BLOG: MIGS was born in a developing nation
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The widespread adoption of microinvasive glaucoma surgery has been one of the most exciting developments in ophthalmology in the past 10 years.
The lower morbidity allows earlier surgical intervention against glaucoma than previous surgical techniques. In the cover story of this issue of Healio | OSN, we explore how MIGS procedures are now being taught in developing nations, where patients can scarcely afford drops and surgical follow-up for other procedures is challenging. Ironically, MIGS was born in a developing nation in a rarely told story about a young ophthalmologist from Southern California named Richard Hill.
I’ve had the pleasure of knowing Rick Hill as a close friend through dozens of trips we have taken together to Armenia. We’ve had countless harrowing adventures, from depressurization of an ancient Russian aircraft during travel to power outages during surgery in the middle of the night. With a little coaxing, Rick told me this story.
In the mid-’90s, Rick was a young glaucoma faculty member at the University of California, Irvine, Department of Ophthalmology. He had first visited Armenia, a country of 3 million in the Caucasus, at the urging of Roger Ohanesian, who founded the group now known as the Armenian EyeCare Project, which was honored with the Chang-Crandall Humanitarian Award in 2022 by the ASCRS Foundation. Rick noted with regret the limited affordability of drops and challenging environment for surgical success with trabeculectomies and tube shunts in Armenia. He dreamed about a better solution for people with glaucoma.
Around the same time, as part of his faculty duties, Rick attended a meeting at the NIH to review Small Business Innovation Research grants. One grant centered on laser coronary angioplasty and its frequent failures. It led Rick to consider creating a stent that could address another area of abnormal flow — the trabecular meshwork (TM) of the eye. Previously, openings in the TM were disregarded as ineffective for adult glaucoma because they were thought to overgrow with tissue and fail.
Rick learned, through 3 a.m. visits to the microsurgery lab at UCI, that indeed the potential space of Schlemm’s canal could be cannulated by an internal approach. The problem then was how to create a stent small enough for this tiny area. He partnered with serial entrepreneur Olav Bergheim, whom he met through a patient, to create Glaukos in 1998. The third founder, Morteza Gharib, a Caltech engineering wizard, showed how the device could be made to tolerances of 3 µm to 5 µm. In less than a year, Rick and Glaukos engineer David Haffner achieved the first in-human trials.
Although the earliest human testing of the iStent was performed in the Dominican Republic, Mexico, Germany and Spain, clinical trials eventually found their way back to Armenia, where Rick was still making twice-yearly volunteer trips. Armenia had abundant disease, highly educated doctors, and a low-cost and willing institution, Malayan Ophthalmological Center. The same institution was also home to Lilit Voskanyan, a brilliant young glaucoma specialist who had completed her fellowship training with Rick at UCI. Voskanyan shepherded the iStent through its early trials. Her surgical skill, her personal commitment to patients and her staff’s dedication are as responsible for the success of MIGS as any other factor. In fact, Voskanyan’s early data favored iStent so strongly that their validity was questioned when they couldn’t be replicated in the U.S. in early trials. Only years later, under the extraordinary and enduring leadership of CEO Tom Burns, did more study and more experience with gonioscopic surgery yield similar positive outcomes and create the category of MIGS.
The rest of the MIGS story is well known to most of us — more innovation, more companies and more approaches. Drug delivery has come along with the approvals of Durysta (bimatoprost intracameral implant, Allergan) and iDose TR (travoprost intracameral implant, Glaukos), and both femtosecond and excimer lasers will soon be available. It’s both exciting and ironic that MIGS is now returning to the parts of the world where it began — in dimly lit ORs where the hardest-working doctors battle not just disease but severe poverty.
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