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Implantation of two trabecular micro-bypass stents for POAG

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Title: Implantation of two trabecular micro-bypass stents for POAG
Author (s): Tanner Ferguson, MSIV, University of South Dakota School of Medicine, Craig Chaya, MD, Moran Eye Center, University of Utah
Date: 09/24/17
Keywords/Main Subjects: MIGS (minimally invasive glaucoma surgery); glaucoma surgery; glaucoma
Diagnosis: POAG; Glaucoma
Description of Case: This video demonstrates the implantation of 2 trabecular microbypass stents prior to phacoemulsification by Craig Chaya, MD at the Moran Eye Center. Below is our surgical technique for implantation of the 2 stents and standard postoperative regimen.

Note: This video features a repositioning of the second stent. After initial insertion, the stent was not securely placed and the surgeon removed and repositioned the stent.

Note: This video is best viewed in high resolution (720p).

Summary of the Case:
Notable Surgical Instruments

• Swan Jacob gonioprism with Berdahl gonioprism stabilizer
• Healon GV (Abbott)
• iStent trabecular micro-bypass stent (Glaukos Corp.)

Surgical Protocol

1. Two clear corneal incisions are created; one superiorly and one temporally, approx. 90 degrees from superior paracentesis.
2. OVD is instilled through superior incision to stabilize and maintain anterior chamber.
3. OVD is injected onto surface of cornea as coupling medium between the cornea and lens.
4. The patient’s head is tilted approximately 30 degrees away from the surgeon and the patient is instructed to look opposite the surgeon. The microscope is adjusted to a comfortable position.
5. Swan Jacob gonioprism placed on surface of cornea with non-dominant hand while pre-loaded stent injector device is inserted through main incision.
6. After angle anatomy is identified and the trabecular meshwork is visualized, the first stent (on tip of inserting device) is guided at approx. the 2 o’clock position at 20-degree angle into the posterior portion of the trabecular meshwork.
   1. Note: More pigmented regions of the trabecular meshwork are targeted if visualized that may suggest presence of collector channels.
7. Once the stent is released, the inserting device is used to tap or nudge the heel of the stent to ensure it is securely placed.
8. Steps 6-7 are repeated for the second stent and the second stent is typically inserted 3-4 clock hours away from the first stent.
9. Once both stents are securely placed, the remaining viscoelastic in the anterior chamber is washed out using irrigation and aspiration.

Postoperative Guidelines

Drops

• Patients are kept on their preoperative glaucoma drop regimen until the one week postoperative visit.
• Postoperatively, patients were prescribed antibiotics for 1 week, nonsteroidal anti-inflammatory drugs for 4 weeks, and steroid drops for 4 weeks.

Visits

• Recheck at PO 1 day, PO 1 week and PO 1 month.
• Reevaluate intraocular pressure 3 months after surgery to assess need for further treatment.

Format: Video
Faculty Approval by: Craig Chaya, MD
Identifier: Moran_CORE_24336
Copyright statement: Ferguson ©2017. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/