Are there any advantages of the suprachoroidal implants

Are there any advantages of the suprachoroidal implants in Deep Sclerectomy ? Dr. J. Loscos Hospital Universitari Germans Trias i Pujol Badalona, Barcelona

Dr. P. Romera Glaucoma Consultant Dra. A. Moll Resident 4 th year Conflict of interest: The authors declare no conflict of interest Dra. N. Romanic Resident 3 rd year DO J. Castellvi Optometrist

Why is Casablanca one of the best movies in history?

How does it work ? _ Ciliary muscle Relaxation (A) / Contraction (B) _ Increase (A) / Decrease (B) aqueous humor outflow through muscle bundles

How does it work ? ˃2. 5 mm Suprachoroidal Uveoscleral outflow increase <1. 5 -2 mm Supraciliary Ciliary body detachment _ Decrease in aqueous humor production _ Decrease in choroidal resorption

How does it work ? Supraciliary Intrascleral

How does it work ? Jan 2013 May 2015 Oct 2013 Oct 2015 Sept 2016

Results Author Implant Nº Years Pre IOP Post IOP Nº Pre Nº Post Bissing Aquaflow® 105 10 26. 8 12. 2 2. 3 1. 3 Galassi SKGel® 200 3 21 12. 85 2. 4 0. 3 Mousa Esclera 20 1 33. 1 14. 6 ** ** Devloo Esclera 24 1. 2 25. 6 15. 7 1 0. 5 Lachkar Aquaflow® 258 6 24. 4 15. 8 2 0. 8 Ravinet T-Flux® 23 2 28. 1 13. 2 2. 5 0. 4 Ravinet Healon GV® 23 2 23. 5 12. 2 0. 2 Studeny T-FLUX® 40 5 26. 7 18. 3 2. 5 1. 8 Mansouri PMMA 30 1 21. 4 13. 8 2. 4 0. 6 Mansouri Aquaflow® 30 1 21 13. 3 2. 4 0. 7 Karlem Aquaflow® 100 1. 5 27. 8 14 2. 2 0. 2 Chiselita Aquaflow® 17 1. 5 27. 7 20. 9 ** 0. 8 Mermoud Aquaflow® 44 1. 2 25. 8 18. 3 ** 0. 5 Intrasclerall Author Nº Years Pre IOP Post IOP Med Post. Med. Post El-Sayyad 39 1 27. 9 15. 6 2. 4 0. 3 Perez-Rico 47 4. 8 21. 19 12. 76 2. 06 1. 06 No implantl Author Implant LOC Nº Pre IOP Post IOP Med Pre 61 27 Ye ars 1 1 26. 4 26. 6 14 15. 3 2. 8 2. 5 Med Post 0. 3 Muñoz Loscos T-Flux® Esnoper SUPRA Loscos Clip® Esnoper® INTRA SUPRA 33 2 24. 6 16. 1 2. 7 0. 4 Supraciliary

Is it worth it?

Results IOP Eyes pre Suprachoroidal 41 Intrascleral 42 IOP post Nº Preop Nº Postop Medicat 23. 46 ± 6. 47 14. 62 ± 3. 64 2. 68 ± 0. 02 0. 24 ± 0. 66 23. 74 ± 6. 9 15. 43 ± 4. 27 2. 58 ± 0. 04 0. 32 ± 0. 76 Comparative Analyses of Two Positioning Variants of The Acrylic Implant Esnoper V-2000 In Deep Sclerectomy: a Multi-Center Randomized Controlled Trial. Belda JI, Loscos J, Mermoud A, Lozano E, Rebolleda G, Rodriguez-Agirretxe I, Canut M , Rodriguez-Calvo PP and the ESNOPER V-2000 study group.

Results : Goniopuncture Eyes Days IOP reduction Suprachoroidal 15 (36. 58%) 165 Intrascleral 210 6. 36 22 (52. 38%) 6. 88 Comparative Analyses of Two Positioning Variants of The Acrylic Implant Esnoper V-2000 In Deep Sclerectomy: a Multi-Center Randomized Controlled Trial. Belda JI, Loscos J, Mermoud A, Lozano E, Rebolleda G, Rodriguez-Agirretxe I, Canut M , Rodriguez-Calvo PP and the ESNOPER V-2000 study group.

Results N Pre IOP Nº Preop Medications Supraciliary 58 27. 66 +/- 9. 19 2. 91+/- 0. 40 Intrascleral 27 24. 02+/- 10. 01 3. 13 +/- 0. 64 Post IOP Nº Postop Medications 13. 38+/- 4. 88 0. 14 +/- 0. 43 14. 92 +/- 3. 61 0. 35 +/- 0. 64 Goniopuncture % Reduction 41. 79% 59. 68% 33. 34% 32. 46%

Results : Goniopuncture The eyes with suprachoroidal outflow decreased 5. 09 mm. Hg ± 3. 62 (-24. 73%) whereas the ones without suprachoroidal outflow decreased 4. 36 mm Hg ± 6. 86 (-16. 86%)

Results N Conjunctival Bleb Uveoscleral Outflow Cyclodialysis 12 m 40 32 (80%) 15 (37. 5%) 6 (15%) 24 m 18 15 (83. 3%) 9 (50%) 3 (16. 6%) 36 m 15 11(73. 3%) 8 (53%) 2 (13. 3%) _ Cyclodialysis does not exist with high funcional conjunctival blebs _ High functional conjunctival blebs do not exist with cyclodialysis _ Uveoscleral outflow can exist in both situations

Complications : Hyphema DS Intrascleral 0. 8%3 - 22. 7%4 DS Supraciliary 6. 6%1 - 14. 58%2 _ Low postoperative IOP at 24 hours _ Implant in touch with supraciliar vessels 1 - Muñoz G, Nonstitch suprachoroidal technique for T-flux implantation in deep sclerectomy. J. Glaucoma 2009; 18: 262 -264. 2 - Loscos, Valldeperas, Parera, Camara Deep sclerectomy with supraciliary hema implant: results and complications. Int Ophthalmology 2015 Oct; 35(5): 693 -9. 3 - Lachkart Y, Neverauskiene , Nonpenetrating deep sclerectomy: a 6 -year retrospective study. Eur J Opthalmol 2004; 14: 26 -36. 4 - Raviinet E, Bover E, Mermoud T-Flux implant versus Healon GV in deep sclerectomy. J. Glaucoma 2004; 13: 46 -50.

Complications : Hypotony. . . clinical hypotony may be the variably low pressure that, in an individual eye, leads to lost of function and tissue changes overtime. _ 34 eyes _ Maculopathy 25% (32. 4 % Spontaneous recovery) _ No significant difference in the rate of cataract or choroidal effusion

Complications : Hypotony

Complications : Hypotony

Complications : Hypotony 1 1 - Nadal J, Carreras E, Canut M I, Barraquer R, Vitrectomy and internal limiting membrane peeling for macular foldssecondary to hypotony in miopes Clin Ophthalmol. 2015; 9: 859– 864.

Conclusions _ Not quantitative _ Alternative when transcleral outflow is limited _ Unconventional pathways could be increased _ Less bleb dependence _ Avoid the need for suturing _ Supraciliary / Suprachoroidal _ Identify risky factors _ No more complications than MMC

Moltes gràcies http: //drloscosoftalmologia. com/