TAG Episode 29 - 29Jan2018 FELLMAN Fluid Wave (mp3)

TAG Episode #29 FELLMAN Fluid Wave

[This is the .mp3 un-enhanced version of this podcast. The AAC .m4a version has chapter markers and artwork embedded in the podcast to enhance the experience on devices/apps that support this, which includes most podcasting apps on iOS and Android devices. It is the preferred version for experiencing this podcast.]


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:

  1. Intro: Ron Fellman
    1. Glaucoma Associates of Texas
  2. Fluid Wave: what it is
    1. Related strictly to conventional outflow
      1. Evidence of patency of this system
    2. When unroofing Schlemm’s canal a decade ago when viscocanalostomy was being popularized, injecting BSS you could see the outflow pathways
      1. At times there would be no flow into the adjacent veins
      2. Was I in the wrong spot?
    3. Five years ago during Trabectome, wondered if the outflow could be visualized
      1. Reduced the Episcleral Venous Pressure by putting patient into some raverse Trandelenberg and raised the bottle height to its highest
      2. You don’t see this during normal phacoemulsification because usually you are forcing the Schlemm’s canal closed
  3. How does the fluid get to the episclera?
    1. 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
    2. Blanching is occurring as all the blood runs out of the tissue
  4. Improve outflow where there isn’t or optimize existing flow?
    1.  Aqueous wants to go out the path of least resistance 
    2.  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
      1. The blanching correlates best with the patients with the lowest IOP; averaging 11.9 on 1 med vs 19 on 3 meds
      2. Zero re-op on those with good flow vs 36% in patients with a poor wave seen intra-operatively
      3. 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
  5. Would fluid wave work for other MIGS procedures?
    1. With circumferential sclerotomy see a near uniform fluid wave
    2. 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
    3. What’s the outcome marker for MIGS surgery? With Trab, its bleb formulation; with MIGS don’t see something when the case ends

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

Robert M Schertzer, MD, MEd, FRCSC
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 podcast@iguy.org 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.