What would you tell a comprehensive or cataract surgeon who wants to adopt MIGS?
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Learn the fundamentals of angle surgery
It is difficult to give just one piece of advice for someone who is starting out on the journey of minimally invasive glaucoma surgery.
However, my best advice would be to learn the fundamentals of angle surgery. Learning that will allow you to master any type of MIGS procedure because it is all about the angle. You could start with practicing with a gonioprism in the operating room, tilting the microscope about 30° to 45° and then turning the patient’s head away. After you have done your cataract surgery and implanted the lens, turn the patient’s head away, turn the microscope toward you and put the gonioprism on the eye with your nondominant hand. Practice seeing the angle in a good view first; then, you could add using the cannula tip of a viscoelastic syringe in your dominant hand to touch the angle structures so that you can get used to the hand positioning.
These fundamentals — holding the gonioprism light on the eye for a good view without corneal striae and using a second instrument — are important to get the best view. Then, once you have learned that, you just need to set yourself up for success. When you are ready to start your specific procedure, make sure that you have at least three to five patients scheduled on that first day, so that you can hone in on the details of the procedure. Doing this gives you a chance to learn the nuances of the procedure, and then on the second surgery day, it is still fresh in your mind.
If you want even more pearls, I suggest taking a look at my book, The Building Blocks of Trabectome Surgery: Patient Selection. Although the title says Trabectome, it is a book for all MIGS surgeons and talks about these finer points of how you set yourself up for success, both in the clinic setting and also in the operating room.
Constance O. Okeke, MD, MSCE, is the lead glaucoma specialist at Virginia Eye Consultants.
Be comfortable with a procedure
The introduction of MIGS to our glaucoma armamentarium has made this an exciting time, but along with any new procedure that we do, we need to make sure that we give it enough time. We have to have enough cases to properly assess them in our own hands to determine which of them do better and which of them do not do quite as well.
As we can see with our prior older glaucoma surgeries, such as trabeculectomies and tube shunts, the outcomes of our patients are best dictated by the comfort level and experience of the physicians themselves.
The good news about MIGS is there is a wealth of options a physician can pick from. However, that can also create an issue. Because there are so many options to choose from, it can be hard to become an expert at every single one.
My recommendation is to practice before you commit. Before making a decision about which MIGS procedure is good in your own hands, make sure you have done enough procedures to make that judgment call. This can be difficult because there are so many procedures to do. There is also a lot of outside pressure to try them all out before you can make a clear decision as to which works in your own hands. Make sure you have done enough with each of them to make that decision on what is the best fit for you and for your patients.
Savak “Sev” Teymoorian, MD, MBA, is an OSN Glaucoma Board Member.
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