Ep 29 Talking About Glaucoma - 29Jan2018 FELLMAN Fluid Wave (AAC enhanced)

Talking About Glaucoma (AAC)

In this episode, I’m talking with Ron Fellman from Glaucoma Associates of Texas about the Fellman Fluid Wave and its clinical implications in glaucoma surgery.
Episode Chapters:

Intro: Ron Fellman

Glaucoma Associates of Texas

Fluid Wave: what it isRelated strictly to conventional outflow

Evidence of patency of this system

When unroofing Schlemm’s canal a decade ago when viscocanalostomy was being popularized, injecting BSS you could see the outflow pathways

At times there would be no flow into the adjacent veins

Was I in the wrong spot?

Five years ago during Trabectome, wondered if the outflow could be visualized

Reduced the Episcleral Venous Pressure by putting patient into some raverse Trandelenberg and raised the bottle height to its highest

You don’t see this during normal phacoemulsification because usually you are forcing the Schlemm’s canal closed

How does the fluid get to the episclera?

In Trabectome, adjacent to the tip, can see segmental fluid outflow if focus at the limbus; first let foot off the foot-pedal to drop the eye pressure and look for blood to reflux in to AC, then floor the pedal and if there’s a connection through to the collector channel, then the fluid gets through the episclera via deep venous plex, mid venous plexus and then to the episcleral venous plexus super highway

Blanching is occurring as all the blood runs out of the tissue

Improve outflow where there isn’t or optimize existing flow?

Aqueous wants to go out the path of least resistance

If you see a blanching it means the deep and mid venous plexus are both open and this is where the trabectome will work the best

The blanching correlates best with the patients with the lowest IOP; averaging 11.9 on 1 med vs 19 on 3 meds

Zero re-op on those with good flow vs 36% in patients with a poor wave seen intra-operatively

However we still don’t have a way to modulate wound healing with a trabectome; so can still get granulation tissue that ruins the surgery

Would fluid wave work for other MIGS procedures?

With circumferential sclerotomy see a near uniform fluid wave

With an iStent if you hit the right spot, usually won’t see more than 1 or 2 clock hours of a fluid wave; and this would only be seen AFTER the iStent is in place so you can’t do this BEFORE putting in the iStent

What’s the outcome marker for MIGS surgery? With Trab, its bleb formulation; with MIGS don’t see something when the case ends

Reference:

Episcleral Venous Fluid Wave: Intraoperative Evidence for Patency of the Conventional Outflow System

Fellman, Ronald L. MD; Grover, Davinder S. MD, MPH

Journal of Glaucoma: August 2014 - Volume 23 - Issue 6 - p 347–350

Production information:
This episode was originally recorded March 2016 during the Annual Meeting of the American Glaucoma Society in Ft Lauderdale using two Shure SM58 microphones with a Marantz PMD661 digital recorder. Mixing and sound levelling were FINALLY completed in January 2018 on an iMac using Hindenberg Journalist Pro software. Narration was overdubbed using a Blue Yeti Microphone with Journalist Pro.

Opinions expressed in this podcast are those of the speakers and are not intended to be taken as the standard of care for glaucoma treatment. Please always weigh the complete clinical picture and involve patients with any decisions in their care.

Ronald L. Fellman, MD
Glaucoma Associates of Texas
Dallas office: 214-360-0000
Plano office: 972-612-9522
Fort Worth Office 817-923-2000
[e-mail]
http://glaucomaassociates.com/glaucoma-specialists/ronald-l-fellman-md/

Robert M Schertzer, MD, MEd, FRCSC
[e-mail]
Twitter - http://twitter.com/robschertzer
or http://iguy.tv/twitter
Blog - http://wholelottarob.com
or http://iguy.tv/blog
Facebook - http://facebook.com/talkingaboutglaucoma
Glaucoma Patient Group (support group) - https://www.facebook.com/groups/glaucomapatientgroup/
or http://iguy.tv/patientsupport
I am pleased to announce that I am returning to Vancouver, BC. Follow my website for the latest news and for Eye Facts for patients to learn more about glaucoma. http://westcoastglaucoma.com or http://iguy.tv/office
Theme music "Middle East Gold" ©Daniel Schertzer 2010 and published by Les Prods DOSWA Enr
© 2018 DOSWA Prods Enr/Robert M Schertzer MD. MEd, FRCSC

Future episodes include a long discussion with Murray Johnstone and a talk about the new glaucoma drug Rhopressa.

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Drop me a line at [e-mail] with your comments, visit WholeLottaRob.com, WestCoastGlaucoma.com, or follow me on twitter @robschertzer. Links to all of these are in the show notes. Remember to keep fighting glaucoma by early detection so that nobody loses vision from this group of diseases.