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New eye stent helping glaucoma patients in WNY

Betty Fecteau has always valued the importance of taking care of her eyes.

"You only have one set," said Fecteau, 85, a retired accounting and purchasing specialist who lives in West Seneca.

She and her husband, Bill, a retired Bethlehem Steel worker with diabetes, have made regular eye exams a part of their health and wellness regimen for decades.

During a biannual exam several years ago, Dr. Paul C. Holmwood, an ophthalmologist, discovered Fecteau had refractory glaucoma, a condition that affects eye pressure and is shared by 3 million other Americans. It is often asymptomatic until it worsens and causes peripheral vision loss or blind spots.

"This is why it's important to have not just a screening but a full eye exam," Holmwood said. "Eye pressure screenings at a health fair are not enough. One-third of patients with glaucoma have normal pressures at any given time. ... During an exam, you look at the optic nerve and you do a peripheral vision test."

Holmwood, one of four ophthalmologists with Eye Care & Vision Associates, started Fecteau with traditional glaucoma treatment: eye drops to better regulate fluid drainage and balance the pressure in her eyes.

Earlier this year, he recommended a new treatment for her right eye when it became clear he also had to address a cataract in the eye: an XEN Gel Stent.

In a procedure at Buffalo Ambulatory Center that added about 2 minutes to the cataract surgery, Holmwood inserted a shunt the width of an eyelash into Fecteau's eye to more naturally handle drainage. He is the first doctor in the region to use the XEN stent, approved by the Food and Drug Administration last November. He predicted other physicians will soon follow suit.

"It's a very gentle procedure, the recovery time is much quicker and it greatly reduces the risk of complications," said Holmwood, 56, an Orchard Park native and graduate of Canisius College and the University at Buffalo medical school.

Dr. Paul C. Holmwood, an ophthalmologist with Eye Care & Vision Associates, recommends an eye exam at least once a year for those age 65 and over. (Robert Kirkham/Buffalo News)

Holmwood did his ophthalmology residency at the Cleveland Clinic and followed that with a glaucoma fellowship at Northwestern University in Chicago. He and his wife, Beth, live in Williamsville with their three children, Alex, 20; Katie, 19; and Cassie, 16.

Q. What is refractory glaucoma?

Generally speaking, the pressure in the eye is uncontrolled and something has to be done to bring the pressure under control to prevent progressive visual loss. It's usually asymptomatic, so patients don't realize they're in trouble until it's way too late. That's why it's important to come in regularly for an eye exam.

Q. Do you recommend an annual eye exam?

The American Academy of Ophthalmology recommends all adults 65 and over have an annual exam. Depending on family history, others should have one every three to five years.

Q. What is the standard course of treatment when glaucoma is discovered?

In the United States, it's typically to start out using drops to lower the pressure. We can use any number of drops or combinations.

Q. How do they help relieve the pressure on the eye?

They prevent the fluid-producing portion of the eye from making as much fluid as is accustomed, so the drain, which is letting the fluid out, is not so burdened. You have a bad drain, so instead of cleaning the drain, you turn down the faucet.

Q. Can that create dry eye at times?

It can cause surface issues with the eye. Systemic side effects can occur. With a beta blocker drop you could slow the heart rate; you could precipitate an asthma attack. Drops are not without the consequences. Sometimes their effectiveness wanes. When it does, we take the next step, which in Betty's case was the stent.

Q. Talk about the XEN stent. What does it look like and how does it reduce Intraocular Pressure (IOP)?

The XEN Gel Stent is surgical implanted during microscopic surgery, using this shooter device.

It's ridiculously small, and works like a stent in other parts of the body. … Think of it as a miniature soda straw. It's a hollow tube and it's inserted through the wall of the eye, with one end in the eye. Fluid flows through it and exits the eyeball itself through the other end of the straw. There's a membrane covering it, so it doesn't exit the body, just the eye.

Q. How is it implanted?

Surgery, performed with a microscope. The stent comes prepackaged in a shooter. There's a thin metal tube holding the stent. At the end of the tube there is a hypodermic needle. You insert this device into the eye, you position it to where you want it to pierce the eye and exit from the outside, and you shove the tube in with a tiny plunger. I never hold the shunt. I do the surgery under a little intravenous sedation and use drops to numb the eye.

Q. How does the procedure differ from conventional glaucoma surgery?

Conventional surgery requires an external incision through the membrane that covers the white of the eye, which leads to some bleeding, inflammation. You have to do cautery to stop bleeding. You have to cut a hole in the eye with a flap. To keep it from leaking too quickly, you have to use sutures. The pressure can go too low. It can stay high. There are numerous complications if you're not doing it on a regular basis: low pressure, decreased vision, outright failure. It can heal shut. There can be inflammation. The recovery time can take weeks.

Q. Any potential complications with the stent procedure?

There is a risk of hemorrhage. The probe could perforate the membrane on the surface of the eye, which could require you to alter the position for implantation. The shunt can become dislocated, which is unusual. But by and large, it's a very safe procedure.

Q. What are the costs and coverages including versus conventional surgery?

Conventional surgery is generally covered by health insurance. Various carriers have their own fee schedule. We're still waiting for a lot of the carriers to come out with the fee schedules for this procedure. Meanwhile, patients can choose to pay out of pocket or do the conventional surgery. The cost is roughly $1,500. Aetna currently covers it. I expect others to do so in time. It's cheaper and causes fewer problems.


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