Minimally Invasive Glaucoma

Surgery
(Shunts)
Dr. Manish Mahabir
SR, Unit IV

Anatomy

Approach
MIGS
Abinterno

Ab-externo

Filtration
Filtration
Trabecular microbypass
Intracanalicular
scaffold
Suprachoroidal
stent

Subconjunctival

Device
iStent, iStent inject
Hydrus
CyPass, iStent Supra (Ab
Interno)
SOLX Gold shunt (Ab
Externo)
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
Ophthalmology.
2011 alone
Mar;118(3):459-67.
surgery

At 12 months:
15% of iStent vs.
35% cataract group
on medication
(p=0.001)
Ophthalmology. 2011 Mar;118(3):459-67.

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

5.2 mm long
80 microns thick
2.5 to 3.2 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 minimalinvasive 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

Thank You!