EX-PRESS device is advancing glaucoma surgery to a “new eraâ€

We are in a new era of glaucoma surgery. There are so many new innovations and devices we hear about every day. But have we found the Holy Grail? The answer is we are still in a mode where we are trying to find something as effective but safer and more predictable than trabeculectomy. Despite what you hear about the innovations, trabeculectomy is a good procedure because it works. Many people use this technique and will probably continue to do so for years to come. But can we marry the effectiveness of trbeculectomy and enhance the safety of the type of procedure that it encompasses? The real issue is finding something that works as well as trabeculectomy with increased safety, less tissue trauma, more precision, more pre- dictability, and more control. If we can find that, then we will continue to advance the field of glaucoma surgery. That’s what I think about the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas). It is a starting point. It is a new platform. It is an advance. We still come back to drainage surgery because we cannot argue with the efficacy. In primary glaucoma filtration, nothing has been proven to be more effective than trbeculectomy. It is that aspect of the surgery that continues to draw us to it. In all of what we have seen, we have seen innovation, and we have seen technology trying to do things better. The other aspect of this advancement is the idea that glaucoma surgery doesn’t always have to be more successful to be better. I like the analogy of phacoemulsification versus ex- tracapsular cataract extraction (ECCE). Phcoemulsification, with a posterior chamber lens implant, is no more effective than or more successful than ECCE. But we all agree that phacoemulsification is better. If we threw away evidence-based medicine back in the 1970s, when Charles Kelman, M.D., introduced us to it, who knows what kind of cataract surgery we would be doing today. The EX-PRESS device procedure has been found to have fewer complications than stan- dard trabeculectomy. Advantages include less hypotony and choroidal effusions and faster visual recovery.1,2 The idea is starting with something better, something safer, something that we have more control over, with more precision, more predictability, less trauma, and if we can do as well in terms of efficacy, then we have a better procedure and we begin to advance. With the EX-PRESS device procedure, the likelihood of an intraoperative or post-op hyphema in patients taking anticoagulants has been decreased by making a bigger inci- sion in the sclera. I believe the EX-PRESS device procedure gives more control intraop- eratively and post-op. Additionally, wound management is the same in the EX-PRESS device procedure as it is in standard trabeculectomy. Furthermore, the EX-PRESS device procedure is usually per- formed without viscoelastic, which contributes to its ease. In my opinion, it helps me to better manage these patients with openangle glaucoma. Discussants A participant in this discussion is Ike K. Ahmed, M.D., who is an expert in the OR, a phenomenal innovator, and a tremendous contributor to surgery and ophthalmology in general. Dr. Ahmed discusses his experiences with the EX-PRESS device and will help us to hone in on some of the pearls and aspects of the procedure that he finds useful. Next, we have Malik Kahook, M.D., who is a rising star in the field of glaucoma surgery, a great investigator and clinician. Dr. Kahook reviews his recently published study, “Assessment of bleb morphologic features and postoperative outcomes after EX-PRESS drainage device implantation versus trabeculectomy.†Richard A. Lewis, M.D., has been a tremendous leader for innovation in glaucoma as a past American Glaucoma Society president and as an advisor to various glaucoma surgery start-up companies. Dr. Lewis’s profound influence on new innova- tions in glaucoma surgery have helped to improve the outcomes of glaucoma surgery. Dr. Lewis will compare trabeculectomy with the EX-PRESS device procedure and comment on several other types of glaucoma surgery.

References

1. Good TJ, Kahook MY. Assessment of bleb morphologic features and postoperative outcomes after EX-PRESS drainage device implantation versus trabeculectomy. Am J Ophthalmology. 2011;151(3):507-513. 2. Maris P, Ishida K, and Netland P. Comparison of trabeculectomy with EX-PRESS miniature glaucoma de- vice implanted under scleral flap. J Glaucoma. 2007;16(1):14-19