Eyeworld

9 EW ASCRS NEWS August 2018 World view New options, new opportunities G laucoma is a challenging disease. Tra- ditionally, we have suffered alongside our patients with a paucity of options to treat this progressive and debilitat- ing disease. Fortunately, many new options have arrived since the U.S. Food and Drug Ad- ministration approved the first MIGS device (iStent, Glaukos, San Clemente, California) in 2012. Since that time, an unprecedented interest in innovation and investment in the field of glaucoma has delivered a tremendous number of safe and innovative treatments for glaucoma. In this issue of EyeWorld, we learn how to maximize our use of many new MIGS surgeries. First, we need to consider whether MIGS may eventually replace traditional glaucoma surgery. Who better to address this question than Marlene Moster, MD, and Valerie Trubnik, MD. Both agree that as MIGS ramps up, the traditional glaucoma surgeries are decreasing, although they certainly still have a welcome place in glaucoma management. Given that a large number of our glaucoma patients have already undergone cataract extraction, the issue of performing MIGS procedures on pseudophakic eyes is at the top of glaucoma surgeons' minds. How- ever, performing a vision-neutral glaucoma surgery without coupling it with the visual enhancement characteristic of a cataract extraction changes the equation. To provide MIGS procedures on their own, we must truly understand what our glaucoma procedures can offer so that we can prepare our patients and ourselves for success. We reached out to three glaucoma innovators to learn more. Savak Teymoorian, MD, has offered standalone MIGS procedures to his patients but concedes that patient payment responsibility can be an issue. We heard from Richard Lewis, MD, who in many ways led the MIGS movement by pioneering ab externo canaloplasty, a safe and successful standalone procedure. Dr. Lewis said that many patients are highly educated and are coming to him already with an awareness about off-label, standalone MIGS procedures, and that it is his job to deliver what he thinks will be best for the patient. Finally, the versatile Constance Okeke, MD, pointed out that we still need to take a conservative and step-wise approach. As with other glauco- ma topics, the nuances are copious and intriguing. As we begin to stretch the indications of MIGS procedures, we may think about combining trabecular, supraciliary, or subconjunctival approaches. Brian Francis, MD, Steven Sarkisian, MD, Won Kim, MD, and I discuss the nuances of combining MIGS procedures after 6 years of experience. Finally, Dana Wallace, MD, and I discuss the growing number of ways that a surgeon may address aqueous egress obstruction at the level of the trabecular meshwork and the canal of Schlemm. In this article, we dig into the nuances of accessing the traditional outflow pathway and review many of the available technologies. With new options come new opportunities. We thank our contrib- utors for allowing us to enhance our ability to deliver on safe yet effica- cious glaucoma surgery. EW Nathan Radcliffe, MD, Glaucoma editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S August 2018 Vol. 23 • No. 8 Publisher Donald Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Senior Staff Writer Liz Hillman liz@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Berlin, Germany Vanessa Caceres Bradenton, Florida Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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