 Thank you so much, Dr. Kamansky. Our next presentation is another one of our fellows, our glaucoma fellow, Arwa Alsamore, who's gonna be talking about the triumphant trabeculectomy. All right, good morning, everyone. I'm just gonna be talking about the triumphant trabeculectomy, no financial disclosures. Basically, this is a talk on why filtering gloves are here to stay. And so I'm gonna talk a little bit about the basics of glaucoma and trabeculectomies, and I'll talk a little bit about some issues that exist with trabeculectomies and some alternative options that we have for traps. And then I'll briefly talk, I mentioned about the trap versus tube study, which was something I was recently published, and I'll talk about a briefcase presentation. So glaucoma is, it represents a second leading cause of blindness worldwide, so there's a lot of morbidity associated with it globally. It's defined as an optic neuropathy for which intraocular pressure is a modifiable risk factor. And so all of our treatment modalities rely on getting that pressure lower, so that includes medications to lower the IOP, whether it's topical or oral medications, laser procedures, and then minimally invasive glaucoma surgeries versus the traditional incisional surgical interventions, including the trabeculectomy and things like a tube shunt. In terms of the history of surgical management, I think you mentioned William McKenzie as one of the people that you mentioned. And so he published one of the first sort of glaucoma interventions in 1830 by passing a narrow knife, one millimeter posterior to clear cornea and allowing surgery to drain that way. In 1857, the first LPI was described, and then sort of an old school trap was published in 1870s, but the more modern day trap that we're still doing today was published in 1968 in the American Journal of Ophthalmology by Cairns there. And we're doing it somewhat similarly at this point. And so a trabeculectomy for those who might not be familiar, essentially when you do a limited conjunctival peritomy with a partial thickness scleral flap, you create an ostomy to allow fluid to drain from the anterior chamber subconjunctivally. And there's a lot of variation for how you do a trap in the sense that you can do it exactly the same way, but in terms of how you're closing the scleral flaps, you might need two sutures, you might need three, back to the brisket, I had a patient where we did six or seven sutures, so it really depends on the flow afterwards. So there's a little bit of sort of voodoo and surgical nuance associated with traps. And the other thing is that if you think you're doing a trap exactly the same way in two different patients, they can respond very differently. So one trap can be perfectly fine and have a beautiful filtering blab and have very well-controlled pressures, and the other patient will scar down right away and have a poor outcome. So that's one of the reasons why people have started sort of straying away from traps is sort of the variability that exists with traps and the frustrating results that can come out of that. There's a lot of meticulous post-operative management when it comes to traps as well. So you're seeing these patients one day after, three days after, twice the next week, twice the following week, weekly for a couple months. I mean, you're following them very, very closely and sort of raising that trap and raising that blab almost like your own child. And so there's a lot of close follow-up associated with that and there's a lot of variability as to when you're doing laser suture lysis, when you're injecting with mitomycin, 5FU, needling, things like that. So there's a lot of close follow-up and that's another reason why people have sort of straight away from them sometimes. The other thing to mention is that traps, although they can be extremely successful, can also have very complicated outcomes. So you can have patients with hypotiny maculopathy who do very poorly. You can have cordial effusions and hemorrhages. You have a lifetime risk of blabitis and blood-related endothelitis. So again, people have been sort of searching for a different version of a trap that would work without causing all of these side effects and complications. And so this is a little bit more for the residents here. So if you're seeing a post-trav patient and you're seeing them on call and the patient has a trap and a low IOP, you're gonna look at their blab. So if their pressure is low and their blab is high, then you say, well, that blab is working too well, so you're over-filtering. If the pressure is low and they have a low blab, you wanna make sure it's side down negative and that you don't have a blab leak, you wanna look for coroitals and hypotiny, which you can see in traps. If they come in and they have a high pressure with a trap and you see a high blab with sort of a ring of steel phenomenon, you're worried that it's an encapsulated blab and it's essentially not functioning. If you see a high blab, I'm sorry, a low blab with a high pressure and they have a low anterior chamber depth, you're worried maybe this could be pupillary block versus something like a supracordial hemorrhage or malignant glaucoma, so you wanna take a look for that. And then if you see that they have a low blab and a high pressure, you can stick a gonio lens on there and look and see if the osteum is blocked and if you need to laser that to allow for fluid to flow. So these are all sort of part of the post-operative management of traps. And so there's been a recent glaucoma renaissance in the glaucoma world where folks have been trying to develop alternative ways to get the pressure lower surgically without having to put patients through a trabeculectomy. And so it sort of started more recently with the eye stent and now the eye stent inject. And we've got the hydrous now which cannulates about three clock hours of Shalem's canal and you've got things like the omni device which will allow you to do either 180 degrees or 360 degrees of viscocanolostomy sort of dilating the channels distally alongside a trabeculotomy. We have things like the cut hook dual blade and ECP which is endocyclo-photocorrigulation where you're lasering the ciliary processes so that they decrease aqueous production. We have the zen which is down in the left corner there which Dr. Trier calls a trap light sort of a less efficient but somewhat functional trap. And then you have eye tract catheters to do again more viscocanolostomy and things like that trabeculotomy. So the thought was okay, MIX could be the end of trabeculectomies and that's just not true. So as Brock mentioned a few weeks ago when he gave his MIX talk, the question is are these minimally invasive procedures or are these really minimally effective procedures? MIX are really at the mercy of episclerol venous pressure as well. So from the Goldman equation pressure equals the rate of aqueous formation over the facility of outflow plus episclerol venous pressure. So even if we decrease the rate of aqueous formation to zero which is not really possible but even if we do that and even if we maximize the facility of outflow you still have to deal with episclerol venous pressure. And so for patients who have normal tension glaucoma who will progress at a pressure of nine or 10 and they need to be in the low single, you know in the single digits, the only option you really have at this point for long-term consistent success of the trabeculotomy. So there's really always a place for a successful and effective trap especially for these patients who are going to progress at a pressure of 13 or something like that. There's not really a MIX procedure that will consistently get you to low pressures. There's no real procedure that will do that long-term other than a trabeculotomy at this point. So then the question comes about, so what about tubes? And so this was studied recently in the trap versus tube study which was a multicenter randomized clinical trial across 17 institutions. The thing to note is that these patients, the majority of them were enrolled after having already had a previous trabeculotomy and or a cataract or cataract surgery in the past and they had had poorly controlled glaucoma on max medical therapy. And so they looked at outcome measures in these patients putting either a second trap or a tube in these patients and they looked at their pressure, their vision, medication use and then failure. And they defined failure as a pressure of more than 21 or a pressure that was not reduced by more than 20% and they looked at hypotiny as failure as well and they looked at requiring REOP as failure and an outcome of NLP as failure. And so when they looked at the five year results of these patients, the IOP differences in the mean number of medications were better in the trap group so that overall the pressure was lower in the trabeculotomy group, which we know trabeculotomies are going to get you the lowest pressure out of any glaucoma procedure when they're successful. So the mean IOP was lower in traps and the mean number of medications required was lower in traps. And then the statistically significant results was failure probability and re-operation rate. And so the failure rate that they quoted very, very high failure rate. So nearly 30% of tubes were considered as fail. And remember we said that's pressure of higher than 21 or they didn't reduce by 20% NLP, things like that. And so two failures, about 30% trap failures, almost 50% of traps failed in the study. It's a very high failure rate. So in terms of consenting patients for a trap, I were to say, yeah, you have a 50% of failing. That's a not very convincing evidence for a trap. Again, remember these are second traps for the most part. So if they had already failed a previous trap or scarred it down, there's a good chance they're going to fail a second trap. And then in terms of re-operations, tubes needed 9% of the tube patients needed a re-operation. And nearly 30% of the trap patients needed a re-operation. And of the re-operations, the most common re-operation in the trap group was tubes. So they ended up getting a tube after failing a second trap. And so the most common reason for failure was an inadequate IOP reduction. And then hypotiny was more common in the trap group than the tube group. And again, that's the caveat again, is that a lot of these patients had already failed the trap. So it does introduce bias in the study towards tubes. So that's something to think about when you're thinking about the trap versus tube study. And so I just wanted to talk to you about a sort of roller coaster course, one of our patients that we did a trial on a couple of months ago. This is a seven-year-old patient with a past medical history of primary opening, glaucoma in the right eye, moderate stage, mild stage in the left eye. She had had a very successful trap years ago in the right eye. Her pressure is seven on no drops in that right eye. She's very happy with that right eye. The left eye, she's coming in with a pressure of 38 on max topical therapy. And just to show you her fields. So the right eye is the one that had the trap a few years ago. And that's the eye with a more severe glaucoma. The left eye doesn't have significant glaucoma as damage on Humphrey visual field. Little bit of thinning on the left eye on OCT. And so we had sort of altered her medications and things and tried to maximize her medical therapy even more to see if we could get this under control without surgical intervention in that left eye. But her pressure remained in the 30s despite varying regimens. And she did not wanna start having visual field loss in that left eye. This is her better seeing eye. We talked to her about surgical options. She had a great trap in the right eye. So she said, let's go ahead and do a trap in the left eye. Gets her off for her drops and it's her sort of given her experience in the right eye. It's a reasonable option. So we went ahead and took her to the operating room for a trabeculectomy in the left eye. We placed three sutures, two wing sutures and a central suture. And then, so then here we go. So post op day one, her pressure was 18. She looks great. And remember, she was nearly 40 before surgery. Post op day three, it's 16. She's very happy. This particular patient has a, she checks her pressures at home and texts us her pressures. And so she texts us on post op day six. Says that her pressures are in the 50s. Feels okay, but you know, pressures are in the 50s. And so we tell her to come on in and let's take a look. So she comes in and she has a flat blood on exam. It's nearly a week out. So we think it's pretty reasonable at this point to do a laser suture lysis. And what that basically means is the three sutures that I mentioned. So you're going to cut those sutures with a laser to allow for that trapdoor partial thickness scleroflap that you created to open up and allow flow. So we cut one of her wing sutures and it was completely flat. There was no response whatsoever when we cut the wing suture. Said, okay, let's just, let's cut one more suture. So we cut the central suture and you just see fluid just kind of coming out of the subcontinue entirely there. So that opened things up. She still has one suture there that we don't mess with at this point because she now has an elevated flat there. And so post op day seven, her pressure's one. So we have her on steroids. We're trying to sort of allow her pressure to increase. And she's checking her pressure at home, pressure zero. She comes in, she's got an exuberant blood and her pressure's zero. We're concerned at this point, she's hypotenuse. It's two weeks out. And so we're worried that this is her better-seeing eye and we're worried about something like hypotenuse maculopathy. So we actually take her back to the OR two weeks out and we replace two 10-0 nylon sutures for her and close everything back up. So this should be happily ever after. And it's not. So post op course number two, so post op day one, pressure's 40. It's way too early to do an anti-relaser suture license at this point. So we treat her with aqueous suppressants and diamox and she comes down to 18. She hates the diamox, it makes her feel terrible. So we cut back on the diamox a little bit. She's still on some diamox and her pressure's 30 at post op day four. And we sort of hold our breath and we cut a stitch and she comes back post op day six, her pressure's 40. So we cut a second stitch. And she comes back post op day 10. This is deja vu all over again, pressure's 40 and she's literally hanging by a thread, right? That central final suture. Last time we cut that, you know, we took her back to the operating room for hypotenuse. So we cut that stitch and then we do what any glaucoma specialist goes home and does. And we go and pray and hope that things go well because that's all we have. And she does really well. So thankfully we don't have to take her back to the operating room again. Her pressure two months out now, her pressure's eight off of all drops in that left eye. She's really happy despite that post operative course. She's got a diffusely elevated bleb. It looks great. This could have ended up very differently and we've all seen it end up very differently with traps but thankfully there are patients who have great outcomes despite, like I said, the post operative course can be very, very challenging in these patients. And the hit ABC show, Ray's Anatomy Knows This. And so they said the following. I'm going to play this. Oh, bleb. Why is there a trap lining up along? I don't know what it is. It just takes out a sense. Bleb. Is this dead or what? It's not a word. It's not a word. It's a sound effect. Bleb. Well, who? And her. I don't know what you're doing. So, so what's on the horizon? We've got an infocus coming out at some point. I think every glaucoma specialist is pretty excited about this. This is an ab external approach to, sort of a less, a more minimally invasive bleb and they've had great outcomes with this so far. And so that's sort of on the horizon and that could potentially rid us of this, you know, the old school way of doing a bleb, which like I said has a lot of complications but can be very, very effective and still very much has a place in glaucoma. And so we'll see how the infocus does clinically once it's FDA approved here. But I think we're all very excited about offering something to our patients that can be just as effective without all of the issues that come along with doing a trapezoid activity. So, any questions? Question? I'll just comment. So, I think that my favorite reasonable patient to put it that way, unless you need a very reliable feed, it's a patavian female, no primary surgery. This is probably a pretty good success. And the other exciting thing is on APSnet, there's a video by Wong Kim and also apparently Brian Francis are now doing an ab external zen. I think that would be exciting to see how that does. Yeah, we're excited to try that an external approach. I talked to Dr. Chai about it yesterday, actually. I think Dr. Risky had mentioned that, some of the, you had mentioned that part of the success that comes with trapecolectomies is approaching things from an ab external approach. And that part of the issue with zen, even besides just the tenons issues, is that it is an ab internal approach. And it seems to be that so far with zen, I think there is something to be said. For example, as compared to infocus, which is ab external, and you look at the data and the ab external approach seems to be much preferred. So maybe if you have external with zen, we'll be helpful, but certainly the failure rate of zen is pretty high. And I agree on this patient, you could look at doing other things, but I know her well and know her. I could just, I could comment on her in the context, and I know we have another presentation, but I just, and thanks, Howard, I think that's a great presentation. I just wanna make just four quick comments. First off, in patients that have, that really need a low pressure, and we could talk a lot about who those patients are. There is, there does seem to be something about getting a pressure that averages, a procedure where the pressure is average about 12. And you could look at literature, you can look at the advanced glaucoma intervention study, et cetera, et cetera. There does seem to be something about getting the pressure to 12 or less in people who need it. And in my opinion, there's only one way to get there, and that's a true eclectomy to get there reliably. The on migs, there is, Episcopal venous pleasure is the floor, right? But the interesting thing about migs, and we estimate that the Episcopal venous pressure is between eight and 11, but the thing about migs is that the floor is higher than that. There's some other factor. And you look at all the migs daily, you look at all the migs studies, and the pressure floor is in the mid-teen somewhere. So it's actually above Episcopal venous pressure for some reason. And we're just learning about that now, this kind of downstream resistance. So that's an important thing to think about in migs, although I do migs all the time, if you're really aiming low, I think there's only one way to get there. And then finally, the TVT study that you quoted, there's so much press given to that study, I did a great summary. I have a lot of issues with that TVT study, and it really surprises me how much press it got. It basically concludes that tubes are better as second procedures. And duh, we know that, that's why tubes exist. And but this got kind of out there in the literature, and people started doing tubes instead of traps, and there is nothing in that study that gives, I think, justification for doing that. Plus the complication rate on the trap side was just way too high. So I think there's a lot of problems with that. And then on the primary TVT study, which one year data has been published last year, traps clearly had a lower pressure. And why no one really talks about that study, I don't know. But if it was presented at AGS last year, there's clearly a pressure advantage when you're talking about primary procedures with trap versus tubes. So trap is still the low pressure winner versus tubes when you're talking about primary surveys. And then finally, just to comment, I always heard me say this, it was all my fellows. Sometimes your patient, what they need is for you to step up to the plate and hit them a home run. And a home run is a well-functioning trabeculectomy. That's what they need. They need pressures of eight, nine, 10, less than 12. There is something real about that in these progressors that are beating you with their progressive disease. And they need you to hit them a home run. Well, sometimes when you're swinging for the fence that you're gonna strike out to, and that's the thing about trabeculectomy, sometimes you do. But I have always found that your patients in this setting, their vision's going down or their pressure's 40 and you cannot control it. They tend to really understand the situation and they'll be your advocate with you and you try your best to get their pressure down to where it needs to be. And so that's kind of the game of traps, but when they need it, they need it. And it's just kind of the way it is. So thanks, that was a great presentation. I just have one comment too, along with what you were talking about. When you look at surgical studies, one thing that happened was that everybody took the data from the first trap versus two and assumed that meant they could do the trap with two of them, first line. And the dad didn't support that at all. Second thing is, it was not surgical. It wasn't controlled on surgical. There were too many surgeons, two, two cases of the dog. All the dad was going through the run. So when you look, when you study a surgical paper, you need to know who's doing the surgery. It's gonna need to know. And you can't take that and start doing two since the first primary surgery. And that's what people are doing. So if you're in the East Coast, you get two first. You're in South Florida, you get again, but you get out of the place. And the rest of us will help you get through the surgery. That came out of that, so that's a very interesting outcome, not really understanding the surgery. All right, thanks everyone, thanks Arva.