This article is more than 5 years old. Information may no longer be current.
Surgeon recommends ODs keep MIGS referrals ‘general’
ORLANDO, Fla. – Optometrists should know the available options for minimally invasive glaucoma surgery and their mechanisms of action, but they should not recommend a specific procedure to a patient when making a surgical referral, Constance O. Okeke, MD, MSCE, said here at the Optometric Glaucoma Society meeting, held prior to the American Academy of Optometry meeting.
Okeke, assistant professor of ophthalmology at Eastern Virginia Medical School and a glaucoma specialist and cataract surgeon with Virginia Eye Consultants, urged optometrists to perfect their gonioscopy skills, understand the minimally invasive glaucoma surgery (MIGS) techniques and look for ideal patients.
Such patients would need a pressure reduction of 20% to 30%, she said, need to reduce the number of medications, have open and normal angles and mild to moderate open-angle glaucoma, and be noncompliant or intolerant to medications.
Okeke said to consider: “Is the patient stable? Do they have a visually significant cataract? Are they noncompliant and progressing? Have they had selective laser trabeculoplasty?”
She said to avoid patients with significant synechial angle closure, active neovascularization, plateau iris, angle recession, trauma or a severely opacified cornea.
“Once you’ve established the patient is a good candidate, look for doctors who do those procedures and refer,” she said.
“There are different patients for different procedures,” Okeke continued. “We talk about areas of resistance – it might be mainly in the trabecular meshwork but is sometimes in Schlemm’s canal, sometimes you don’t know. We look at the anatomy to help us decide. If there’s a lot of peripheral anterior synechiae (PAS) formation, one can use certain devices to do lysis.”
Practical challenges also exist, she said, such as what the patient’s insurance covers.
“Some of these procedures have to be done in conjunction with cataract surgery,” Okeke said, “and others can be standalone. Some facilities will limit you on what you can do there. Be ‘MIGS general’ when you send a patient to the surgeon.”
Okeke reviewed the various available procedures and their mechanisms of action. She also reviewed postoperative considerations.
Comanaging optometrists can expect to see slightly blurry vision, a clear cornea and anterior chamber with 1 to 2+ cells, and a microhyphema or scattered heme.
“IOP is typically low,” Okeke said. “If it is elevated, then we burp the wound.”
Patients should be advised to do no heavy lifting or bending, use a shield at night and refrain from using blood thinners for 3 days. Postoperative medications include a steroid, nonsteroidal anti-inflammatory agent and an antibiotic.
“If a patient has a propensity for PAS, they’re put on pilocarpine to keep the angle tissues apart,” she said. “If they’re a known steroid responder, adjust to a low-dose steroid such as loteprednol. I stop any prostaglandins (they slow the inflammatory process), but I continue all other glaucoma medications.”
Follow-up is 1 day postoperative then at 3 weeks if there are no issues. – by Nancy Hemphill, ELS, FAAO
Reference:
Okeke CO. MIGS – What is available and how do we choose? Presented at: Optometric Glaucoma Society meeting; Orlando, Fla.; October 22, 2019.
Disclosure: Okeke reported she is a consultant and speaker for Aerie, Alcon and Bausch + Lomb; a consultant for Allergan, Novartis, Reichert, Santen and Sight Sciences; a speaker for Ellex; a researcher, speaker and consultant for Glaukos; and a trainer and speaker for NeoMedix.