The Building Blocks of Trabectome Surgery: Volume 1: Patient Selection

As we enter what I believe to be a new era in the management of glaucoma, my dear friend and colleague Dr. Constance Okeke brings the ophthalmic community a timely, thoughtful and extremely practical resource in assisting our transition to intervening earlier in the glaucomatous disease process. In the recent past, glaucoma was managed primarily as a medical disease with incisional glaucoma surgery generally being considered a treatment option of last resort. Dr. Okeke does a masterful job of preparing ophthalmologists to think differently about our glaucoma patients.

If we truly value the quality of life of our patients, intervening with micro-incision glaucoma surgeries such as the Trabectome should be considered long before patients are on the verge of legal blindness. Clearly medical compliance for our patients is a major problem. Although helpful, glaucoma medications are clearly toxic to the aqueous outflow system and introduce numerous adverse effects such as periorbital pigmentation and fat atrophy, allergic conjunctivitis, ocular surface disease, cataract and cystoid macular edema not to mention systemic side effects including fatigue, depression, erectile dysfunction and systemic hypotension to name a few. Patient forgetfulness and medication cost must be included in any discussion of patient medical adherence challenges as well.

In addition to their glaucomatous disease, many glaucoma patients suffer from significant visual disability due to concomitant cataract. By not offering procedures such as the Trabectome at the time of cataract surgery, surgeons are almost certainly offering inferior care to their patients. Dr. Okeke’s extensive experience with the Trabectome and giftedness as an educator allows her to bless us with an incredibly detailed and successful approach to truly enhancing the lives of our glaucoma patients in this situation. Why should glaucoma patients be relegated to a life of feeling they are living in the prison without walls of taking chronic glaucoma medication while suffering with vision that does not allow them to carry out their activity desires when technologies like the Trabectome have been available to cataract surgeons for over 10 years with a superb insurance reimbursement profile?

I want to personally express my gratitude to Dr. Okeke on the completion of this immense labor of love. While we live in an age when the amount of medical information currently available to us is almost overwhelming and not necessarily worthwhile, this book is eminently worth your time to read from cover to cover. This resource is easily readable, comprehensive and offers information up in a very practical fashion. Her use of patient case examples and pearls learned from less than ideal patient outcomes allow us to optimize our Trabectome outcomes without using the trial and error method of learning. Her utilization of a MIGS calculator in patient surgical decision-making is particularly instructive. Thanks to physicians like Dr. Okeke, the day of refractive glaucoma surgery has finally arrived!

Steven Vold, M.D.

In recent years, micro-incision glaucoma surgery (MIGS)* has become an increasingly important and exciting approach in the surgical management of glaucoma. MIGS has transformed glaucoma surgical treatment because it offers a safer alternative for intraocular pressure (IOP) control with less risk of complications compared with traditional trabeculectomy and tube shunt procedures. The heightened media attention that MIGS has recently received has brought various procedures to the limelight, such as trabeculotomy by internal approach, trabecular micro-bypass stenting, goniotomy, canaloplasty, and supraciliary micro-stent. The Trabectome (NeoMedix), which removes a strip of trabecular meshwork, thus creating a goniotomy or trabeculotomy via an internal approach, can be considered the first MIGS product as it was made commercially available in 2006. It really stands in a class of its own as it is the only FDA cleared device with the intended use for surgical management of infantile and adult glaucoma as a stand-alone procedure or combined with cataract surgery. Trabectome surgery offers more than a decade of robust research and clinical studies showing that it is a safe and effective procedure for mild to moderate, and severe glaucoma.

If you are reading this book, chances are that you are already familiar with Trabectome.

* MIGS Trademark, https://trademarks.justia.com/854/46/migs-85446847.html

Foreword
Steven Vold, M.D.

Preface

How to Use This Book

Acknowledgements

Building Block 1: Speculate ‒ Why Trabectome?
Introduction How to Be a Part of the Migs Explosion
Chapter 1 Advantages and Disadvantages: What Can Trabectome Do for Me?

Building Block 2: Analyze ‒ Tell Me More about Trabectome
Chapter 2 Understanding Trabectome

Building Block 3: Search ‒ How to Survey Trabectome Candidates
Chapter 3 Characteristics for Success
Chapter 4 The MIGS Patient Selection Calculator
Chapter 5 Gonioscopy Overview

Building Block 4: Select ‒ Who to Choose for Trabectome?
Chapter 6 Real Clinical Cases: Good Candidates
Chapter 7 Real Clinical Cases: Suboptimal Candidates

Building Block 5: Advise ‒ How Do You Make the Recommendation?
Chapter 8 Practical Tips for the Doctor Patient Discussion

Building Block 6: Conclude ‒ Leaving a Lasting Impression?
Chapter 9 Thoughts on the Future of Trabectome in the MIGS Line Up
Chapter 10 FAQs and Advice for the Initial Cases

Afterword

Appendix/Sources

References

Index

About the Author

Dr Okeke compiled the finest source of information to date regarding the use of Trabectome for glaucoma patients. The book is unique because it addresses both the most mundane to the most complex issues surrounding the use and importantly misuse of MIGS. The information in these pages is useful not only to the novice but to the highly experienced anterior segment surgeon as well. Each page reveals her secrets of glaucoma surgery with pearls gleamed over years of compassionate clinical care. It is a treat to see this materialized into a good read on how to better care for patients with glaucoma.
Ronald L. Fellman, MD
Glaucoma Associates of Texas, Dallas, Texas

In The Building Blocks of Trabectome Surgery: Patient Selection, Dr. Constance Okeke speaks in the tone of a true coach, guiding her players (those who want to adopt and even those who are skeptical about adopting a new surgical procedure) along the process of becoming a proficient Trabectome surgeon. The book provides a true ‘360 perspective’ on Trabectome surgery, covering everything from contemplating Trabectome, to pre-operative planning, intra-operative steps with links to helpful videos, to postoperative management. The book is loaded with many helpful pearls, beautiful illustrations and a useful Trabectome patient selection calculator to aide in picking patients who would benefit most from the procedure. This book is a must read for anyone interested in performing MIGS surgery and will be a useful training guide for future MIGS surgeons.
Louis R. Pasquale, MD, FARVO
Professor of Ophthalmology, Director Glaucoma Service, Harvard Medical School, Boston, Massachusetts

When I first encountered Dr. Okeke presenting at a national meeting, I was astounded by her phenomenal surgical technique, well produced surgical video and extensive experience with micro-incisional glaucoma surgery. Her book, The Building Blocks of Trabectome Surgery not only provides a truly comprehensive analysis of Trabectome surgery, but also allows the reader to access Dr. Okeke’s ample knowledge on the disease of glaucoma, optimizing patient care and delivering on the MIGS promise. I learned a lot and am confident that readers involved in many aspects of glaucoma care will gain from Dr. Okeke’s book.
Nathan Radcliffe, M.D.
Director, Glaucoma Service, Clinical Assistant Professor, NYU Langone Ophthalmology Associates New York City, NY, USA

Dr. Okeke is a pioneer of MIGS. With this advancement she has helped improve the quality of life for the many patients who take advantage of the Trabectome technology.
Sherri Becker, OD
Becker Eye Care Center, Hampton, Virginia

As an optometrist, I found the clinical applications in this book to be easily accessible and something I can utilize when evaluating glaucoma patients who are ready for cataract surgery or progressing under traditional therapy. In this book, Dr. Okeke lays a framework for any provider to establish whether a patient is a good or sub-optimal candidate for Trabectome, but in doing so, delivers so many clinical pearls, it will make you re-evaluate how you systematically examine your daily glaucoma patients. It is an excellent reference for Trabectome, MIGS, and glaucoma care in general.
Christopher Kuc, OD
Virginia Eye Consultants, Norfolk, Virginia

This book is an extremely comprehensive labor of love from a very experienced surgeon, for anyone wanting to learn Trabectome and even for those already performing it. The multiple clinical cases and her approach to helping guide the reader through selecting appropriate patient candidates is invaluable!
Anup K. Khatana, MD
Director, Glaucoma Service, Cincinnati Eye Institute, Cincinnati, Ohio

As a glaucoma surgeon and program director, conveying novel surgical concepts to trainees in a manner that is easy to understand is of the utmost importance. Dr. Okeke’s book is thought provoking, easy to follow, and encompasses ALL aspects of Trabectome surgery – including doctor-patient discussions and post-operative considerations. I especially enjoyed the case-based approach to patient selection. This is definitely a “must-read” for anyone adopting Trabectome (or any MIGS surgery, for that matter).
Chandru Krishnan, MD
Assistant Professor of Ophthalmology, Director, Ophthalmology Residency Program, Tufts Medical Center, Boston, Massachusetts

This book was very interactively written. It felt as if Dr. Okeke was talking to me. The book was a very welcomed and organized read on a topic that can become complex very quickly when writing about. From a new optometrists perspective, this was a very informative and easy to understand resource for Trabectome. It taught me a lot and walked me through the steps in understand patient selection, candidacy, technique, post-operative, and realistic outcomes. Jillian Janes, OD Optometry resident, Norfolk, VA

The Building Blocks of Trabectome Surgery: Patient Selection is written in a unique, user friendly format. A valuable resource for the beginning and experienced Trabectome surgeon. Dr. Okeke discusses clinical scenarios of both the ideal and more challenging patients for this procedure, and offers a MIGS patient selection calculator to help the surgeon in this identification process. Filled with surgical pearls and personal insights from an experienced surgeon, it is an outstanding recourse to increase the understanding of Trabectome and all MIGS surgery.
Eydie Miller-Ellis, MD
Professor of Clinical Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Director, Glaucoma Service, Scheie Eye Institute, Philadelphia, PA

A surprisingly comprehensive yet easily read textbook regarding the Trabectome; I definitely recommend this book to all Ophthalmologistsin- training, glaucoma fellows, and to anyone else considering using the Trabectome.
Asher Weiner, M.D.
Ophthalmic Consultants of the Capital Region, Troy, New York

Dr. Okeke’s The Building Blocks of Trabectome Surgery is an excellent guide and resource for ophthalmologists in training who want to start learning more about MIGS and Trabectome. The book is full of useful pearls, interesting cases and a unique MIGS calculator that are all very practical and especially useful to the resident in training. This is an exciting time in the field of glaucoma, and this book highlights why MIGS and Trabectome are on the forefront of the newest treatment options that we can offer to our patients.
Luke Moore, MD
Ophthalmology Resident, Eastern Virginia Medical School , Class of 2017

Dr. Okeke provides a comprehensive, detailed, yet concise review of Trabectome. She uses compelling personal experience as well as published data that should convince even a Trabectome skeptic of the procedure’s merits. The book has a tremendously useful step-by-step practical approach beyond patient selection and technique in how to incorporate the procedure into one’s glaucoma treatment armamentarium including but not limited to coding, economics, patient counseling and consent, practice steps prior to first case, and comparisons to other MIGS procedures. Despite having nine personal years of Trabectome experience, I found myself at the conclusion of the book with a long list of invaluable pearls to incorporate into my own practice.”
Michael C. Stiles, MD
Medical Director, Stiles Eyecare Excellence and Glaucoma Institute, PA

Dr. Okeke does a fantastic job walking readers through each element of the Trabectome, from the procedure itself to patient selection. Further, she does it in such a way that it’s impossible not to want to get out there offer it to your patients! I really enjoyed the clinical cases. This is the perfect read for students and clinicians alike who want to learn more about a new procedure in order to provide new options to their glaucoma patients.
Amber Huleva
Optometry Student, Pacific University College of Optometry, Class of 2017

I think the book did a great job of discussing Trabectome on a variety of levels. As a graduating medical student preparing to enter a residency in ophthalmology, I really liked the sections breaking down systematic gonioscopic technique and normal angle anatomy variants. I also enjoyed the case-based sections, which were an engaging way to emphasize the importance of careful patient selection for successful MIGS.
Hayley James
Medical Student, Eastern Virginia Medical School, Class of 2017

Dr. Okeke maps out the steps in a systematic fashion to allow beginning Trabectome surgeons to have a successful outcome with surgery. She writes in a fashion that draws the audience to her personal story. I think that having the patient scenarios was very compelling, as it was good to see how real patients performed. The patient testimonials were also powerful. I also like how Dr. Okeke notes the appropriate patients for Trabectome, but just as importantly, notes the patients who are NOT appropriate for Trabectome. Dr. Okeke draws on her personal experience with over 1,000 Trabectome surgeries in this book which can serve as a “How-to” manual for beginning Trabectome surgeons, and in a style that is a great read!
Leon W. Herndon, MD
Professor of Ophthalmology, Duke University School of Medicine, Durham, North Carolina