OSN Associate Medical Editors discuss key innovations of 2010s
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To celebrate the 40th anniversary of Healio/Ocular Surgery News, the Associate Medical Editors are sharing what they think are the most important ophthalmic innovations of the 2010s.
MIGS procedures
Leon W. Herndon Jr., MD: Today I cringe when I see a patient with mild glaucoma on whom I performed trabeculectomy 20+ years ago. We simply did not have a lot of other options then for the surgical management of these patients other than filtration surgery and glaucoma drainage device surgery. When all you had was a hammer, every surgical glaucoma eye looked like a nail.
In recent years, a push has been made for alternative surgical approaches to lower IOP that reduce the need for glaucoma medications and some of the serious risks associated with traditional glaucoma procedures, such as the risk for hypotony, choroidal effusion, hemorrhage, tube exposure, bleb leaks, blebitis and endophthalmitis. Collectively, this class of procedures is known as microinvasive or minimally invasive glaucoma surgery. Saheb and Ahmed first described the characteristics of microinvasive surgery in 2012 to include an ab interno surgical approach, minimally traumatic to target tissue and at least modest efficacy with quick postoperative recovery. While the iStent (Glaukos) was not the first microinvasive procedure, it led to rapid expansion of the field after the publication of the randomized controlled trial that assessed the safety and efficacy of the iStent in combination with cataract surgery in subjects with mild to moderate open-angle glaucoma.
MIGS presents a breakthrough opportunity for glaucoma surgeons to achieve lower IOP and reduce medication burden without the risks and occasionally difficult postoperative course of traditional glaucoma surgeries. Medicare data demonstrate a significant trend toward MIGS over traditional incisional glaucoma surgeries. In 2017 alone, 174,788 glaucoma surgeries were performed. Of these surgeries, 75.5% were MIGS. It is great that we have options that are not cringe-worthy for those patients with milder forms of disease.
- References:
- Ma AK, et al. Clin Ophthalmol. 2020;doi:10.2147/OPTH.S257361.
- Saheb H, et al. Curr Opin Ophthalmol. 2012;doi:10.1097/ICU.0b013e32834ff1e7.
- Samuelson TW, et al. Ophthalmology. 2011;doi:10.1016/j.ophtha.2010.07.007.
Endothelial keratoplasty and another vote for MIGS
John A. Hovanesian, MD, FACS: Eye care is such a wonderful field because it reinvents itself about every 10 years. New technology comes along that changes fundamentally the way we treat patients. In the decade following 2010, both glaucoma and cornea were dramatically changed by the introduction of minimally invasive glaucoma surgery and endothelial keratoplasty, respectively.
MIGS began with the approval of the original iStent (Glaukos) in 2012. I had a front-row seat when it was invented by Rick Hill, my volunteer counterpart in the Armenian EyeCare Project. Facing many disastrous glaucoma cases in Armenia, Rick had the idea to bypass the trabecular meshwork with a novel device. It worked, controlling IOP in so many Armenians who could not afford drops. The FDA trial and many subsequent real-world studies confirmed just how transformative this technology was. This great idea was further validated by many follow-on technologies such as the Hydrus (Ivantis, now Alcon), numerous goniotomy procedures and efforts to dilate Schlemm’s canal.
Posterior lamellar keratoplasty, the precursor to deep lamellar endothelial keratoplasty, was first described by Gerrit Melles in 1998, and just a few of us tried these procedures in the early 2000s. My first DLEK in 2004 was inconsistent and highly technique dependent. Precut tissue did not exist; we created freehand donor discs on an artificial anterior chamber. The evolution to the Descemet’s stripping endothelial keratoplasty technique and the creation of precut tissue by eye banks made Descemet’s stripping automated endothelial keratoplasty a much more consistent and reproducible procedure that was ready for the masses. That it grew to 50% of U.S. transplants by the early 2010s is a testament to its effectiveness and the readiness of corneal surgeons for a better way to treat endothelial disease.
Today, practically any patient with glaucoma or with endothelial corneal disease is a candidate for MIGS or EK, respectively. And thanks to brilliant innovations and a supportive investment community, the future shows much promise for both diseases.
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