Dr. Robert Noecker: So, I'll just share a few cases and kind of what's evolved with each of these patients over a little bit of period of time. These cases I would say are not the most typical cases, but I'll kind of compare and contrast where I think UBM probably has the best utilization

You know, it wasn't that long ago we were using--you know, we basically had to put our--you know, it's like, okay, patient, you're going to get your UBM. Let's go down to the dark room with [unintelligible] kind of like a little mad scientist and we'll put you in the dark--you know, lay down. We'll put this plastic cup in your eye, and it was a rather--we used to make all the residents do it just so they could appreciate what a UBM was like, and they weren't too appreciated. It was not a trivial exercise as the patients go through a UBM

Now, using the Quantel device, it's something with a very low threshold for doing, so I do it for every patient I see with narrow angles. I think it's a great tool. I basically explain to the patients their actual anatomy and say, "Hey, we have to do a, you know, iridectomy for your eye." I think it's a great patient education tool, and it's something you can do in just a couple minutes. It's very quick to do. It's, as we alluded to earlier, very patient-friendly, so we don't feel bad about doing it. So, we do it much more frequently, probably a couple times a day now in clinical practice

Okay, first case--a 65-year-old woman with chronic angle closure glaucoma, had a trabeculectomy, and it was just a routine trabeculectomy. Post-op day one, pressure was five. Tumor's a little bit shallow, but things were working. Post-op day three, we saw them again for the weekend. A little bit more shallowing and the pressure was starting to rise. They said, "Okay, maybe some scarring is going on," performed laser sutralisis [sp]

Here's the UBM images. On the first day, we can see there's some shallowing--you know, we can appreciate there's some shallowing of the anterior chamber. Let's see what happens. Post-op day five, the chamber is getting much more shallow. There's starting to be peripheral iris-corneal touch. The blood was not filtering and the pressure was rising rapidly. We couldn't identify any choroidals

And this is the anterior chamber two days later after that prior image, and when you see this here where the iris is really just flattened up and the ciliary body is kind of rotated like this--this is really pathic pneumonic for malignant glaucoma

So, I think for--when you have these patients that you're really wondering what's going on, if you see this, it's--we don't have to wonder anymore exactly what's happening when you have this loss of chamber, kind of this squashed up appearance of the structures against the cornea

So, we treat her as a malignant glaucoma case. We did an iridectomy. We went ahead and performed it for her. We basically put her on atropine, some Cyclogyl in the short term [unintelligible] suppressants

Unfortunately, the patient was aphakic, so despite our best attempts to kind of work peripherally lasering, it didn't work and finally they had to have a vitrectomy performed. With a vitrectomy, which is kind of the definitive go-to treatment to basically crate--make the eye unicameral, the anterior chamber deepen, the IOP reduced to the mid-teens, and actually the patient had a successful post-operative course, so a kind of resumption in normal anterior chamber depth

But, I think this is a case where--especially in malignant glaucoma cases, which do occur with eye surgery, especially glaucoma surgery on a regular basis, it's really nice to be able to get the decision earlier. Often the view is not so good, you're wondering if there's a peripheral choroidals, and this really helps to make the diagnosis quickly and move to a definitive therapy

So, a 41-year-old guy, had a lot of CME, vasculitis. He's been treated with steroids, and he's a steroid responder, so he had really high pressures. He had around one tube. Got his pressures down moderately. Then he needed a second tube, so basically had two tubes in his eye, but then his--and he was good for about six months, and then we couldn't find one of the tubes

He started to get some cataracts from all the steroid therapy, which he needed for his macular edema, and so we had to basically--we decided to reposition the tube. Here, we can see over here--this is one tube that's kind of stuck in the iris. So, that's the inferior tube. The [unintelligible] tube, which is right up over here, is not visible

Here we go. So, we basically found the tube, which is right here. This is after cataract surgery. And, our decision was, well, we still have the short tube to deal with. We could use an extender, but we decided to basically reposition it more posterially and place it in the sulcus, which is actually my preferred position for tubes because there's no way it's going to hit the cornea and cause corneal decompensation

But, we were a little bit nervous because we were taking this relatively short tube, we redoubled it and we placed it more posterially, from this entry point back here into the sulcus. And, the nice thing with a UBM, we can confirm that we are in the exact right position

And, like I said, for primary surgeries, if patients are [unintelligible] phakics, this is where we prefer to place our tubes, in the sulcus. I think it's a very safe, easy place to put them

Here, we see the anterior surface of the IOL. This is what we want to sit on top. We have a bevel, which typically if it's a primary placement, we'll do a reverse double to keep the opening away from the iris. But, here we see very good placement. The IOP remained under good control, and this is a nice, relatively easy fix for this patient, and his base--his IOPs were mid teens off of glaucoma therapy, despite being bombarded with continuing steroids. So, very nice placement, like I said

I think we hear a lot of--hear of all these minimally invasive glaucoma devices. I think it's very helpful to assess these things. I do a lot of [unintelligible]. My tubes are all in the sulcus. I think with glaucoma surgical devices, it's very nice to be able to ascertain the correct position if there are questions about function or if you just want to see it better

Okay, last case, and this is a little bit--this case I would say is a little bit more typical of how we use UBM on a daily basis. A 75-year-old woman came in for decreased vision and glaucoma. She was noted on exam to have narrow angles and perhaps a plateau of the iris configuration on the gonioscopy. Pressures were relatively high on a couple medications, and she had fairly dense cataracts

Here's the appearance of her eye. It's a little bit hard to tell without a [unintelligible], but her anterior chamber was somewhat shallow due to the dense cataract. Here's the gonioscopy, and you really can't see any angle structures, just kind of a hint of [unintelligible] with some pigment on it

So, she had an anterior segment OCP for comparison purposes, which, you know, does give us the hint that, yes, she has very narrow angles and a big lens. Here's her UBM, though, and it basically shows us her angle, but also, most importantly, it shows us this anterior positioning of the ciliary body

And, so still the treatment, whether it's narrow angles or plateau iris, is still to do a PI first, so we did that and it really didn't make much effect. Didn't really a change on gonioscopy when we did the UBM. We see that, once again, while we have a hole in the iris, this area of the angle is still compromised, once again, from this anterior rotation of the ciliary body

So, we decide to take out her lens. At the same time, we did an ECP. Here's the endoscopic view of the back of the iris. The iris is kind of hyper inflated here, but we see this kind of anterior knuckling of these anterior aspects of the ciliary processes endoscopically, and what we do with the ECP is basically shrink this anterior aspect. Our goal here is not really to decrease the production, but really change the anatomy, so that's what we do interoperatively

And, so here's our gonioscopy a couple weeks post-op, and we can see--it's very easy to visualize trabecular meshwork now with scleral spur, maybe a little hint of ciliary body there, but obviously a much more open angle. And, you know, just to illustrate the value, this is a series of her with variable iris dilation, but the difference--you know, here's pre--post LPI. It doesn't really do much for plateau iris

And, then post ECP, we see that we basically truncated this anterior aspect of the ciliary processes and the angle is open and will no longer be compromised. This picture has a little dilation of the iris, but it shows you the value where stopping at a PI is not going to be adequate. We need to do either iridoplasty or I prefer to do ECP on the ciliary processes

Her outcome? Her vision got a lot better. Her angle is much more open. Interocular pressure was basically fixed by removing the plateau component on the lens component, which was on mid teens for a number of years and really just followed as a routine patient at this point

So, I think all these cases--you know, in a surgical glaucoma practice, I think UBM is really essential, but, once again, anyone who sees a fair number of patients with narrow angles, I think it is extremely important to differentiate whether they have plateau component, and it's one of these things like the more you look for it, the more you see there's a lot of plateau iris out there where stopping at doing just a laser iridectomy will be inadequate in some of the cases and they're still at risk for angle closure components later on

And, thank you very much