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Glaucoma Symposium Review – Surgical Management Advances in the Surgical Management of Glaucoma – The Role of the EX-PRESS ® Glaucoma Filtration Device A report on the satellite symposium ‘Advances in glaucoma surgery: new evidence in filtration surgery’ held at the World Glaucoma Congress, 30 June 2011, Paris David W Cope, Medical Writer, Touch Medical Communications, UK Reviewed for scientific accuracy by Robert Fechtner, 1 Leo de Jong, 2 Elie Dahan, 3 Malik Kahook, 4 Marlene Moster 5 and Ivan Goldberg 6 1. Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, NJ, US; 2. Academic Medical Centre, Amsterdam, The Netherlands; 3. Ein Tal Eye Hospital, Tel Aviv, Israel; 4. Department of Ophthalmology, University of Colorado, Denver, CO, US; 5. Wills Eye Institute, Philadelphia, PA, US; 6. Glaucoma Unit, Sydney Eye Hospital, and Discipline of Ophthalmology, University of Sydney, Australia Abstract Clinicians aim to arrest the glaucomatous process by reducing intraocular pressure (IOP). 1–5 Available strategies include medical, laser and surgical techniques. Trabeculectomy is the traditional standard drainage surgery technique to achieve this. These MIGS techniques therefore appear to be adequate for patients whose glaucomatous damage is mild to moderate and whose target IOPs fall into this range. To achieve lower IOPs in patients with more advanced visual loss, efforts have simultaneously been made to fine-tune trabeculectomy. The use of the EX-PRESS ® Glaucoma Filtration Device (Alcon) under a scleral flap is one such approach. How does the EX-PRESS Glaucoma Filtration Device benefit the conventional trabeculectomy procedure? What tips and tricks can contribute to its successful use? How safe is it? Is the additional cost to our health system justifiable? The satellite symposium ‘Advances in glaucoma surgery: new evidence in filtration surgery’, held at the 2011 World Glaucoma Congress, chaired by Dr Ivan Goldberg and sponsored by Alcon, set out to try to answer these questions. Keywords Aqueous outflow, filtration surgery, glaucoma, intraocular pressure, trabeculectomy Disclosure: David Cope is a medical writer at Touch Medical Communications. Received: 30 August 2011 Accepted: 20 October 2011 Citation: European Ophthalmic Review, 2012;6(2):83–91 Support: The editorial support for and publication of this article were funded by Alcon. Glaucoma is a progressive optic neuropathy caused by the death of retinal ganglion cells and degeneration of their axons in the optic nerve. 6 This leads to damage of the optic disc and subsequent loss of the visual field. 6 Glaucoma is known to be one of the principal causes of blindness worldwide. 7,8 Population-based data indicate that 1–9 % of adults older than 40 years have some form of glaucoma, with prevalence depending on age, gender and ethnic background. 6,9,10 In 2010, 60.5 million people worldwide were estimated to have glaucoma and, because of increasing population numbers combined with increased population ageing, this will probably affect approximately 80 million people by 2020. 11 The economic burden associated with glaucoma globally is considerable and related not only to treatment costs, but also to rehabilitation and patient costs, including increased household costs and loss of earnings. 12,13 Although statistically elevated intraocular pressure (IOP) is no longer a defining criterion for glaucoma, 6 it is a major risk factor for the development and progression of the disease. 1–5 Medical, laser and surgical therapeutic treatments that reduce IOP can delay or halt, but not reverse, disease progression. 14,15 Trabeculectomy has been © TOUCH BRIEFINGS 2012 the traditional standard of filtration surgery for 40 years, and is the primary method for the surgical management of open-angle glaucoma following the failure of medical therapy or non-incisional procedures such as laser trabeculoplasty. 16–18 Trabeculectomy can control IOP effectively, 19–22 even five years after surgery. 23–27 However, published success rates vary considerably, in part because of the lack of standard definitions for success 28 and also because trabeculectomy is associated with complications, including early postoperative hypotony, bleb leaks, blebitis and bleb failure, choroidal effusion, endophthalmitis, hyphaema, shallowing of the anterior chamber and accelerated cataract progression. 16 Moreover, trabeculectomy can fail to control IOP adequately in some patients, who therefore require a secondary surgical intervention such as a repeat trabeculectomy or implantation of a drainage device. 29 As a result, some studies indicate that the risks associated with trabeculectomy outweigh the benefits. 24,30 However, incremental improvements that refined the trabeculectomy technique have proved valuable, including the use of a corneal traction suture to control eye position; appropriate and optimal use of wound-healing techniques to prevent fibrosis 83