BLOG: Dear MIGS, look at how quickly you have grown

BySavak Sev Teymoorian, MD, MBA

One of the most rewarding aspects of being an adult is watching our children grow up, whether they are our own or those you know closely. Every day the world becomes clearer to them as they learn through experiences. This development is not limited to their mental capacities as their physical maturation can be just as astonishing. We can all relate to the same question when we look at our little ones — “How did you get so tall?” As a glaucoma specialist involved in the evolution of MIGS, I am experiencing the same feelings. The way we manage our patients today doesn’t look the same from just a few years ago. What is even more encouraging is that this situation will continue to improve with the addition and advancement of each MIGS intervention.

A perfect example is canaloplasty. Originally, it was introduced as an ab externo procedure. This included dissection and, more importantly, use of valuable conjunctival tissue along with the incorporation of tensioning sutures. If reproducible and done well, the IOP reduction was great. Some studies even have comparable data to that of trabeculectomy. However, as with all surgical interventions, the selection of a surgery cannot take into account only the benefits. There needs to be careful consideration of risks and an understanding of goals especially as it pertains to patients’ quality of life. In the case of ab externo canaloplasty, the resulting benefit-to-risk ratio placed this procedure further down in the spectrum of glaucoma care closer to the conventional gold standards of trabs and tubes.

In similar amazement to witnessing the progression of our children’s advancement, canaloplasty has had a makeover to an improved version. This is achieved through an ab interno approach with the use of a catheter (iTrack) to perform ABiC (Ellex). This surgical approach allows for viscodilating the trabecular meshwork, Schlemm’s canal and collector channels. The goal is to improve aqueous outflow though these areas of resistance. The following are important differentiating points for that option:

Provides access to structures critical to the procedure through clear corneal incisions as opposed to conjunctival dissection needed for the prior ab externo approach.

Maintains a better safety profile that allows for faster recovery and less negative effect on patients’ quality of life as compared with its ab externo version, trabeculectomy and tube shunts.

Re-establishes the natural flow of aqueous while preserving both internal and external tissue if additional surgery is needed.

Exists as a stand-alone procedure or can be combined with cataract surgery.

ABiC as the next iteration of canaloplasty and also a valuable addition to the MIGS armamentarium continues this positive trend in surgical growth and advancement. It provides a strategic option to provide more effective care for our glaucoma patients. This trend becomes more obvious as glaucoma evolves from a medical to a procedural disease. The next step in this process is to complement MIGS with SLT to further improve outcomes. The combination of these will help to reduce the deficiencies created by noncompliance from drops by applying a “MIGS and SLT” approach. Each step helps use get closer to our goals of “happy patient, happy doctor.”

Disclosure: Teymoorian reports he is a consultant and speaker for Ellex.