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Should MIGS be considered for glaucoma patients before more invasive surgery such as trabeculectomy or tube shunts?
Surgery should be considered early in disease process
 Brian A. Francis |
The traditional glaucoma treatment paradigm consisted of medication, followed by laser trabeculoplasty and then external filtration surgery as a last resort. As such, the majority of patients undergoing glaucoma surgery had advanced optic nerve damage and visual field loss. MIGS procedures — canaloplasty (iScience), Trabectome (NeoMedix) and iStent (Glaukos) — were developed to enhance internal filtration via Schlemm’s canal and the collector channels while decreasing some of the more serious risks associated with filtration surgery, such as hypotony, choroidal effusion or hemorrhage, and endophthalmitis. The goals of these procedures are to lower IOP to physiologic levels while reducing dependence on glaucoma medications. Thus, they are not meant to replicate the IOP lowering of filtration surgery and are aimed at a different glaucoma population. The ideal candidate for MIGS is a patient with mild to moderate glaucoma damage, high baseline IOP and a target in the mid teens.
Concurrent cataract extraction, rather than being a risk for failure such as with trabeculectomy, can increase the efficacy of MIGS. If we shift our treatment paradigm to include surgery earlier in the disease progression rather than waiting as a last resort, then current and future MIGS procedures will become a preferred choice for most glaucoma patients.
Brian A. Francis, MD, is a surgeon at Doheny Eye Institute, University of Southern California, Los Angeles. Disclosure: Dr. Francis is a consultant for NeoMedix.
Clinical setting should dictate treatment strategy
 Douglas J. Rhee |
In general, I think we should move away from thinking algorithmically that there is one particular procedure, whether it be trabeculectomy or any one of the MIGS procedures, that should be used in all cases following failure of medical or surgical treatment. I believe that the literature is beginning to show that different procedures work optimally in different clinical settings. We should move toward having the specific clinical setting dictate which procedure we should use, whether it be trabeculectomy, tube shunt or any of the new MIGS procedures.
Douglas J. Rhee, MD, is an OSN Glaucoma Board Member. Disclosure: Dr. Rhee has no relevant financial disclosures.