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EW FEATURE 42 Glaucoma's armamentarium • August 2018 by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor AT A GLANCE • MIGS procedures could potentially help surgeons cut back on their use of traditional glaucoma surgeries. • MIGS procedures don't have some of the risks of traditional glaucoma surgeries, but this should be weighed against the effectiveness of the procedure. Sometimes a trabeculectomy is still necessary when lower pressure is needed. • MIGS procedures could have potential in patients with a previous traditional glaucoma surgery that has failed. she did a XEN, and these patients did even better in terms of visual recovery. Dr. Moster noted that in cases where there is not a lot of disease, it's not appropriate to take a lot of risk; therefore, the iStent is some- thing that she relies on in these mild cases. If there's more moderate glau- coma, she will often use a CyPass or GATT, along with cataract surgery. Meanwhile, if the goal is to lower pressure for a patient who has a thin conjunctiva or a myope, she will consider a XEN, and she hopes the InnFocus MicroShunt will be approved soon. When asked if there's a type of glaucoma that has remained "untouchable" by MIGS, Dr. Trubnik said that she wouldn't use that term. "I don't think anything is untouch- able," she said. However, for uveitic patients, she doesn't use options like the CyPass or iStent because she's concerned about clogging of the stent with fibrin or white blood cells or inflammatory cells. Dr. Trubnik Dr. Trubnik thinks the XEN is safer than a trabeculectomy, and she said that the bleb is not as ischemic. "I think that the risk of infection from bleb leak is less likely with XEN than with traditional trabe- culectomy," she said. As far as the CyPass, Dr. Trubnik said she doesn't have a lot of experi- ence with it, and she has been wary about trying it because of reports of late myopic shift and hypotony. "That's concerning to me—taking a patient with good central VA and promising a less invasive surgery," she said. Potential for myopic shift, even if a rare complication, is concerning to her, as is the fact that there could be sudden IOP spikes with it. Patient selection Dr. Trubnik said that in all of her pa- tients, even moderate and advanced cases, she's transitioning the tradi- tional procedures to XEN Gel Stents. She's had multiple patients where she did a trabeculectomy before the XEN was covered by Medicare. They did well, but for the second eye, Dr. Moster agreed that she has cut back on the number of tradi- tional glaucoma surgeries she does. "With the available MIGS, we've been able to cut down the triple procedures," Dr. Moster said. "Where before we had mostly tubes and trabs, now we can operate soon- er with decreased risk." Dr. Moster said she is currently using the XEN, the iStent, the KDB, the CyPass, and gonioscopy-assisted transluminal trabeculotomy (GATT), and she will be trying the Omni Combined Procedure System (Sight Sciences, Menlo Park, California). She also has experience using the InnFocus MicroShunt (Santen, Osaka, Japan) in clinical study. "The best part of the MIGS space is that the conjunctiva is preserved, so a trabeculectomy is always an op- tion," Dr. Moster said. Balance of safety and efficacy Dr. Moster thinks that MIGS proce- dures are a safer option compared to traditional glaucoma surgeries. "They are being extensively studied, giving us a better understanding of their limitations and side effects," she said. "We can now pick and choose which MIGS device is best to use for which patients." Dr. Moster added that it's important that the surgery balance the degree of damage. "With tubes and trabs, there are increased risks including hypotony, bleeding, suprachoroidal hemorrhage, and flat chambers," she said. If the patient needs a lower pressure and there's no other way to get it without these risks, they are worth taking. "But in mild to moderate glaucoma, if we can avoid these standard risks, this is certainly an advantage," she said. "We are still doing a lot of trabs and tubes but no longer in everyone." "I think the XEN is a safer option, and I think visual recovery is faster," Dr. Trubnik said, adding that she's more likely to use it with a toric IOL. "I used to do toric with combined trabeculectomy/cataract surgeries," she said. However, Dr. Trubnik is now more likely to use the XEN in these cases because she finds less trampolining of the ante- rior chamber and less likelihood of hypotony. "I think it's a better op- tion for patients with good central visual acuity," she said. Experts discuss how MIGS may decrease the role of traditional glaucoma procedures W ith MIGS procedures expanding and the utility of new devices being explored, glau- coma surgeons now have a variety of options for the en- tire spectrum of glaucoma. Valerie Trubnik, MD, Ophthalmic Consul- tants of Long Island, Lynbrook, New York, and Marlene Moster, MD, Wills Eye Hospital, Philadelphia, dis- cussed how this has changed their practice and the different procedures that they use. Reducing traditional glaucoma surgeries Dr. Trubnik said she has been able to cut back on the number of tradition- al glaucoma surgeries she performs, and she has recently transitioned most of her trabeculectomies to the XEN Gel Stent (Allergan, Dublin, Ire- land) procedure. She noted that her use of tubes has stayed relatively the same because she generally reserves this option for someone with a failed trabeculectomy or XEN stent. In her practice, Dr. Trubnik uses the iStent (Glaukos, San Clemente, California), endoscopic cyclophoto- coagulation (ECP), the Kahook Dual Blade (KDB, New World Medical, Rancho Cucamonga, California), the XEN, and the CyPass (Alcon, Fort Worth, Texas). MIGS in relation to traditional glaucoma surgery InnFocus MicroShunt 1 year after placement; IOP is 14 mm Hg on no medications; preop IOP was 26 mm Hg on three medications Source: Marlene Moster, MD

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