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Editors Selection IGR 11-1

Surgery: Safety gold microshunt

Comment by Richard Lewis on:

23352 Efficacy and safety of gold micro shunt implantation to the supraciliary space in patients with glaucoma: a pilot study, Melamed S; Ben Simon GJ; Goldenfeld M et al., Archives of Ophthalmology, 2009; 127: 264-269

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Among the various new approaches studied to surgically manage glaucoma, canal and suprachoroidal are quite appealing as they do not depend on a filtering bleb, conjunctival wound healing or scleral fistulas. Accessing the canal space by various ab interno and/or ab externo approaches have been described and prospective, one to two year studies have been reported with good IOP lowering success. On the other hand, little has been published about the use of suprachoroidal space to treat glaucoma. The goal of surgery in the suprachroidal or supraciliary space is to enhance uveoscleral outflow beyond the accepted 10-15% to achieve reduction in IOP. The cyclodialysis procedure, a popular surgical approach for glaucoma prior to the 1980's, is an early example of approach. Unfortunately, surgically creating a cyclodialysis for a few clock hours in the angle was beset by fluctuating IOP and unpredictable outcomes. This prospective study by Melamed et al. (413) examines the efficacy and safety of when placing a gold micro shunt implantation in the supraciliary space in patients with glaucoma. This is one of the first publications where a device is placed to maintain the cyclodialysis cleft. Thirty-eight patients underwent implantation in a prospective non-randomized, prospective trial. The IOP decreased from 27.6 (4.7) to 18.2 (4.6) with a mean follow-up was 11.7 months. There are problems in this study including the lack of a randomized control group, the length of follow-up, the type of glaucoma under study, the prior intraocular surgery and the complications reported. However, there is value in this investigation in knowing that the gold implant was found to be safe. The study raises many unanswered questions: stability of the implant, determining the size of the implant, the size of the openings to control of IOP, ease of the surgery, long term effect on the visual function/crystalline lens/corneal endothelium/etc. This is an exciting and burgeoning space for placing glaucoma devices. Let's hope that we see additional success and more detailed answers to the questions raised.

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