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Dr. Singh: 
The suprachoroidal or the supraciliary space is another and a new target that we have for our MIGS procedures. What are some of the emerging implants that utilize this space?

This is CME on ReachMD, and I’m Dr. Paul Singh.

Dr. Petrakos:
And I'm Dr. Paul Petrakos. Overall, there has been a growing interest in ophthalmology, and specifically in glaucoma, to utilize the suprachoroidal space. The suprachoroidal space is a hypothetical space between the sclera and the choroid.

So the CyPass was the first suprachoroidal drainage device. It was 6.3 mm in length, but it was removed voluntarily from the market because it led to endothelial cell loss.

The iStent Supra is 4 mm in length, curved to follow the eye’s anatomy. It creates a channel enabling the aqueous outflow to the suprachoroidal space. And it was approved in the EU and other countries but is currently not available in the United States.

The MINIject is a porous structure, half a millimeter into the anterior chamber with bio integration that's currently approved in the EU and other countries.

Paul, are there any other devices that you've been using that utilize the suprachoroidal space?

Dr. Singh:
Yeah. And absolutely, I've been lucky enough to have utilized almost all the products that you've mentioned and all the different technologies as well. And I think it is a significant space for us because there's a negative pressure gradient. That's really important. When we think about our outflow MIGS procedures, our stenting, our canal dilating procedures, our cutting procedures, we don't really know ahead of time preoperatively where the resistance to outflow is. Is the trabecular meshwork the issue? Is it the Schlemm’s canal that's collapsed? Is it the distal collector channels that aren't functioning well? And we're kind of guessing in a lot of ways, of which is the right pathway and where we’re trying to bypass. 

But what's nice about the supraciliary spaces is, once you open that space up, there's nothing else back there. So not only do we have to not worry about all the other potential barriers to resistance, but also, we have a significant degree of IOP reduction because it has that negative pressure gradient. So we can get down, a lot of times, to those low teens and get patients, a lot of times, off of a lot of drops, and sometimes 70%, 80% drops reduction depending on the studies you look at. So significant benefits.

And of course, there are some risks with that space as well. Number one is that that space can sometimes close up over time like anything else, and when it closes up, the pressure can spike significantly, like a cleft closing. Also, there's some bleeding that can occur depending on the technique. You can get significant bleeding, you can get hyphema, even a kind of vitreous hemorrhage can occur when doing the procedure as well. And there’s a learning curve to understand how to get into that space. 

But all in all, I think a very powerful space and something that we can utilize as you see with all those different products out there. I think something that we can help with, especially for those patients who need that lower IOP as well.

Dr. Petrakos:
Well, thanks for sharing. I mean, these are all great points about this potential space. It’s great to have another MIGS option, and I’d just encourage our colleagues to keep an open mind when thinking about glaucoma surgeries and looking to the future, and future procedures that target the suprachoroidal space. I think there's a lot to be had there. A great way to bring down the intraocular pressure for our patients with, potentially, a safety profile that would be beneficial as well. 

Dr. Singh:
Absolutely. And I'll just add that we're seeing technology consistently evolving and that's what's exciting about it. You know this space is important because more companies are coming out. In fact, a company called Iantrek that has something called the AlloFlo, which is a scleral reinforcement device that basically allows us to keep a cleft open, so to speak, and that’s something we've actually performed in our office as well a few times already. So I think this space is here to stay. We’re seeing more technologies coming out to help us achieve that outcome that we need. And I think for patients who, let's say, the conjunctiva isn't very healthy, let’s say somebody already had a conventional outflow MIGS, you don't want to do a trab or a tube or a XEN or something else, I think this ab interno supraciliary space can be a great opportunity for a lot of our patients to safely reduce the IOP and not have to worry about a bleb as well.

But I think that’s all the time we have for today. Paul, thank you so much for being here. Appreciate that. 

Dr. Petrakos:
Thank you, Paul.

Dr. Singh:
And this has been CME on ReachMD. Take care. 

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