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Part 2 of 2: Reason No. 47 for loving microinvasive glaucoma surgery — the ocular surface
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I believe there are a lot of reasons why doctors and patients will come to love the results of microinvasive glaucoma surgery. One of the best is its friendliness to the ocular surface.
The best way to reduce the toxicity of medications is to not use them at all. Minimally invasive glaucoma surgery (MIGS) involves the implantation of a device to bypass the trabecular meshwork and allow aqueous a more direct exit from the eye. Some devices such as the Glaukos iStent and the Ivantis Hydrus direct fluid into Schlemm’s canal, while others such as the Transcend CyPass direct fluid to the suprachoroidal space. FDA approval is being sought for a number of devices, and so far only the iStent is approved.
All MIGS procedures aim to at least reduce medication usage in glaucoma patients. Although most of these devices are approved to be implanted in the setting of cataract surgery, I’m very hopeful that we’ll see they’re equally effective in the pseudophakic — or for that matter, phakic — patient.
After all, how many millions of Americans who already have lens implants take glaucoma medications? What would be the benefit to their ocular surface, to say nothing of the cost benefit to society, of reducing or eliminating these drops? Time and continued post-market surveillance will determine the value of the iStent in the pseudophakic patient, but conceptually the idea is very promising. Early experience in the former Soviet Union with the iStent showed that it indeed had great value in pseudophakic patients, so this result is likely to be reproduced in regular use in the U.S.
Having now implanted three iStents since FDA approval, I’m excited about the pressure reduction my patients are already seeing. MIGS is clearly going to remain a part of my cataract surgery practice, and there’s a good chance I’ll soon be offering it to non-cataract patients as well.
Disclosure: Hovanesian is a consultant for Ivantis.