What does it take for us clinicians to change our surgical techniques or develop new methods by which to improve our patients' compliance with medical therapy? I would like to believe that ours is an evidence-based specialty and that most of us adopt new surgical techniques and approaches to medical therapy after the literature supports their use. The mantra of evidencebased medicine is not to let our last patient's outcome determine the next patients' treatment. Good surgeons take their patient's outcomes personally and will go to great lengths to avoid—and especially not repeat—bad outcomes. Watching surgical videos on Eyetube.net is a great way to learn from others' approaches to surgery and medical therapy.

RETAINED SURGICAL DEVICES

We glaucoma surgeons are always looking for the optimal balance between efficacy and safety, and perhaps no topic better exemplifies this quest than the use of antifibrotic chemotherapy with mitomycin C (MMC). To enhance the procedure's success, some surgeons use adjunctive MMC when performing trabeculectomy or a revision of a trabeculectomy, when placing an Ex-Press Glaucoma Filtration Device (Alcon Laboratories, Inc.), or when inserting a glaucoma drainage device.

Mobius Therapeutics, LLC, recently received FDA approval for Mitosol (mitomycin for solution) for use in glaucoma surgery. Mitosol contains MMC as well as precut sponges. Although this approval means that MMC may now be used on label for glaucoma surgery, some surgeons are concerned that the sponges used to apply the solution may be left behind in the eye after the procedure. Retained surgical devices are considered to be preventable medical errors and are treated as serious adverse events. Often requiring patients to return to the OR, retained sponges may compromise glaucoma filtration surgery and can result in hospitals' imposing large fines on physicians. The most commonly retained surgical instrument in general surgery (eg, abdominal) is a sponge. As a surgeon with an unknown number of surgeries involving MMC sponges in his future, I occasionally worry about my lifetime cumulative risk for a sponge used for the application of MMC to be retained in whole or in part (usually behind the equator of the eye).

In his video, Robert Schertzer, MD, recovers a retained MMC sponge and demonstrates how to use miniature neuropatties during trabeculectomy. The latter are surgical sponges used in neurosurgery that have a string through them to ensure that multiple sponges can be removed as one unit. First, Dr. Schertzer demonstrates his standard technique, which includes two 8- × 8-mm surgical instrument sponges soaked in MMC. During the surgery, Dr. Schertzer has trouble locating one of the sponges. He explains how excessive manipulation of the conjunctiva when searching for missing sponges is counterproductive in a surgery in which preserving tissue is key. He also points out that the goal of a diffuse posterior MMC application has likely increased the risk of lost sponges. Next, Dr. Schertzer shows how to use miniature neuropatties to avoid retained foreign bodies in the eye (Figure 1). A package of these sponges costs $9, and they are identical in size to most MMC sponges.

Another potential solution for avoiding retained sponges in the eye is to inject MMC into the subconjunctival space. This approach is gaining favor among glaucoma surgeons. Although many of us are injecting MMC for primary trabeculectomy, this approach is becoming more favored during the revision of a trabeculectomy, where a full conjunctival dissection is not typically performed. Steven Vold, MD, demonstrates a revision of a trabeculectomy with an injection of MMC into the subconjunctival space. Using a 27-gauge needle, Dr. Vold injects 0.2 mL of a 50/50 mixture of 0.4 mg/mL MMC and 1% preservative-free lidocaine into the fibrosed bleb. Through the same needle site, he then instills Healon5 (Abbott Medical Optics Inc.) to provide hemostasis and to maintain the subconjunctival space, an effect that lasts for about 7 days after the revision (Figure 2). After injecting the ophthalmic viscosurgical device, Dr. Vold revises the flap with the tip of the 27-gauge needle. His trabeculectomy revision is a neat technique that involves several creative ideas.

LASER TREATMENT TO REDUCE IOP

David Gossage, DO, presents the results of a study of 13 eyes treated with micropulse diode laser trabeculoplasty (MDLT) for the reduction of IOP. Micropulse delivers energy in a series of short-duration, low-powered micropulses. Each pulse is followed by a pause to allow the tissue to cool, theoretically making the treatment less destructive than argon laser trabeculoplasty (ALT). The patients in Dr. Gossage's study were newly diagnosed with chronic primary open-angle glaucoma and opted for MDLT instead of medical therapy. The mean preoperative IOP was 26 mm Hg (range, 21-38 mm Hg). None of the eyes was previously treated, but five patients had previously undergone ALT on the fellow eye. Dr. Gossage reported a mean reduction in IOP of 18% at the 4-month follow-up visit. The IOP in one eye increased by 1 mm Hg. Subsequent ALT was performed on this eye, but there was no change in pressure. Based on these results, Dr. Gossage said he is comfortable offering MDLT as a first-line option for lowering IOP. The treatment offers a long-term advantage for those patients who experience a loss of effect over time, because MDLT is repeatable. MDLT also offers flexibility for patients who have an inadequate response to a previous ALT procedure, he said.

EARLY INTERVENTION

In his video titled, “The Glaucoma Battle: Do We Even Stand a Chance?” Alan Robin, MD, shares his thoughts on why patients' glaucoma progresses. He notes that one in five glaucoma patients does not see an ophthalmologist within 18 months of diagnosis and that twice that many do not get their prescriptions filled within 2 months. Additionally, only half of patients can correctly name the medications that they take. Dr. Robin notes that simplicity is the key, and he adds that patients on only one medication do better than those on two. Dr. Robin demonstrates how even experienced eye drop users are unable to accurately deliver an eye drop to their eye. His video, which is interactive and presents several cases, provides meaningful and practical advice on how we can partner with our patients to improve their compliance. For me, the video was a unique opportunity to get inside the mind of a physician scientist who has a great passion to improve the compliance of glaucoma patients.

On the topic of medical therapy and early surgical management, Richard A. Lewis, MD, debates whether or not glaucoma is primarily a surgical disease. According to Dr. Lewis, 85% to 90% of glaucoma cases are currently managed with medications, but given Dr. Robin's video regarding patients' poor compliance with glaucoma therapy, the percentage of patients on medical therapy seems high. Dr. Lewis discusses the benefits and current limitations of microinvasive glaucoma surgery, with the most significant limitation's being a lack of long-term safety and efficacy data. He also presents an interactive case in which the viewer can vote on which intervention best fits the patient's clinical presentation. With the recent approval of the iStent (Glaukos Corporation), the videos by Drs. Robin and Lewis are timely and highlight the interesting and exciting times that glaucoma surgeons face as we head into the era of microinvasive glaucoma surgery.

CONCLUSION

By watching the videos of our colleagues, we have a front row view of the expertise of surgical innovators and experienced practitioners. We can learn from their mistakes and share the glory of their successes.

Section Editor Nathan M. Radcliffe, MD, is an assistant professor of ophthalmology at Weill Cornell Medical College, New York- Presbyterian Hospital, New York. He is a consultant to and speaker for Alcon Laboratories, Inc. Dr. Radcliffe may be reached at (646) 962-2020; drradcliffe@gmail.com.