several interesting and relevant points to review in this case. The choice of an adjunctive glaucoma procedure is important in ideally achieving relative medication independence in this young female patient of childbearing age. It is first important to recognize the relationship between previous vitrectomy and the development of elevated IOP independent of preexisting ocular hypertension.1 Oxidative stress causing progressive damage to the conventional outflow system has been proposed as a mechanism of this observation.2 Furthermore, the patient's young age suggests the possibility of a JOAG pathophysiology, which also may point to a trabecular meshwork and conventional outflow-centered disease. Both observations suggest the possibility of trabecular meshwork bypass procedures as a treatment of choice. In choosing between Schlemm canal-based procedures, there may be a beneficial role in a microstent as opposed to incisional techniques, as incisional goniotomy and trabeculotomy tend to result in greater earlier postoperative hyphema. Because of the zonulopathy and the fact that the patient has had a vitrectomy, there is a greater chance of posterior segment spillover of the hyphema, resulting in significant delay in return to visual function. While Schlemm canal microstents are labelled for use with only mild-to-moderate glaucoma, a strong case for improved predictability and patient safety can certainly be made in this context, and I would favor pushing back against payors as much as possible to do what is best for the patient. I would delay the use of a subconjunctival procedure, reserving it for a later stage if additional IOP or medication reduction is required to achieve the patient's goals. The presence of previous vitreoretinal surgery may have resulted in some conjunctival scarring, which may preclude subconjunctival MIGS procedures, but conventional subconjunctival approaches, such as tube shunts, may be indicated. That being said, MIGS devices in general can certainly have a role in all levels of glaucoma severity, as the disease severity itself may not be as relevant as the desired IOP goal and medication reduction requirements.

In terms of working up the patient for Marfan syndrome given her zonulopathy, it is important to recognize that the patient already has numerous other risk factors for zonular weakness and laxity, namely her history of vitrectomy and her axial myopia. However, because of the Marfan syndrome habitus, the likelihood of a congenital predisposition to zonulopathy may exist. Again, as the patient is thinking about having a child, genetic testing with appropriate counseling may be helpful for this patient and her growing family.

Disclosures: The author does not have a financial or proprietary interest in any material or method mentioned.

1. Chang S. LXII Edward Jackson lecture: open angle glaucoma after vitrectomy. Am J Ophthalmol 2006;141:1033–1043

2. Siegfried CJ, Shui YB, Holekamp NM, Bai F, Beebe DC. Oxygen distribution in the human eye: relevance to the etiology of open-angle glaucoma after vitrectomy. Invest Ophthalmol Vis Sci 2010;51:5731–5738

Davinder S. Grover, MD, MPH

Dallas, Texas, USA

Angle surgeries tend not to work well in patients with POAG who are highly myopic. I am not sure whether this finding is due to my personal selection bias or due to stretching of the downstream episcleral venous plexus that impairs outflow, or if it is possibly due to other reasons. For this concern alone, I hesitate to consider angle surgery in this case. If the patient were opposed to any more invasive filtration surgery, I may consider a gonioscopy-assisted transluminal trabeculectomy (GATT); however, I would not expect a GATT surgery or any angle surgery to get her off all glaucoma medications. Of note, zonular weakness puts patients at high risk of a vitreous hemorrhage after angle surgery.

Given her young age, she may be on the JOAG spectrum; however, the myopia and prior retina surgery are confounding this picture. If she were a JOAG patient, I would lean heavily toward a GATT surgery. But because of the prior retina surgery and high myopia, I think there is more going on than just impaired trabecular outflow.

Given the patient's advanced glaucoma stage (the cataract is likely affecting her visual field) and young age, my target IOP would be the low teens. She needs a surgery that will definitively get her IOP in the low teens on as few drops as possible.

My first choice for this patient is cataract surgery and a XEN45 gel stent augmented with 60 mcg of mitomycin-C, but the zonular weakness changes things. If I were to experience intraoperative zonular issues, I would be concerned of dislocating the lens during ab interno implantation of the gel stent. I may consider an ab externo gel stent to avoid excessive anterior chamber manipulation, but this patient will likely need subsequent surgeries for a potential dislocated IOL or additional retinal detachment, and such surgery could possibly cause the stent to fail. Therefore, I may consider a 250-nonvalved implant as this would provide more resilience with subsequent eye surgeries, and I would augment the tube with low-energy cilioablation if the IOP is not at target.

Because of the finding of very loose zonular fibers, connective tissue disorders could have implications for the patient and her future children. Therefore, I would recommend a workup for Marfan syndrome.

MIGS limitations based on staging are due to insurance-imposed limitations and pertain to devices (stents). Goniotomy and GATT are not tied to a specific staging of disease and can be used more flexibly. For POAG, I use stenting procedures in very mild glaucoma on 1 or 2 drops. I use a goniotomy procedure for mild-to-moderate disease on several drops. I use GATT on moderate-to-advanced disease on several drops when I need significant pressure lowering. I do not typically use angle surgeries for advanced POAG. In secondary open-angle glaucomas, I use GATT in relatively advanced cases as they tend to do well. I will consider either goniotomy or GATT in severe secondary open-angle glaucomas. I do not use stenting procedures in advanced glaucoma unless the patient cannot be taken off blood thinners.

Disclosures: The author does not have a financial or proprietary interest in any material or method mentioned.

Sarah H. Van Tassell, MD

New York City, New York, USA

We are presented with a young woman of childbearing age with JOAG in both eyes; she is hoping to conceive a child soon.

The right eye has moderate glaucoma with concern for progression over the last year to an IOP of 18 mm Hg, with the patient on 3 topical IOP-lowering medications. She will likely need incisional surgery in her lifetime, but it is worth it to attempt an angle surgery, particularly because eyes with JOAG can be exquisitely sensitive to the effects of angle surgery. I would perform gonioscopy-assisted transluminal trabeculotomy or goniotomy with a dual blade (Kahook, New World Medical, Inc.); additional angle surgery approaches might also be successful. True surgical success would reduce her IOP as well as her medication burden, so her treatment regimen could be better tailored to her pregnancy and postpartum needs.

For the left eye, I have the option of assessing the early response to angle surgery in the first eye before finalizing a surgical plan. If her IOP reduction in the first eye was substantial, I would repeat the same surgery in the left eye despite the severe glaucoma. Failure of early response in the first eye would point me away from angle surgery in the second eye. Given the patient's axial myopia and young age, I would avoid trabeculectomy. Although one could consider placement of a gel stent, cataract extraction together with placement of a glaucoma drainage implant is my preferred plan. It is worth bearing in mind that her timeline for attempting pregnancy may result in limited opportunities for surgery in the years ahead. Cataract extraction with placement of a glaucoma drainage implant has a high likelihood of IOP and medication reduction with little need for antifibrotic injections, needling, revisions, or additional surgery.

It is rare in ophthalmology to have the opportunity to save a person's life, but identifying undiagnosed Marfan syndrome is precisely such an opportunity. This patient has Marfanoid body habitus, high myopia, zonular weakness, glaucoma, and a history of retinal detachments, all of which are more common in patients with Marfan syndrome.1,2 Discussing the possibility of Marfan syndrome with this young woman is prudent. Pregnancy and the postpartum period are high-risk for aortic dissection and rupture in women with Marfan syndrome, and such a diagnosis would be important for her family planning and pregnancy risk management.3 In the absence of a Marfan syndrome diagnosis, I would strongly consider JOAG genetic testing, which may have implications for family planning and monitoring of her children.

Severe glaucoma describes a heterogenous population of eyes,4 and many eyes with severe glaucoma can benefit from the “moderate risk, moderate reward” paradigm of MIGS. As an example, eyes with nasal steps in both hemifields routinely do beautifully following a variety of MIGS; it is unfortunate to arbitrarily exclude eyes such as in this case that may benefit from MIGS. I generally avoid MIGS in eyes with fixation-threatening visual field defects, although there are cases in which MIGS can be appropriate in such eyes, as described above.

Disclosures: Dr. Van Tassell is a speaker for New World Medical, Inc.

1. Esfandiari H, Ansari S, Mohammad-Rabei H, Mets MB. Management strategies of ocular abnormalities in patients with Marfan syndrome: current perspective. J Ophthalmic Vis Res 2019;14:71–77

2. Maumenee IH. The eye in the Marfan syndrome. Trans Am Ophthalmol Soc 1981;79:684–733

3. Cauldwell M, Steer PJ, Curtis SL, Mohan A, Dockree S, Mackillop L, Parry HM, Oliver J, Sterrenberg M, Wallace S, Malin G, Partridge G, Freeman LJ, Bolger AP, Siddiqui F, Wilson D, Simpson M, Walker N, Hodson K, Thomas K, Bredaki F, Mercaldi R, Walker F, Johnson MR. Maternal and fetal outcomes in pregnancies complicated by Marfan syndrome. Heart Br Card Soc 2019;105:1725–1731

4. American Academy of Opthalmology, American Glacoma Society. ICD-10 glaucoma reference guide. American Academy of Opthalmology AAOE Practice Management website. Available at: https://www.aao.org/Assets/5adb14a6-7e5d-42ea-af51-3db772c4b0c2/636396205914600000/glaucoma-quick-reference-guide-update-8-29-17-pdf?inline=1. Revised June 2018. Accessed December 2, 2019

Thomas Patrianakos, DO

Chicago, Illinois, USA

The management of this patient's glaucoma and coexisting cataracts requires multiple considerations due to her complex ocular history. She has documented progression on her visual fields, which means her IOP control has been suboptimal and needs to be lowered. She is also hoping to conceive in the near future, which will limit her use of topical medications. In addition, she is a high myope, which can make traditional glaucoma filtration surgery (GFS) more complicated due to an increased risk of choroidal effusion/hemorrhage. Her previous retina surgery poses additional surgical challenges secondary to scarring of the conjunctiva.

The safest option would be to perform a nonincisional surgical procedure, such as a transscleral micropulse laser procedure. However, the pressure-lowering effects may be short-lived and therefore the patient should be counseled that further surgical intervention may be required. A more definitive approach would be an ab interno viscodilation of Schlemm canal, goniotomy, or both combined with cataract extraction. The combined viscodilation and goniotomy would be my preferred procedure as I feel, in my hands, it would be the safest and most efficacious procedure to achieve her target IOP.

MIGS is traditionally not as efficacious as GFS and therefore reserved for mild-to-moderate glaucoma. However, the risk for devastating complications with traditional GFS in this patient with severe glaucoma would make me favor the use of the safer MIGS procedure. More invasive surgeries, such as tube shunts or a Schocket procedure, with greater rates of complications, can be reserved for later in the disease process if needed.

The patient also should be tested for Marfan syndrome as she exhibits many ocular signs of the disorder, including cataracts, loose zonules, retinal detachment, and glaucoma. Arguably, testing for Marfan syndrome is even more paramount in her case as there is an increased risk of a dissecting aortic aneurysm occurring during delivery. The future parents should also be counseled on the genetic probability of passing the disease on to their children.

Disclosures: The author does not have a financial or proprietary interest in any material or method mentioned.

EDITOR'S COMMENT

Thomas W. Samuelson, MD

Minneapolis, Minnesota, USA

As uniformly expressed by the panel of expert consultants, there are many important considerations to address in this case. The panel has outlined them beautifully. Consistent with the times, our consultants were quite varied in their recommendations. In 2020, we have a luxury of riches with numerous different glaucoma procedure options from which to select. While the array of options can be confusing indeed, it helps to frame the portfolio of incisional glaucoma surgical options into two broad classifications: those procedures that augment physiological outflow, and those that create a novel and new outflow pathway. The former class of procedures involves canal-based surgery, while the latter represents transscleral surgery. Of course, each of these broad classes have numerous subdivisions. Five of 9 consultants chose a canal-based glaucoma surgery for this patient while 4 recommended transscleral procedures. As an aside, it would be interesting to know how many would have opted for a supraciliary device had that been available. I suspect some would have; endothelial matters related to Cypass notwithstanding. Of those opting for canal surgery, 3 consultants preferred incisional goniotomy with or without canal dilation, while 2 planned on placing a canal stent. Of the 5 consultants preferring transscleral surgery, 1 recommended a long tube, while 3 preferred one of the newer, device-assisted transscleral outflow procedures, such as Xen or PreserFlo. Note, while PreserFlo has the Conformité Européenne mark, it is not yet available to U.S. surgeons. In this particular case, axial myopia and the patient's aspirations to conceive a child were critical considerations. As emphasized by the expert panel, this case also poignantly demonstrates that procedure selection is far more complex than the device labelling would suggest. While device labelling is based primarily on disease staging, procedure selection is very nuanced. In addition to disease severity, one must consider disease velocity, desired IOP target, anticoagulation status, axial length, availability of glaucoma medications postoperatively, longevity, and perhaps most importantly, likelihood of future progression.

This was my patient and I after considerable discussion she elected to proceed with phacoemulsification combined with the Hydrus microstent (Ivantis, Inc.) (Video 1, available at http://links.lww.com/JRS/A20 and Video 2, available at http://links.lww.com/JRS/A21). We viewed her pending pregnancy as an important impediment to medication use requiring purposeful utilization of punctual occlusion and careful drug selection, but not an absolute contraindication and not necessarily a reason to take on significant additional surgical risk. Indeed, we did not expect, nor did we achieve, a medication-free result, at least thus far. Two months postoperatively, her IOP is 15 mm Hg and 16 mm Hg, respectively, while using latanoprost each evening and timolol each morning. Her uncorrected visual acuity is 20/20 in the right eye and 20/70 J1 in the left eye with “mini-monovision.” The patient is quite pleased with her outcome yet remains well aware that she may need transscleral surgery at some point should her field progress.

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