Segmented, Pulsatile and Dynamic
Aqueous angiography has now been performed in living patients – and holds the promise of truly personalized glaucoma surgery
Alex Huang |
At a Glance
- For the first time, aqueous angiography has been applied to living subjects (both humans and non-human primates)
- Real-time data from live patients was consistent with previous post-mortem aqueous angiography: outflow is segmentally heterogeneous
- Furthermore, live-patient data confirmed a pulsatility to outflow and resulted in the discovery of dynamic features of aqueous outflow – a unique observation
- Increasingly, aqueous angiography appears to have the potential to guide surgery to patient-specific regions, thereby enhancing MIGS outcomes.
Impaired aqueous humor outflow (AHO) is usually associated with resistance in the trabecular outflow pathways – the trabecular meshwork (TM), Schlemm’s canal (SC) and collector channels (CC). So it makes sense (on the face of it) that procedures aiming to bypass or ablate the TM – minimally-invasive glaucoma surgery (MIGS) – are increasingly popular. Big question then: why don’t trabecularly-oriented MIGS procedures drop IOP dramatically in every patient? At least part of the problem may be that AHO is not uniform around the limbal circumference. As some segments have better outflow than others, it’s almost certain that some are better sites for a MIGS procedure than others.
Clearly, we need a tool that allows detailed visualization of the AHO idiosyncrasies in each individual patient, helping us identify sites of outflow resistance. Such a tool would take the guesswork out of the MIGS game, and might permit truly personalized glaucoma surgery. But what would be the key features of such a tool? The ideal tool would be able to provide real-time, physiologically-relevant and comprehensive information from the patient’s eye in situ. In this context, ‘comprehensive information’ would cover structure and function across all trabecular AHO pathways in their entirety: both linearly (from the anterior chamber [AC] to the episcleral vein) and circumferentially (360° of coverage). But how close are we to this ideal?
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