This article is more than 5 years old. Information may no longer be current.
BLOG: Like it or not, you’re a glaucoma specialist
What’s the most common glaucoma surgery performed in the U.S.? Phacoemulsification, for sure. A few years ago, when we began recognizing the consistent pressure-lowering effect of cataract surgery, we began to understand that most glaucoma has a phacomorphic component, which explains the benefit of cataract surgery. We also learned that cataract surgery is an ideal time to perform additional procedures, now known as MIGS, to sustain lower pressures in patients with coexisting glaucoma.
Learning to perform gonioscopy-guided surgery can be a barrier for some cataract surgeons. Like learning indirect ophthalmoscopy, it requires a new type of coordination. It also requires us to understand the angle anatomy and consistently identify the trabecular meshwork, at least in the case of the iStent (Glaukos), the Hydrus (Ivantis) and Visco360 (Sight Sciences). Use of the CyPass stent (Alcon) requires only entering the supraciliary space, and although this too requires gonioscopy, it is a more intuitive approach than cannulating Schlemm’s canal. Finally, the Xen stent (Allergan) penetrates to the subconjunctival space for probably the best pressure-lowering effect of all.
All of these techniques are quite learnable, and I would assert that every cataract surgeon has a duty to gain familiarity with one or more techniques. By and large these procedures are designed to be performed with cataract surgery, so if we perform cataract surgery alone in a glaucoma patient, we are missing an opportunity to additionally lower pressure and reduce the burden of eye drops.
One more reason to adopt MIGS with cataract surgery is the high level of patient satisfaction it delivers. Cataract patients come in hoping for relief from visual disability. When we additionally reduce or eliminate the need for drops among those with glaucoma, we become an even greater hero in the eyes of our patient — pun intended.
Disclosure: Hovanesian reports he is a consultant for Glaukos, Sight Sciences, Ivantis and Alcon.