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MIGS and Cataract Surgery for Glaucoma
Dr Rhee: Did you hear any updates about MIGS procedures? What was your perception from this meeting?
Dr Patel: MIGS has definitely been the talk at a lot of these meetings. They did a great review of the available procedures, including the iStent (Glaukos; Laguna Hills, California), which is now available for use in the United States. There is a learning curve, and people are becoming more familiar with these surgical techniques that are based on angle-based surgery. In the future, there will be even more data on its success and the various complications, as well as more procedures that are available. It is a good start.
Dr Rhee: I had the same impression. There was great information about our US Food and Drug Administration-approved procedures and devices, which include the Trabectome® (NeoMedix; Tustin, California), or ab interno trabeculectomy. for removal of trabecular meshwork tissue. There was also the use of the iStent in conjunction with cataract surgery to lower pressure. It was great to hear how some of the procedures and devices that are still in evolution are coming along, including the Hydrus™ (Ivantis; Irvine, California) and the suprachoroidal stents from Transcend and Glaukos.The field appears to be coming along with these newer devices, which is nice to see.
I would like to ask something else that is especially salient to the comprehensive ophthalmologist. Cataract surgery as an intraocular pressure (IOP)-lowering procedure seems to be gathering more evidence. What do you think, and what are your impressions from the meeting about it?
Dr Patel: When data on the MIGS procedures are presented, that point comes up. Where is most of the IOP drop coming from? Is it from cataract surgery alone? Is it from the combination, or is it from the MIGS procedure?
We have more data, and more people are looking at evidence that cataract surgery alone leads to a significant drop in IOP that persists for years after surgery. Using that as a glaucoma treatment is a very legitimate technique, and we may have to do a combined procedure much less frequently. I would need a patient with significantly increased IOP or very advanced glaucoma in whom I am worried about snuffing the nerve from the cataract procedure alone before I would do a combined procedure.
Dr Rhee: I tend to approach it a little bit more algorithmically. The indications for adding a filtration procedure are the same ones that I use, but I also consider doing a filtration procedure (MIGS or a trabeculectomy) if the patient is well controlled but has advanced disease. The risk for an IOP spike is actually fairly low if a modest number of medications are being used for the patient. However, if the patient is on three or four medications, then the risk for a pressure spike is significant. In that case, I will add a filtration procedure.
It has been great to talk with you, Dr Patel, about this year's meeting. Thank you for sharing your insights with me and with Medscape Ophthalmology.
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