Surgeons should be skilled in gonioscopy for MIGS
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A good understanding of gonioscopy is a prerequisite to approach minimally invasive glaucoma surgery, according to a specialist speaking at Real World Ophthalmology.
“People get into trouble because they are not rotating the head away from them enough. As you start to rotate toward you, the perceived distance between tissue planes — trabecular meshwork, scleral spur and ciliary body — becomes smaller. You start to lose your view, and you might end up doing surgery or placing devices in the wrong tissue plane. If you are not where you want to be as far as your view goes, you need to rotate the head farther away from you,” Arsham Sheybani, MD, said.
A good view of Schlemm’s canal will show that this part of the anatomy has distinct planes.
“If you place a MIGS device in the wrong plane, it will not work well. Take time to make sure you are in the right area within the canal,” he said.
When MIGS is combined with cataract surgery, the angle procedure is better performed first, according to Sheybani. Visualization will be better, and in case of complications, such as vitreous loss, the risk and consequences of postoperative IOP spikes will be reduced.
“There is also a psychological component that comes into play. While you are doing cataract surgery, you may be nervous waiting for the angle surgery to come up. So, better get it out of the way and then proceed with your phaco,” Sheybani said.
During irrigation and aspiration, the blood will be removed, and the chance of reflux and resultant hyphema will be minimized.
“Manage blood so that it doesn’t go posterior to the iris,” he said.
There are many MIGS procedures, but there is no need to learn them all.
“Have one angle surgery in your armamentarium, stent or stripping/cutting. Maybe add one subconjunctival device for advanced cases with higher pressure, but you don’t need to know them all,” Sheybani said.
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Sheybani A. MIGS in the real world. Presented at: Real World Ophthalmology; April 2, 2022 (virtual meeting).
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