Minimally Invasive GlaucomaSurgery (Shunts) Dr. Manish Mahabir SR, Unit IV Anatomy Approach MIGS Abinterno Ab-externo iStent Supra (Ab Interno) SOLX Gold shunt (Ab Externo) Aquesys .Filtration Filtration Trabecular microbypass Intracanalicular scaffold Suprachoroidal stent Subconjunctival Device iStent. iStent inject Hydrus CyPass. 25 mm x 120 µm (bore diameter) • Weight: 60 µg • Surgical grade non-ferromagnetic titanium • Heparin-coated to facilitate outflow • First FDA approved MIGS implant .iStent • 1 mm x 0.33 mm • Snorkel: 0. iStent : Mechanism • Creates a bypass through trabecular meshwork to Schlemm’s canal • Improves aqueous outflow through the natural physiologic pathway . . . . 50% with cataract Ophthalmology.At 12 months: 68% of iStent subjects with IOP ≤ 21 mm Hg without medication vs. 2011 alone Mar. surgery .118(3):459-67. 35% cataract group on medication (p=0. .001) Ophthalmology. 2011 Mar.At 12 months: 15% of iStent vs.118(3):459-67. . . . . highly elastic and biocompatible • Dilates Schlemm canal by 166 microns along the length and 241 microns at the device inlet • Increases outflow facility . an alloy of nickel and titanium.Hydrus • 8 mm in length • Crescent-shaped • Composed of nitinol. . . . 35 mm length 510 microns external diameter 310 microns internal diameter 76 micron diameter pores Biocompatible polyimide Retention rings at proximal end .CyPass • • • • • • 6. . . . . . only open lumen .1 mm sleeve 365 microns external diameter 165 microns internal diameter Biocompatible polyether sulfone (PES) • Titanium sleeve • No fenestrations.iStent Supra • • • • • 4 mm in length 1. iStent Supra . Gold Micro Shunt • • • • 5.2 mm wide 99.9 % biocompatible pure gold .5 to 3.2 mm long 80 microns thick 2. . . . Aquesys • • • • 6 mm in length 3 sizes with varying internal diameter Composed of cross linked gelatin Designed to swell during implantation to secure in place and prevent migration . . . 7 eye drops postoperatively. 15.-6.3 (-29% drop) at month 12. -6. The IOP was reduced 30% from baseline after 6. 15.3 at 12 months.7 meds after 9 and 12 months.First results of the innovative minimalinvasive glaucoma surgery technique: the AqueSys Aquecentesis procedure Results: The mean preoperative IOP of all our patients was 21. 9 and 12 months. .5 (-30% drop) at month 6 and ?6.2 at week 1.3 (-28% drop) at month 1. The number of eye-drops applied was reduced from 2 medications preoperatively (mean) to 0.3 mm Hg compared to the mean IOP in mmHg at postoperative intervals which were: 12. Conclusions: The new Aquecentesis procedure proved to be a minimally invasive and straight forward surgical approach.1 (-42 % drop) at week 1. The medications were reduced from 2 eye drops (mean) preoperatively to 0. The mean decrease in IOP was -9.0 at month 1.2 at 6 months and 15. Complications • Hyphema • Inflammatory membrane blocking shunt • Scarring in supra-choroidal space • Early transient hypotony (< 1 month) • Peripheral anterior synechia . Limitations • Low to moderate IOP reduction compared to traditional trabeculectomy and glaucoma drainage devices. • Angle closure glaucoma • Neovascular glaucoma • Congenital anomalies • Raised episcleral venous pressure • High cost . Advantages • Lower dependence on topical medications • Low complication rate • Less number of post-operative visits • Cost – effective in long run • Higher quality of life • Conjunctiva sparing • Minimal training . Thank You! .