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Surgeon shares customized approach to selecting best MIGS procedure

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WAIKOLOA, Hawaii — Disease status, change over time, age, IOP and previous surgery are all considerations when choosing a MIGS approach to an individual case, according to Malik Y. Kahook, MD, who related the risk/benefit tradeoffs that he discusses with patients before making a choice of which device “to take off the shelf.”

In a case of moderate disease with stable change in a young and healthy patient whose IOP goal is in the mid-teens and who has not had previous surgery, “This is where the iStent [Glaukos] is the workhorse in my practice,” Kahook said in a presentation at Hawaiian Eye. “For mild to moderate disease, where the main goal is decreasing medication, the iStent does a very good job.”

Malik Y. Kahook

The iStent has a superior safety profile with modest IOP lowering, and options remain for future approaches to be used, Kahook said.

“If you can get that patient off one or two of their medicines, I think that’s a home run,” he said.

In another scenario, the patient has slowly progressive moderate disease, age is older and health is good, IOP goal is in the mid-teens and an Ahmed drainage device was previously implanted. For this patient, Kahook said stand-alone endocyclophotocoagulation (ECP) is ideal in this case with previous glaucoma drainage device implantation, wherein the device is still functioning but goal IOP has not been achieved. This is a good choice before committing the patient to a second glaucoma drainage device, he said.

“We have many options now that go beyond trabs and tubes for mild to severe disease,” Kahook said.

Standalone outflow procedures work well for moderate disease, and standalone inflow procedures also work well for moderate disease when there is a higher-teen IOP goal, he said.

Take into consideration several factors before deciding on the best approach and, importantly, involve the patient in the decision, he said. – by Patricia Nale, ELS

Reference:

Kahook MY. A case-based approach to caring for the glaucoma patient. Presented at: Hawaiian Eye; Jan. 16-22, 2016; Waikoloa, Hawaii.

Disclosure: Kahook reports financial interest in Glaukos and New World Medical.