Presented by: Siempis Thomas MD, FRCOphth, FEBO
Edited by: Penelope Burle de Politis MD
Adequate management of primary open-angle glaucoma (POAG) is paramount for preserving vision in affected patients over the long term. As intraocular pressure (IOP) is the only controllable factor in this multifaceted disease, it remains the primary target of medical treatment. Although the antiglaucoma pharmaceutical arsenal has evolved tremendously over the past two decades, practical issues — including cost, side effects, and disruption of daily routines — are important determinants of poor compliance and consequent poor outcomes. As life expectancy increases and patients often require multiple medications for systemic conditions, adding lifelong topical ocular therapy — sometimes involving multiple medications and complex dosing schedules — can be extremely inconvenient, particularly for relatively young and active individuals.
Microshunts developed for interventional glaucoma therapy represent an excellent option for achieving effective IOP control without compromising patients’ quality of life. PRESERFLO™ MicroShunt is a minute, flexible stent made of poly(styrene-block-isobutylene-block-styrene) – SIBS –, a biocompatible, degradation-resistant material. The proximal and distal ends of the device are positioned in the anterior chamber (AC) and the subconjunctival space, respectively. In addition to lowering IOP — by an average of up to 15 mmHg — it offers the advantages of being permanent and less invasive than traditional glaucoma surgery. The vast majority of patients become medication-free and require fewer follow-up visits after implantation.
In this video, recorded at the Ophthalmica Eye Institute in Thessaloniki, Greece, Dr. Thomas Siempis (MD, FRCOphth, FEBO), consultant in glaucoma and advanced anterior segment surgery (GAASS), and specialist in interventional glaucoma and microinvasive glaucoma surgery (MIGS), performs a PRESERFLO™ MicroShunt implantation in the right eye (RE) of a 56-year-old male patient with POAG and poorly controlled IOP despite treatment with multiple antiglaucoma eye drops. The patient had originally been diagnosed with glaucoma in both eyes (BE) 7 years earlier, with IOP measurements up to 44 mmHg in the RE without treatment and not lower than 24 mmHg under maximum topical drug combination. Central corneal thickness (CCT) was 545μm. There were no postoperative complications such as leaks, flat anterior chamber or choroidal detachments. Postoperative IOP measurements in the RE were: 10 mmHg at day 1, 10 mmHg at day 7, and 11 mmHg at 6 weeks. At 10 weeks, IOP measured 14 mmHg before ripcord removal and decreased to 9 mmHg shortly thereafter. There was minimal effect on astigmatism, and best-corrected distance visual acuity (BCVA) was preserved at 7/10.
The surgical steps and timing in the video are as follows: corneal traction suture (00:01); conjunctival dissection and radial limbal peritomy (00:05); perilimbal cauterization (00:19); Tenon’s dissection for sub-Tenon’s pocket creation (00:24); application of mitomycin C (00:32); 3-mm mark from the limbus for corneal entry parallel to the iris and away from the corneal endothelium (00:53); inferior paracentesis (00:57); scleral pocket creation with MANI slit-angled 1.0 mm knife and stopping at the limbus (01:04); scleral tunnel creation, entering the eye at the iris plane (01:13); stent insertion into the AC using smooth-tip forceps (01:36); sealing of the paracentesis (01:49); confirmation of aqueous flow (01:56); ripcord suture placement (02:05); Tenon’s closure while ensuring no shunt obstruction (02:40); conjunctival closure (03:43); leak check (04:37); end of the procedure (04:43).
“Any intelligent fool can make things bigger and more complex. It takes a touch of genius — and a lot of courage — to move in the opposite direction.” – E.F. Schumacher
Video:
