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MIGS will change the face of glaucoma management
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Google “will stents replace bypass surgery?” and within 0.53 seconds you’ll have more than 450,000 results. This is pretty amazing when you consider it’s been more than 30 years since Sigwart and colleagues deployed the first coronary artery stent as a scaffold during transluminal angioplasty in an attempt to prevent restenosis.
One would think 30 years later we’d have the definitive answer on whether stenting will replace coronary artery bypass (CABG) surgery.
Prior to the introduction of coronary artery stenting, cardiology faced much the same challenges we face today in managing glaucoma. They knew medications to be a viable consideration early in the course of coronary artery disease (CAD), but things like cost, compliance, side effects and diminished efficacy (in the face of worsening disease) were very real limitations. They also knew, on the other end of the treatment spectrum, CABG offered tremendous upside, but not without significant surgical risk and potential long-term failure.
What cardiology lacked was something in between. That something came in the form of percutaneous coronary intervention with arterial stenting. What has transpired since has been a concerted effort to define just where stenting falls within the treatment paradigm. Surgical skills have improved, stents have evolved (think drug eluting), and the cardiology community has a much better sense of which patients derive the greatest benefit from stenting (think SYNTAX scoring). The bottom line is that many variables play into the decision as to who gets medicine, stenting or CABG.
In many respects, the eye care community is witnessing a similar paradigm shift. Micro-invasive glaucoma surgeries (MIGS) are ushering in a new era in glaucoma management. Like cardiology, we are very much aware of the limitations of medical management, namely: cost, compliance and side effects. Even more so, we worry about the shortcomings of interval dosing as it relates to flattening diurnal curves and providing 24-hour IOP control. Arguably, MIGS addresses many of these shortcomings.
Like cardiology, we also strive to align each patient with the most appropriate treatment. With so many MIGS options emerging, we are just getting a sense of which technology is best suited for a given patient. As each procedure targets a specific anatomical zone, it will likely take time to sort this all out. Like cardiology, we won’t want to dismiss our tried-and-true procedures such as tube shunts and trabeculectomy. While higher risk, these options remain the gold standard for IOP reduction.
As primary eye care doctors, optometrists will play a critical role in the evolution of MIGS. Our understanding of these technologies, the applicability of each to any given patient and evidence of long-term safety and efficacy will largely play out in optometric practices. This month’s feature article, “MIGS provides early, effective glaucoma treatment”, is devoted to this emerging discipline. Our contributors, all of whom possess a wealth of knowledge and experience, provide a comprehensive overview. While each offers a slightly different perspective, they are all of the opinion that MIGS will ultimately change the face of glaucoma management.