Kahook, Samuelson debate MIGS procedures with phaco

KOLOA, Hawaii — Excisional goniotomy is just as safe and effective as device procedures for the treatment of mild-to-moderate glaucoma, Malik Y. Kahook, MD, argued at Hawaiian Eye 2020.

“Goniotomy is the second most common surgical [glaucoma] procedure performed in the United States today,” he said, addressing the procedure’s safety profile during a debate with Thomas W. Samuelson, MD.

Kahook’s first choice of surgical intervention is a device-free, implant-free approach, since a healing response will lead to scarring over any device placed in the angle.

In addition, endothelial cell loss is a real-world problem.

“We have to keep in mind when we’re treating mild-to-moderate patients, younger patients, what are we doing long term?” he asked.

In terms of efficacy, excisional goniotomy has shown an IOP reduction of 24% to 36% and a medication burden reduction of 37% to 70%.

“I choose excisional goniotomy for the reliability and versatility without leaving an implant behind or worrying about reimbursement,” Kahook said. “Implant free is the logical choice.”

Samuelson, however, argued the case for canal-based microinsert surgery when combining cataract and glaucoma surgery.

“If my starting point is mild to moderate, and if phaco alone has already helped some, while I want to enhance outflow if possible, I am reluctant to dramatically alter normal anatomy and physiology,” he said.

In terms of efficacy, five different randomized MIGS trials have shown a reduction in IOP in the study arm better than those who received cataract surgery alone, at an average of 5.3 mm Hg at 2 years.

Samuelson looks to procedures that will have the least likelihood of disrupting anatomy or causing fibrotic healing response in the long-term.

“The iStent inject is 230 µm, both iStents together are about half a millimeter. That’s 1.38% of the angle. We’re leaving 98.7% of the angle untouched,” Samuelson said. For me I like the less disruptive approach.”

MIGS devices also have longer-term data available than goniotomy. Both iStent and Hydrus devices have data showing positive results through 3 years.

“I need longer than 6- to 12-month data. There are a lot of studies on incisional goniotomy, but most of them are 6 to 12 months,” he said. “For now, I like the minimalist approach of canal devices.” – by Rebecca L. Forand

 

References:

Kahook MY. Debate 3. The best MIGS procedure with phaco: The case for goniotomy. Presented at: Hawaiian Eye 2020; Jan. 18-24, 2020; Koloa, Hawaii.

Samuelson TW. Debate 3. The best MIGS procedure with phaco: The case for canal-based microstents. Presented at: Hawaiian Eye 2020; Jan. 18-24, 2020; Koloa, Hawaii.

Disclosures: Kahook reports he is a consultant to and receives royalties from New World Medical. Samuelson reports financial relationships with Glaukos and Ivantis.