Minimally Invasive Glaucoma Surgery

(Shunts)
Dr. Manish Mahabir
SR, Unit IV

Anatomy

Approach
MIGS
Ab-interno

Ab-externo

Filtration
Filtration

Device

Trabecular micro-bypass iStent, iStent inject

Intracanalicular scaffold

Hydrus

Suprachoroidal stent

CyPass, iStent Supra (Ab Interno)

SOLX Gold shunt (Ab Externo)

Subconjunctival

Aquesys

iStent
1 mm x 0.33 mm
Snorkel: 0.25 mm x 120 m (bore diameter)
Weight: 60 g
Surgical grade non-ferromagnetic titanium
Heparin-coated to facilitate outflow

First FDA approved MIGS implant

iStent : Mechanism
Creates a bypass through trabecular
meshwork to Schlemms canal
Improves aqueous outflow through the
natural physiologic pathway

At 12 months:
68% of iStent subjects
with IOP 21 mm Hg
without medication vs.
50% with cataract
surgery alone
(p=0.004)
Ophthalmology. 2011 Mar;118(3):459-67.

Percent of Eyes With IOP 21 mm Hg Without Medication Use

100
80
60
40
20
0

Cataract Surgery

iStent

Percent of Patients on Ocular Hypotensive Medication

At 12 months:
15% of iStent vs.
35% cataract group on

100
50

medication (p=0.001)
0
Cataract Surgery
Ophthalmology. 2011 Mar;118(3):459-67.

iStent

Hydrus
8 mm in length
Crescent-shaped
Composed of nitinol, an alloy of nickel and
titanium, highly elastic and biocompatible
Dilates Schlemm canal by 166 microns along
the length and 241 microns at the device inlet
Increases outflow facility

CyPass

6.35 mm length
510 microns external diameter
310 microns internal diameter
76 micron diameter pores
Biocompatible polyimide
Retention rings at proximal end

iStent Supra

4 mm in length
1.1 mm sleeve
365 microns external diameter
165 microns internal diameter
Biocompatible polyether sulfone (PES)
Titanium sleeve
No fenestrations, only open lumen

iStent Supra

Gold Micro Shunt

6 mm long
80 microns thick
2.8 mm wide
99.9 % biocompatible pure gold

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

First results of the innovative minimal-invasive glaucoma

surgery technique: the AqueSys Aquecentesis procedure
Results:
The mean preoperative IOP of all our patients was 21.3 mm Hg compared
to the mean IOP in mmHg at postoperative intervals which were: 12.2 at
week 1, 15.0 at month 1, 15.2 at 6 months and 15.3 at 12 months. The
mean decrease in IOP was ?9.1 (-42 % drop) at week 1, -6.3 (-28% drop) at
month 1,-6.5 (-30% drop) at month 6 and ?6.3 (-29% drop) at month 12.
The medications were reduced from 2 eye drops (mean) preoperatively to
0.7 eye drops postoperatively.
Conclusions:

The new Aquecentesis procedure proved to be a minimally invasive and

straight forward surgical approach. The IOP was reduced ?30% from
baseline after 6, 9 and 12 months. The number of eye-drops applied was
reduced from 2 medications preoperatively (mean) to 0.7 meds after 9
and 12 months.

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

MIGS vs Trabeculectomy

Thank You