Welcome to the to the afternoon and and to our our next speaker. I don't have enough time to tell you all the accolades that Ike has received in his relatively young career but just you know he's probably internationally known as one of the top cataract complex cataract and certainly innovative glaucoma surgeries surgeons in the world and he deserves that those those accolades because he's really tremendous when he was here as a fellow and neither one of us can remember the year but we think it's about 2001 probably so was it was a really great year in terms of the production here from our department we had a bunch of videos that won awards and we actually won the comedy awarded the ASCRS for that that one we did with the me me me attempting to jump off the top of the Moran one because we dropped a nucleus remember that day actually it wasn't me but we took credit for it but it was good it was all good and Ike was listed as one of the top the under 40 in all of Canada top 10 and then those are awards that are that go to the heart of his intelligence but for me the the joy of today is in is in the man himself because he's a wonderful human being he's very analytical but he shares that with all the world and that's what's important because you know we need the next generation and we need we need people that not only care about taking care of patients but care about disseminating information and I can think of no better example in these complex problems than than Ike and also just being always there to help anybody or any surgeon that that needs help puts all the stuff online beautifully and so you know that's all I don't want to say very much because I want to hear him talk so Ike would love you and more welcome to the distinguished alumnus award for this year which is well deserved so right well Alan you know it's it's always such a you know great feeling to be be with you and to be with everybody here you know I don't know it's two thousand ones a long time now I must say but I still feel like a fellow honestly I used to feel like I got to check in I forgot I got to go see candy at her desk I got to get the clinic in time and and find my cubicle to finish my work so I'm still looking for it though so I heard it in your surgery building though apparently but but but this really is it's does feel like it's coming back to home for me I do feel I have Utah blood in me whatever portion that is and and it's very it's a very sweet feeling I such a memorable year I spoke to many of you last night some of you last night and I shared my feelings and I'll show them again here about my experience it really you know truly what you know the best year of my life here experiencing here being at the Moran I didn't know what to expect you know when I when I and I was my last year at University of Toronto my chairman for the conservative man who you know insisted on ties and shirts and jackets in clinic was already you know a little bit troubled by my long hair and my unshaven beard which was you know Jeff Petty style wherever Jeff is and that was back when hipsters were in cool so you know and it pulled me aside said you know you're going to you're going to Utah it's a very conservative place you know Dr. Crannell you know I'm sure he's not gonna appreciate you know your long hair and so I went to my interview and I remember I basically cut my hair really short and I shaved and I walked in and I was like what the hell happened to you right you know so as soon as I saw that I realized okay you know we're in a you know we're in a very open place and no questions very open place and I was treated wonderfully and just great people I can't I can't say enough about how I feel I think I offend my University of Toronto faculty and alumni what I feel that I'm actually from University of Utah and I know that I know it sounds bad to say that but really I am who I am both professionally and personally because of my year here and my wife will tell you that as well because of the role models that I have here the leadership from the top with Randy the faculty that I have here the wonderful people that I have here and I'm not talking about just the physicians I'm talking about everybody else who works in this who works in that building and now I guess works here as well that was a bit more close knit though back in the other building you know from all the paramedical staff and the text of the nurses and the administrator staff the secretary of staff can you know can you notice how I feel about her you know and the staff that were all part of it so that experience was a wonderful experience and and it really stayed with me so it's really an honor to be here and thank you for the invitation and I want to stir things up I know glaucoma sometimes especially after the you know during the post-prandial you know serotonin release can be a little dry right well I want to shake it up but I want I want to say a few things that are controversial respectfully so and I want to tell again especially residents residents and fellows you know check challenge the norm right challenge the norm challenge what we do and that's of course that you taught me to do here at the Moran but do it respectfully right too many too often we have egos around we have inflated ideas and brilliant people but but the but that can get in the way of success right and so I think being grounded is very important and and I'm not just saying that I think it really helps you actually to progress and I think it's something I learned again being here I will show my disclosures as well and I do have the opportunity to work with a lot of many folks in industry it's very unusual to have a lot of glaucoma development in the past at least but there's a lot of things happening in fact in the glaucoma surgical space there has been over 700 million dollars invested in glaucoma devices and we've seen companies go public and be worth 1.3 billion dollars we've seen companies sold for three 400 million dollars to big strategic and although it's not about the money I mean you realize the money is important to make things happen you see this in refractive and cataract and retina and other areas as well at the same time and again I'm always very sensitive to the issues around conflict of interest and let's face it I mean when you work with industry there's a conflict of interest we love working the industry but quite honestly generally motives are the same but motives are also different shareholders are different I don't ask what your shareholders and I never will I answer to my patients and that's the most important thing to remember in this as well so a couple of things I want I want to just start off and say at the beginning if you think we're treating glaucoma well I think you're wrong or you haven't been in practice for more than 10 years or you move every 10 years if we think that progression is easy to follow I think we're wrong as well and there are challenges and I'll speak to that as well and I think some of the reasons we're not doing great in glaucoma and don't worry we're gonna make glaucoma great again is sorry I woke up I'm not gonna get political I'm sorry is is IP lowering may not be sufficient I have to lead the country so I have to be careful and I love I love the US and we love we like in Canada is written for the OZ want we want these to go well and I'm sure they will and and that's the beauty of a democracy and and the wonderful opinions we have here so is IP lowering and we know that adherence to the problem so I think this is the time we're seeing in glaucoma where things are changing we're becoming interventional in how we think of glaucoma we're going from examining the disk you know and carefully documenting which is still important to be active and being and being preventative in how we treat glaucoma and I think the drive to lower is better is I think something that is resonating or has resonated for many years and I think it's continuing to show the importance of that at least for many glaucoma patients and I think the reason we're seeing this is because we're we have the opportunity now in our hands to have better technology to allow us to do this safer which which is which would be the premise and the thesis of my presentation here so the first thing as a backdrop and just a couple of slides glaucoma progression and blindness is still a problem you know data from Rochester Minneapolis Minnesota you can argue about you know quality this is probably some of our best data longitudinal follow-up in a in a in a registry looking at long-term results seeing patients have gotten better as far as we've gotten better at treating glaucoma preventing blindness you know back from pre 1980 one in four eyes went blind but still one in eight eyes is still too high you know it's one in eight patients going blind in one eye and that was that was pre 2000 well maybe things are a bit better now we see data coming from Europe looking at at how many patients when they die go are blind you know 40% blind in one eye at the time of death and again pretty good data from Malamu where they have pretty good records and patients generally going to the same practitioners over time data from from the same group showing and I want to what I want to show here is the fact that progression you see various patient-to-patient patient some patients progress very fast some patients progress slowly and that's the challenge is figuring out who's gonna progress fast who's gonna press slow but overall again 90% of patients progress as Andres Hale to say the question is not whether your glaucoma patients progress it's how fast they're progressing you basically take it for granted they're gonna progress some data from prospective from me prospectively from New York showing 30% progression here over over six years some were fast some were slow but the bottom line is that there's a big chunk of patients that progress in our practice if you follow them long enough it is a problem and that's the first premise I want to say is I think that's a problem I you know I graduated thinking that you know we've got a pretty good hand on glaucoma we've got all these medications around us that you know I'm gonna have very few patients I go blind and as I get in practice I go 10 years out I'm realizing wow all my patients coming back I thought they were okay and they're not doing as well and that made me really think about where we were and where we have to be in the future we have to remember that glaucoma is still the second leading cause of blindness and I'm not talking about people who are not diagnosed or not treated but this is not a new concept you know back in editorial written by Morton Grant talked about why do people glaucoma go blind he mentioned he talked about three things one lack of diagnosis two under treatment and three poor compliance and fast forward now so silent others writing an editorial again saying glaucoma is still a cause of blindness is still under diagnosed it's still improperly treated and this compliance still is a problem these still these things still remain with us despite the advances in diagnostics and I think they went further talking about the severity of damage is underestimated that pressure still not reduced low enough we don't understand peaks and means of IOP properly and evaluation of progression is still a problem it's still difficult and so the premise of where I think we're going in glaucoma and again I will say I could be wrong is I think our guidelines for treatment and target IPs are off I think they're wrong target IPs are not based on evidence they're based on consensus but consensus is based on what people are comfortable doing to patients understandably and that's limited by what we have access to I think that we need to be driving pressures to the low of the normal just like with diabetes and with hypertension I think that's the true place where glaucoma needs to be but the problem is adherence and until recently we didn't have some of these better options in front of us I look at it like this we're an internet age right some of you are passive you kind of just you know surf online just watching lurking around and others are like you know active they're clicking on every pop-up that comes up and you're the people who have those viruses on your computer right so probably not none of those none of those are great but let's face it glaucoma in general has been a bit passive and I'm not putting anyone down or not condemning the way we treat glaucoma I'm a glaucoma specialist and that's way I generally have looked at glaucoma and I think we need to think about being being active how many know about the EMGT trial I'm sure I'm sure this is something that's talked a lot about right you know and still talked about who was it who wants to put up and tell me what what's the take-home message from the EMGT trial what's your one take-home message residence fellows anybody I told you something interactive keep you awake anyone with their eyes closed they spit it out lower IVP is better right here yep treat norm what what your resident are you very young guy yes norm I agree norm exactly my same feelings I mean yes that yes the byline was treatment lowers progression from 76 to 60% but 60% of patients as norm said still progressed and this was a you know 25% IVP reduction which most guidelines would be that's what that's what you treat glaucoma 25% reduction is usually a target for glaucoma if you look at the European previously at least the Canadian guidelines that's what the drop is but the take-home message is yes treatment of glaucoma with a fairly reasonable IVP reduction we think is reasonable patients still progress and that's exactly the point I took home as well and in fact from the EMGT trial as you follow these patients 30% had low vision or blindness after 20 year follow-up in the EMGT trial and this very good data says very it's a very important study to look at particularly for natural history and for that reason how many of her how many of you see it saw the recent lancid publication from David Garright Heath talking about the UK glaucoma treatment study take-home message there was the Tata Prost is more effective than placebo at one year in preventing progression the pressure reduction you see here was about 20% drop in IOP and these were early glaucoma folks these were this is not advanced glaucoma and and need neither was EMGT these were not advanced patients and most people in the room would would agree advanced glaucoma get them low these are not advanced glaucoma patients these were very early in treatment and yes there was a difference in the rate of progression between both groups as we saw but again you look at the treatment group the treatment group here right in one year with a mild glaucoma disease 20% progressed that's at one year right so these studies are interesting they show treatment helps which I think is good to see this but it doesn't help enough and the question is why are people still progressing and there's no question there are not IOP factors as well we're sure of that but I think we have to ask ourselves again is why do we see tons progression of treatment arm right there's something wrong with this picture here right okay something doesn't fit right here well I think we have to think about inadequate pressure reduction and we see the relative risk of progression go down per millimeter of mercury reduction this is statistical analysis here statistical you know and you know you know assignment here but we do see anywhere from 10 to 20 percent reduction of risk per millimeter mercury IOP reduction and we see a fairly you know dose response relationship to percent IOP reduction and visual field preservation this is not initially new back Odeberg and Odeberg published a study in the 80s showing patients who kept pressures below 15 had less progression compared to patients who were not this was more an advanced glaucoma mind you and surgical patients did better than medical patients and in the cleaning glaucoma study which basically was a process to study randomizing not randomizing basically treating patients here following patients over time and you can see basically 30% of patients still progressed and again I want to mention here again this is early glaucoma this is not advanced glaucoma this is not moderate glaucoma even this is early glaucoma but you can if you see and this was you know the mean treatment was down to about 14.8 millimeters of mercury right but if you if you look at the turtiles the patients that had less than 15 had less progression than patients that were greater than 17 and again showing that you know IOP still plays a role in terms of progression and of course as a very well played maybe overplayed ages data ages seven showing that patients who are maintained at a pressure of on average of 12 or at least 100% less than 18 tend to have very stable visual fields now by the way although this is called advanced glaucoma intervention study all these patients did not have advanced glaucoma they had it was a mixed glaucoma patients in this group but you again see a difference in that and that's why those of you who watch TV a lot know the hit HBO TV series Orange is New Black well remember 12 was a new 21 right you know remember 21 was a target many years ago and then we you know I think gradually we thought okay ages got published 18 should be better right we're kind of lowering the targets a bit and is 12 the promised land does the question I'm going to ask you here is that the promised land for glaucoma will we stop all progression is this for everybody or only for advanced patients do we need to even have target IOP everyone should be down to that level and is there only is surgery the only way to get there so let's flip around and talk about diabetes and hypertension right you know there's data that's coming out that's coming already this shows that tighter glycemic control and keeping blood sugar at the lower end of the targets results in less end organ damage the problem was to get there we had a higher risk of hypoglycemia right you know and the problems around that now that this continuous monitoring continuous infusion pumps and things like that keeping blood sugar under tight control at a low level in a chronic disease we see less progression same thing on hypertension as well so we're seeing against some similarities between chronic glaucoma and chronic disease systemically as well which I think plays a pattern until we have the ability to do that though it becomes hard to promote that so the question is who do we need to be aggressive with for pressure lowering and is it only an advanced glaucoma so first of all I'm not talking about fake glaucoma okay all right just to be clear not fake glaucoma okay all right so I don't care what the media says I'm not gonna fake glaucoma okay but more real glaucoma here okay so I'm not talking about auto hypertension I'm not talking about you know very very early disease I'm talking about real manifest glaucoma they have a visual field defect that they very least will talk about that I can't go that farther and talk about you know other early cases maybe there's a reason for that but I'm talking about patients who have real manifest glaucoma and of course left expectancy also plays a role that seems to remember this and I can't I can't take credit for this quote this is from Francisco Goni but glaucoma is only young ones right think about that and you know when you're when you're young you really have one chance to kind of you know set the tone for how your future goes and we have to get it right the first time ideally that is obviously patients that are at risk that we're going to be more concerned about progressive patients so those fallation patients patients who have lost disease and lost the one eye to glaucoma already strong family history and for me it's a younger patient who has more than early disease that's the one I really really worry about now I guess you can question what what the definition of young means but I can tell you we're seeing a lot of patients 80 and 89 year olds that we're doing surgery on and are in our clinics and I think we we are readjusting what young means but particularly in the young 55 60 year old patient that comes in with with a visual field defect I worry about that patient long-term I worry about this patient who has shown clear progression this this to me is not the patient that we simply add on their drop to and say okay we're gonna read we're gonna add another drop to and follow you up and continue following up every six months and every few years this is the kind of patient that I think really is in danger and needs to be treated and although right now glaucoma is traditionally treated in a stepwise approach we have modest pressure targets we then follow patients with measures I believe are not great visual field variability up and down even OCT and RFL analysis I think not so robust in terms of progression analysis I still think we need to have a lot of work on that and when we do see progression we repeat testing and follow patients again and again and then we really treat them when really we really escalate therapy of this progression to another target and I think that the alternative approach we'll call it is to consider going and get to getting down early and protecting that protecting that patient and avoiding some of the issues and here's a problem with glaucoma and I hope you're following me a little bit here because I'm gonna get the surgery don't worry but I'm setting this up here IP is very random I mean we measure IP in the clinic like who knows what's happening all throughout the day peak IP we don't we don't have a clue on we can do diurnal tension curves but how realistic is that overnight severity is underappreciation I mean what does advanced glaucoma mean all right I mean we have a cup dot nerve with a normal visual field does that patient have early glaucoma I don't I would not think so and I think progression legs and I don't think it's easy to monitor I think that's part of the problem and that's part of the problem with target IOP now I didn't just put the slide up here because I'm in Utah but I'm serious I didn't I I'm sorry but I think I think target IOP is a bit complicated right it's a bit complicated right I think and you know Canadian guidelines you see mild moderate severe glaucoma pressure targets I think a lot of us would argue those targets seem to be a little bit you know high and high on a level it's because again what evidence do we have on this the European guidelines again very to me is very vague right higher target lower target based on severity of damage well severity of damage as I already said I think it's hard to know I mean advanced glaucoma based on a visual field is that really telling us the truth to want to damage to the nerve like the parties hard to figure out untreated IOP do we really know what it is initial risk factors yes and then and then looking at progression so one of the things I think that's very important from it from a target pressure perspective those of you who believe in target IOP and I'm not saying I don't believe in it but is determine a patient's rate of progression that's what that's what that's what that's what that's what we talk about follow patient see other progressing and then tailor your treatment to that well I think there's a bit of a problem with that I think one problem is I think first of all to get reliable progression in this is hard as I said earlier I think that progression is not always linear you know we see that we see this happen where patients you know showing a certain level of visual field index and then they just drop and I think that's part of the problem basically by being you know by being watchful waiting here I understand that though because the alternative is not necessarily ideal either in terms of putting through patients through surgery we're not comfortable with or adding a whole boatload of medications but I'll tell you when you're not confident what do we do when we're not confident we all do this we tend to withdraw we tend to watch we tend to get a bit paralyzed we procrastinate the decision-making we punt it off I'm not going to get in trouble if I don't you know treat a patient aggressively will go to my next year because patients are going to go blind next year but if I do surgery something happens and now it's on my watch and that's that makes us obviously very conservative the same thing again we saw with cataract surgery let's put it off wait till the cataract gets ripe and then do surgery because I think obviously the risk and benefit and the morbidity was a concern for what taking out cataracts that were mild in nature in the past how many of you decide when someone has a coma to watch them to watch for progression so you have a patient pressure 25 their young patient they have a nerve they have visual field damage and you decide to treat them or not to anyone would anyone watch them over a few years to see whether they progress nobody would do that 25 in a visual field yes a clear defect drug will come as damage you treat them and you treat them because the risk of progression is so high an untreated population right 90% disorder affiliation 74% in in in high pressure glaucoma 56% bit less than no tension glaucoma you know maybe no pressure glaucoma you could argue but on that one because it can be very slow in some older patients but let's talk about high pressure glaucoma you wouldn't you wouldn't watch them till they progress right but but why do we watch our treated patients have progressed did you follow me because we're doing the same thing right we're treating them modestly we're saying we're gonna watch you well the progression rates are almost the same as patients who are not treated in some ways they're better but they're they're there so I mean so think about that think about that we're gonna purposely watching a patient we know it's gonna progress because we have data to support that even and this is a bit of complicated slide but my point here is again that reliability variability repetitive phenomena the leg period are all challenges with using visual fields to analyze for progression and other said imaging is also a challenge now we have to remember glaucoma it's not like refractive cataract refractive or cataract surgery we're thinking what we're looking at the long game we need to think like the 10 15 20 or horizon for our patients and what we do now has an impact of what happens in the future for good and for better and whether we decide to be aggressive or not or interviewing or not that is implications for this patient in long run and if you only consider short-term trials which is five years or less or three years in glaucoma that's too short to give you enough evidence or enough idea about the implications of long-term treatment and I realize it's hard I realize it's hard to do that and so you know I think there is a drive to consider to be low to get low on the normal conceptually not just for advanced glaucoma I think we need to reframe and rethink our targets but we have to also ensure we don't compromise adherence that's a big problem we'll talk about that shortly as well and I think this is where we think about what the options are beyond medications here I know many of you will add three or four medications to a patient someone's pressures about 16 17 you're worried about them you add a third or fourth class well it turns out as some of you may may think about as well adding a third or fourth class doesn't do a lot for most of our patients to get a meaningful drop in pressure there are statistical reasons for that and there are also hydrological reasons for that but the bottom line is that don't expect a lot by adding a third or fourth drop we often do it I understand it feels good we're doing something we're being proactive maybe we'll get a millimeter which is a measurement of error with the tenometry but that part of the problem we also know that medical therapy also impacts glaucoma surgery and patients who are more heavily medicated have a lower success rate than patients who have surgery primarily and I think it's well-established that the toxicity of medications are not only conjective but also to regular mesh work and also the episcopal vascular and also super cordal space by the way as well medications and the toxicity have an impact and this has an impact on the success of surgery yet another reason to think about that another aspect think about medications are that any given pressure a surgical pressure of 13 is less likely to fluctuate than a medicated pressure of 13 assuming patients compliant even that's because again considering peaks and trough medications less fluctuation less peak I appease with surgery as well and whether we buy all the things or not we know regardless of those issues compliance remains consistently to be a problem no matter where we look in the world compliance is a major unmet need and a major problem and not only compliance but even getting the drop in the eye right I mean what is the marination technique or the dive off technique I mean it gets pretty messy okay but here's the reality the sobering reality when our patients are not compliant and not adherents right sorry is after lunch I know when they're not compliant and they're not adherent they progress and I'm saying that just because it makes sense theoretically we have good data show that and you know from a health systems perspective when they progress they cost the system more money they cost us all as taxpayers more money to take care of more advanced patients when they progress so addressing adherence is not only a patient issue not only an institutional issue a side issue it's beyond that as far as implications so we know that surgery had the better chance of getting lower we know we address adherence we know if we do it earlier there's less chance of failure because of toxicity for medications we know that the cost are less in the long term but the question has always been recovery and risks and one of the reasons why I thought about glaucoma as a career and I came to the Moran is because I felt despite the trend to go into retina and corny and everything else I thought there was a real opportunity in glaucoma to think differently and think about something differently and one of the reasons I came here was to work with that mindset and of course we have a long way to go I've already addressed some of these issues in terms of surgical considerations and I think it's important to remember again that we're still evolving we're still we're still rethinking about what the role of primary surgery is and these are the kind of things I want I want to I want to mention now this is how we current how many of us currently treat glaucoma surgically we operate late in the disease process right we put a push it off and when we push it off we typically find less predictability with our procedures and we have more complications and as human nature is what do we do the next patient we see we're even more timid and we push it off even more it's the vicious cycle that we must break if we are to really truly revolutionize treatment and hopefully have less patience progress right we truly have to do that that's the battle cry for glaucoma and anybody knows it does surgery if you're not a confident surgeon it affects your decision-making in a major way right cataract surgery in the old times when it was also unpredictable recovery was long refractive results were long there were some very good surgeons out there but still most were not jumping into cataract surgery early for 2040 2030 cataracts now it's not never a question hardly right because the confidence and the and the predictability is so good and that's what we're really looking for and again it's about being reactive versus being proactive and we really need to be proactive as best as we can for a very blind disease so the Cochrane review did review medical versus surgical intervention and what they basically determined was in at least three trials and this was these pasties trials are more severe glaucoma they found that surgery as pride as a primary choice resulted in less progression over a long period of time than medications and even the nice guidelines which are European guidelines in their actual guidelines actually advocate for at least consideration for surgery as a primary choice for advanced glaucoma as a primary choice for advanced glaucoma for early glaucoma thing is still under treatment here and I would even debate that from a moderate disease but at least for advanced glaucoma that's what the guidelines that's what the evidence is basically in this guideline back again in the in the late 80s the Glasgow group showed that progression was less in Trab versus medications and by the way this is Trab surgery we're talking about but there's also medications back from the 80s also very different than now that's why that's what somebody says have been criticized as far as how much can you apply it nowadays the more first primary primary therapy trial again comparing a randomizing laser versus meds versus Trab again done many years ago showed better pressure reduction in the surgery group showed less progression in the surgery group compared to medications and lasers and showed again more stable visual field over time in surgery now this did not necessarily take hold in world wide because new medications came on board because this was a you know one center and did not did not did not receive widespread adoption now the stages trial which was of course American based study collaborative research local treatment study comparing surgery versus medications again prospectively here my name is in Trab versus medical therapy as expected the surgical group had a lower pressure of around 15 than a medicated group overall the results on visual field were the same so the overall message was that medications are similar to surgery as primary therapy that's what that's what the conclusion was but if you look at the data in more detail and separate patients with very very early disease they're about the same although if you follow this line you follow you follow the medication line you see it kind of dripping down a bit over time but certainly no difference over the nine years here but the surgery group is where we really saw a difference here in patients who had modest visual field down i'm not talking about minus 15 decibel loss we're talking about minus eight minus 10 decibel loss and we see how surgery had much more stable visual fields than medical medical therapy despite that and and by the way opt in their progression was more common in medicated group overall compared to surgery certainly there's evidence here at least for primary therapy for patients who have you know modest glaucoma to advanced glaucoma should be considered as primary therapy but the reality is that most physicians whether they're glaucoma specialist or or whether they're comprehensive ophthalmologist are reluctant to recommend primary surgery they're reluctant and i'm sure this also applies to to north america this is this is from from from from england but most are willing to change their attitude if evidence supports surgery as a safer option what about patients well patients actually are not as concerned about the method of how you lower their pressure their bigger concern is they don't want to go blind and so from their perspective if surgery can reach that most of these studies have shown patients are pretty satisfied with surgery and this is actually trap surgery this is not new surgery it's just trap surgery it only could could potentially get better from that aspect with with with potentially newer surgeries so despite all this despite all this trap numbers have been going down over over the last 20 years as many reasons for that we can imagine and we also see again the same phenomena in in the uk so as i said before we are going to make we are going to change things here right okay but what will it take for us to establish surgery to become the norm well it's like again cataract surgery i mean we have to address the issues around invasiveness safety recovery refractive changes and all the rest of it around around surgery and you know safety really safety is really where this is where this is about right you know Dr. Shakur you know where this picture you know where this picture was taken from northern pakistan man only in pakistan right okay all right and it's the shift it's the very shift to surgery and i'm from pakistan so i can talk about pakistan i'm not well the shift to safer glaucoma surgery has resulted i think in the ability to allow us to shift our targets and no question we see the uptake of newer procedures over the last two three years in the united states and i really think that that we're upon this this phenomenon of interventional glaucoma which basically is intervening early in disease addressing compliance treating again patients who really who are more than early disease and being proactive than the main reactive and i think sustained drug drug drug delivery is exciting and coming up i think that safer blep surgery allows us to be more aggressive earlier on and of course mixed surgery when it comes to cataract surgery of course is another aspect to address some of these issues and that's the premise of surgery intervening early avoiding long avoiding having to deal with potentially very high-risk surgery addressing compliance stepwise approach now i will say this is still very early this is somewhat more of a crystal ball talk in some ways because i think we obviously need to have more evidence but i'm gonna i'm making my case here on this one and this is kind of where miggs kind of you know came about initially isn't as an as a potentially a safer less risky a more stable refractive a more standardized recovery period and you know occupying an area between medications and and surgery i i think you know we can certainly say that i think miggs has a role in perhaps all these areas in whether it's early or late late onset uh disease and the concept of new miggs surgery is not just about lowering pressure but it's also about medication reduction as well which i think for many of us in glaucoma surgery we're not we don't need to talk in those terms we're talking about absolute iap terms typically when medications i think are very important to address from patient perspective and from a compliance perspective as well so miggs is a very crowded space now we have internal devices into the canal we have supercillary procedures and we have subquantitile procedures i call these internal and i call these extra miggs a bit more extra pressure lowering but also some also some additional postoperative considerations while internal of course is more of an internal aspect of drainage and a lot of the stuff really came out of the cardiovascular world all the engineers that i had the opportunity to work with and scientists came actually out of the stenting world and coronary artery disease and applied applied things to uh to glaucoma and i do think again that you know uh when it comes to cataract surgery safety is paramount and when it comes to standalone procedure of course safety and efficacy are both of course important in managing these cases because we know faco faco does lower pressure so i don't think we can doubt that but the ability to combine something too faco to get additional lowering or additional medication reduction is where some of the miggs play and i certainly think that when i look at the patient with cataracts it's very much like a patient with astigmatism if i'm thinking about someone who has cataract astigmatism i at least will consider a toroid lens i think it'd be something to strongly consider when someone has cataract surgery and they're going for glaucoma i think at least miggs or something along this line is worth considering at least with the added propensity to potentially get patients off medication now miggs are not perfect one of the problems with miggs is and some of the miggs is we don't get low enough for many patients but for many patients particularly early in disease and with the goal of eliminating medications going internally whether stenting dilating or cutting or going into supercellular space i think are both reasonable options and now in the us of course you have new devices that have been approved you have the ability to divert aqueous or enhance aqueous to the sempz canal versus supercellular space i'm not going to tell you here which one is better or which one is superior i think they both have their potentially pros and cons with regards to efficacy with regards to effort with regards to safety we have to remember of course when it comes to the canal that we have to deal of course in bypassing the tm what we have to also assume that the distal outflow pathway is intact we assume once we bypass the terecular mesh work in the canal that the distal outflow all those very fine aqueous veins and plexus are still intact and there's mounting evidence that in some patients with glaucoma that the disease may be beyond the canal there may be distal disease secondarily perhaps to the initial problem and as i said there are a variety of options when it comes to the canal space we have cutting procedures we have dilation procedures and we have gonioli procedures so now in the us you have a lot of options available to us and it gets very confusing between picking one versus the other and i'll tell you that i think each of them again have their own pros and cons i will think i will i will of course tell you that of course whenever we're cutting we're inducing more trauma there's more risk of i-thema it's p-a-s and the body of evidence i think is still lacking of course in many of these areas of course the ice has been around for the longest it's been the most heavily marketed and by the way as an aside i mean i love working in the industry but i i'm not necessarily big fans of marketing machines again sometimes uh the marketing is about you know well i won't go too far on that but but do distinguish what is reality and what is marketing i think marketing of course is important to get the word out but do your own homework to figure out what does what uh and that means again going back to the studies and and talking to uh clinicians and scientists so you know a very beautiful elegant procedure i mean i love working in the canal and by the way the rest of is normal we see when we see this we expect to see blood reflux from the episcopal venus uh you know venus return there's a there's some nice tri-pan blues showing the uptake in the aqueous veins that are innervated by those two stents showing proof on the table of the nice outflow but remember we still have the episcopal venus resistance that limits our ability to lower pressure below that level and we can debate what that level means but there's good data to show that putting ice stents in with feco and i'm sorry in the u.s you only have the ability to put one in right now at least uh in terms of on label with cataract surgery but does show a reduction in pressure compared to feco alone and does show uh reduction in medications compared to feco alone and does show enhanced outflow facility measuring floor photometry as well so i think i think that there's not a lot of debate in my mind whether it works or not the question is can we make it work better and are there certain patients that would do better than others and we're excited to see scaffolding devices come about and newer devices come about in the future uh that may also enhance outflow by also expanding the space as well and then we have the supercroyal supercillary outflow pathway uvc outflow pathway this procedure is fairly intuitive essentially placing this guide wire disinserting the cellary body attachment and placing this device in the supercillary space one of the advantages in the supercillary space is we don't have the episcopal venus floor to limit pressure reduction but one of the disadvantages of the supercillary space is that there is more healing that we have to deal with the more variability in the response compared to in the canal and to compared to a vascular space uh and so uh this is again where i think time will tell and show us the differentiation between this procedure but they're very you know fairly elegant procedures that we do and often typically combined with cataract surgery and we do that because the ip lowering is somewhat somewhat limited and to justify going in we're already going into the already with cataract surgery and we can basically then achieve a bigger response this was the two-year study looking at the supercillary microstand versus fecal alone first of all fecal lowers pressure that's the one message here right the control group you know off medications you know 44 percent of two years reached target pressure in this population not bad for fecal alone considering the mean washed out pressure was about 24.5 millimeters mercury not bad for fecal alone adding the device did improve though however the odds of getting there and my suggestion is when we talk to our patients don't give them means don't give them averages or standard deviations give them probabilities mrs jones i could do procedure a the probability of reaching this result the 70 percent versus procedure b which is 40 percent let's look at the risk and benefit of this and choose the right process same thing for an iol right i mean this this is i think more more practical and relevant to our patients but but the question still comes back to me you know to bleb or not to bleb and i can tell you that over the last five years i've done more bleb surgery than ever before even though i started my career saying i want to retire the bleb right so the bleb is back or why don't you do why don't you go bleb you never go back right is that how it goes because the bleb is still the best way to get pressures down to that elusive target of 12 going internally we're not there yet maybe if we get some moon healing modulation in the super cordial space we can get lower but still for our patients who really need this like i said the patients earlier i talked about an earlier part of my talk we need this now we also know blebs are also not the same blebs can vary in how they look right many of the surgical technique is well related and also the application of anti-fibrotics there are many ways now it has to create a bleb traps express devices non-partisan surgery large tube shunts and now we're in the era of microstenting blebs we all would agree that a a blebber on a bare belt is very different than a bleb after a trap right and and that's and i think we're seeing differences in morphologies and these blebs are typically not your father's bleb right the old olsemu commercial right where the grandfather father whatever you know uh these blebs tend to be posterior diffuse and with mitomycin tend to again be non-cystic and non-threatening and that's because again of the diversion of aqueous posteriorly which is where we want these blebs to be the the Zen stent is an ab internal delivery device we studied this a lot we went through a lot of iterations one thing we looked at was fluid dynamics because of course having an unguarded procedure we were about hypotony well using the Hagen-Posell's equation looking at flow testing as well assuming you know a certain flow production of aqueous by by addressing the radius of curve radius radius of the lumen the diameter of the lumen and the length of the device we were able to titrate the flow to achieve a steady-state pressure of seven and a half millimeter mercury assuming normal aqueous production and that's particularly important when it comes to early hypotony and protecting early hypotony in order in order again to allow this device to be used earlier in disease or to be safe to use we have to address that now this is a procedure being implanted the needle passes through delivers the microstent in the subcon space and communicates the AC to the to the subcon space typically we inject mitomycin C prior to the the delivery now it turns out it's not as simple as this it turns out that where the implant sits in the subcon space can make a difference I think we see some patients do great with this procedure other patients that don't do a well procedure I think a lot of it is where the device is enriching the tenons we're studying that so stay tuned but again it's obviously more than what you see as far as just simply do it anywhere in the space and you're done place the needle in the right space typically super tenons I think is important and these blebs again in these in these patients diffuse posterior uh with with fairly good pressure lowering competing with traps in the european prospectus study the IPEC study showing pressures are getting down to that 1314 level so may not be as low as getting down to single digits like a trap although I think I would challenge those who would feel that we can get down that low with the trap even consistently the primary two versus trap study that just got presented AGS had an average pressure of around 13.5 or so at one year and again most importantly showing high degree of safety with this device our data from Canada very similar I will point out however we did have a fairly high kneeling rates and I think a lot of this has to do again with trying to deal with where the device is in relation to the tenons because if the device is placed in tenons with only one outlet there's higher resistance in tenons which I think does limit the flow recently we had one of our papers accepted in ophthalmology which will be published soon this is a retrospective study looking comparing the microstent versus trabeclectomy in over 350 i's robust analysis here internationally basically showing success rate fairly similar between both groups achieving pressure between 6 to 17 6 to 21 and even 6 to 14 showing similar numbers the in focus device is another device here this device is a little different this is made of a special material called sips which is a which is a synthetic material that's been used in a coronary arterial world very limited bioreactivity this device is plays that extra you may say well why would I do this if I can do an ab internal delivery well the advantage of this is part of the disadvantage of this procedure is the advantage because we can place it exactly under tenons or where we want to place it as opposed to delivering it with a needle ab ab ab internal and not being sure where the placement is we have found tremendous ip lowering with this procedure and found tremendous safety with this procedure the control of the procedure is is very eloquent the blebs are posterior and this is published work from one by a i mean pressures that are really unbelievable we don't believe some of this data uh seeing how low we get after three years in in a population that isn't necessarily the lowest population but i can tell you when i look at our canadian data and we look at it comparatively we're finding the same same experience and it's really changed my opinion of of how blebs can be i have i have now much more confidence uh when i when i when i do it up these one of these bleb procedures and then what i when i do a trap i know they're going to see 2320 40 in the first few days after surgery i know the chamber is going to be deep and well formed i know the cores are going to be rare if they are they're pretty stable i know that the patient's going to be comfortable and i know that their refractive change is going to be minimal from these and all these blebs are going to be good-looking blebs uh like you all are in Utah here uh and diffused and well functioning although of course long term we always think about wound healing and for that reason actually i'm actually using more mydomycin C even more because i know these blebs are not the typical blebs that typically are at risk so target iop you know i think does probably still play a role in terms of what the level of disease is yes but i can tell you that for me if you're more than mild i want you less than 15 if you're going to live more than 10 years because i know and we know that progression is a big threat and i think although internal mixed procedures like the like the canal procedures and the supercode procedures have high safety they're not going to get you low enough but for the cataract patient with early disease i think is certainly very reasonable because again of the benefit of medication reduction but blebs are still important as ever and i think that that's something we learned eGS guidelines you can see again start monotherapy target not reach add a second drug target not reach substitute or other therapy i think that migs is kind of now messing it up a little bit and turn to changing changing where we're looking at these things as well we have a lot of options in front of you i mean it's a busy field out there with all the options available around the world it's very confusing a lot of them have very limited data and i think time will tell us in terms of where we need to go of course and all the different variables that played into role for me when i make a decision about a procedure am i combining with cataract is that the main reason for the surgery or is it because of their glaucoma is the target pressure controlled not controlled how far are we are we from the target pressure severity earlier or a moderate to advanced medication tolerability and age all play a role in that and each of these procedures have a certain target range i think as far as where they may fit and again as you know i like to play in the space again close to the 12 for more patients with moderate disease so yeah i think we're changing the paradigm a little bit you know to be honest with you i had this i made this slide up five years ago so i said five years from now so maybe we should ten years from now we're not we're not there yet i can tell you my practice though i mean more than ever we are introducing surgery at an earlier time whether it's combined with cataract or whether it's done as a standalone procedure and i think we need to get again prove that these visual fields will be stable with a surgical procedure although again the evidence is pretty it's still it's still pretty important as we presented earlier so again you know think about glaucoma as a disease that is not stable any of you who write down glaucoma stable in your impression i think unfortunately you're probably not right unfortunately i think we always do our best of what therapies we have and just like another person medicine as our procedures and our techniques improve i think we're more willing to be more interventional and more aggressive and i see ourselves moving more and more forward in that level with drug delivery as well drug elution wound healing and of course i'd love to retire the blab but i think the blab is still certainly here more more more than ever thank you again for listening to me here for this talk and thinking about glaucoma again great to be here and i enjoyed the lecture the talks in the morning i mean high quality stuff being presented to moran which i'm very proud of i again i i'm part of the community i'm part of the family here so i feel proud of what's being done in the moran and uh and again keep up the great work um thank you for your hospitality both as a fellow and also in my return as well and i love you as well and thank you for everything you've done for me thank you very much back to your patient who has a pressure of 25 and early onset visual field loss in the decision you're going to do today what surgery would you likely do for that patient early visual field loss pressure of 25 young so and you think surgery is indicated so this patient is not going to cataract surgery right so for me uh you know that patient needs to have external filtration i think going internally won't be enough canal or supercillary space that probably going to end up being in the high teens and or more medicated that patient again for me is a microstenting you know blood procedure the external one probably so you get in the right place that that will be most consistent although again it's obviously a bit more work i think for that for i think that's probably where the debate is internal extra i think we're still going to that debate but no question externally you know where you are you actually actually know exactly where you are um and so i think that's the patient that that that i would think about seriously about thinking about going externally with a safer procedure yes sir have you had much experience with nicks and kids it's a tough population more here yeah so um you know i mean i do a lot of goniotomies i track a lot of these in kids and i think that some of these newer options i think are attracted to gap procedure for example i'll do them in kids i think you know kids are obviously hard to treat and hard hard to manage i haven't ventured into the super cordless space for kids i do think it's going to be limited value with the with the healing of propensity you know stenting stenting in the canal you know in kids i still i'm still i'm apt to cut so doing goniotomies again would be my preference beyond that though i think that for example the in focus procedure i think is a very viable option you know we don't like doing monomycin traps in kids we don't really like big tubes in kids and i think the these microstenting approaches i think have a lot of potential you know we even feel comfortable doing them inferiorly because these blebs are so posterior they're not the typical anterior you know blebs that we worry about at least for the in focus procedure so um i and i've done a number of kids now you know slowly that's that number that the age limit is going lower lower as far as my comfort level in that population yeah yeah yes i know i've heard that personally i've heard that personally yes but but remember the american study overall didn't show it on visual field it did show an optic nerve progression but when you actually look at the patients who had moderate disease like minus eight to minus 10 decibels on average it did show that surgery was superior so i mean that that that that that took a bit of time to show that the preliminary results were like overall the whole group but that's always that's always a problem in the study when you have when you have a bit of a dichotous population early early patients and more moderate patients assuming they're all going to be the same of course it can be a problem and when you look at more moderate patients these patients did do better with surgery so that actually did actually uh support what would would climb and what's roger we're saying but it didn't change practice though didn't change practice yeah it is it is yeah so just just an interesting i'd appreciate your thought about this as well if you look at the glaucoma group historically as a group they were get set against intraocular lenses they were get set against fecal they were get set against fecal what alan clear up into the 2000s yeah and so i wonder if part of the issue we ran into is the traditional glaucoma people were not very comfortable with surgery and therefore rather than say that was the issue they said we think surgery is too aggressive and now we've got and and alan is really i mean those of you here alan's got the credit for the leader of those people and it used to be that the idea that you were a good cataract surgeon and a good glaucoma surgeon was almost an oxymoron and and alan is the start of that and then clearly other people like i could take that on and suddenly we have people very comfortable with surgery it was a whole new and i think that's what's now starting to cause a paradigm shift what do you think about that totally cultural change total cultural change and we're seeing it in type of applicants we see now glaucoma fellowships you know surgically inclined fellows as opposed to maybe those that may be not as much and it's no question you went to glaucoma fellowship because you didn't weren't particularly interested in doing surgery yeah it's not i don't want to knock glaucoma you know my my peeps either right but but i think that that is somewhat somewhat true i think and i think that does result in a bit of conservatism or a bit a bit of you know skepticism with these approaches and glaucoma also is a tougher nut to crack as well mind you but i can tell you now alan has borne the scars of not only of glaucoma but also iowels and cataracts and you as well ran and others as well i've had to deal with the the you know the community uh and yeah i presented the ags many times and it's been it's been a tough time right you know so but i see things are changing a little bit and they're and they're changing so you know like even even cataract surgeons are coming around to glaucoma surgeons because even the ascrs voted gray brown to give the innovators talk this year that's a real step to have a glaucoma guy give an innovators talk i mean again that was considered an oxymoron and i think it was really nice to see rave over the history of the glaucoma devices and how we're evolving now and how cataract surgeons themselves not only glaucoma specialists can start looking at being involved in some of these procedures so i think that this year you're on to the future now you're on top of it well and and and to add on top of it even even even the lucky enough i was able to get the bin course as well that was on glaucoma which was shocking right to everybody and so i said i said that bin course lecture i said you know in the future we'll see the name change name change here ASCGRS okay so watch for that and our and our presidents have been glaucoma been glaucoma specialists right you know so absolutely we see that happening all of you do cataract surgery on glaucoma specialists actually right both for peck hall is because of that fear of doing good trabeculectomy surgery how do you create a plan which is not today to take the creation of what we call the morphing statement and the residents and fellows here haven't seen it go to the website morphing's he's done a step by step i'm not a fan of teaching people step one two three four yeah but when you're teaching internationally this is a great advice that he gave how do you my advice and how don't you create two things of that etc europe was absolutely absolutely yeah and i think both you and he have made a enormous difference in how they work well i'm not i'm on pet cause category but uh whatever we can have whatever we're gonna add in there in there so sure so in your practice uh the trap is going you know honestly uh the reason we do traps are two reasons one i mean the patient who's north pressure glaucoma and i want to get him down to eight which is not common it's hard to get to and honestly for our fellowship training we need our fellows to know how to do a good traps and manage trap post operative issues so that's the main reason why we do traps actually but do you think that that the trap procedure has not changed over so many years and that's the reason that the traps are not giving long-term good outcomes well i mean traps still can give good outcomes it's just that you know you know it's just that we're worried about some of the rare but potentially serious complications and some of the refractive recovery issues with that as well and the variability so um all those reasons why traps are just are just not not popular right there's a whole whole host of reasons why thank you very much thank you