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EW FEATURE 48 Glaucoma's armamentarium • August 2018 AT A GLANCE • The combination of MIGS proce- dures gives surgeons more options for treatment for many glaucoma patients. • There are a variety of MIGS com- binations possible; one common approach is an iStent with cataract surgery and ECP. • Reimbursement issues influence which combinations that surgeons choose. • In the near future, glaucoma special- ists will get a better handle on which MIGS procedures are suitable for specific types of glaucoma. by Vanessa Caceres EyeWorld Contributing Writer makes sense), glaucoma severity, and disease pathophysiology. The use of ECP is common because it's a natural pairing with many MIGS procedures, Dr. Rad- cliffe said. "It can be performed with goniotomy, canaloplasty, and other procedures such as the CyPass Micro-Stent [Alcon, Fort Worth, Texas] and even the XEN Gel Stent [Allergan, Dublin, Ireland]," he said. "Similarly, MicroPulse laser cyclo- photocoagulation can be paired with any of these." One caution he shared is that he might not pair MicroPulse with the CyPass because you could induce some inflamma- tion in the ciliary body and possibly the choroid, which could lead to a little more ciliary effusion. "It's a theoretical concern, but it's not an unreasonable one. With ECP, you're just targeting the anterior ciliary processes." Another example of an effec- tive combination for Dr. Sarkisian has been the Omni Combined Procedure System (Sight Sciences, Menlo Park, California) along with the CyPass. He said this has led to consistently lower IOP. The combination of procedures that target different areas—such as supraciliary and trabecular—give surgeons options in case one ap- proach does not work, Dr. Radcliffe said. "You only go into the eye a series of patients who have had the iStent with ECP. In Dr. Kim's analysis of 56 of his patients who have had combined MIGS procedures in various forms, he has found safety comparable to isolated MIGS procedures. Only two patients had IOP spikes that were unresponsive to medical therapy and required traditional glauco- ma filtration surgery. Among the 56 patients, there was one patient each with a transient wound leak, transient hypotony lasting 2 weeks, transient iritis, cystoid macular edema, and retinal detachment. Dr. Kim also said the patients have had solid efficacy, with an average IOP of 12.2 mm Hg on two medications at the last follow-up period. Brian Francis, MD, professor of clinical ophthalmology, Doheny Eye Institute, David Geffen School of Medicine, UCLA, Los Angeles, has tried several MIGS combinations, including the Trabectome (NeoMe- dix, Tustin, California) with ECP and MicroPulse (Iridex, Mountain View, California). He now usually does MicroPulse along with the Trabectome. "I've gotten pressures in the lower teens versus in the mid-teens with Trabectome alone," he said. Factors he considers when combining procedures include target pressure (if it's below what you might get with a single proce- dure, then a combination procedure Common MIGS combinations Surgeons shared details and results on several of the MIGS combina- tions that they use, although this is not an exhaustive list. One common combination is the use of an iStent (Glaukos, Laguna Hills, California), cataract surgery, and endocyclophotocoagu- lation (ECP), said Nathan Radcliffe, MD, assistant professor of ophthal- mology, Icahn School of Medicine at Mount Sinai, New York. He and several other surgeons began to take this approach after the iStent was approved by the U.S. Food and Drug Administration (FDA) in 2012. "This was a nice procedure because it gave us a dual or even triple mechanism. The cataract surgery opens the angle a bit, the iStent bypasses the trabecular meshwork, and the ECP decreases aqueous produced," Dr. Radcliffe said. Dr. Radcliffe has seen no long-term issues after following these patients for up to 6 years; many have maintained their IOP reductions. The approach described by Dr. Radcliffe, called ICE for short, also has benefited patients of Steven Sarkisian Jr., MD, clinical professor and glaucoma fellowship director, Dean McGee Eye Institute, Univer- sity of Oklahoma, Oklahoma City. In fact, Drs. Sarkisian, Radcliffe, and other surgeons continue to analyze Surgeons zero in on glaucoma severity, treatment goals, and reimbursement when selecting the right combination T he use of combined micro- invasive glaucoma surgery (MIGS) procedures will continue to expand the treatment options available for most glaucoma patients. "Without question, the long- term and short-term safety ad- vantage over traditional filtration surgery is enormous," said Won Kim, MD, Walter Reed National Military Medical Center, Bethesda, Maryland. "With my experience so far, I am satisfied with its efficacy. The vast majority of my patients who have had combined MIGS are still on medical therapy, but most are achieving IOP in the low teens, which is typically the goal for those with severe field loss and certainly welcome for those with any level of disease." With single and combined MIGS procedures available, only some glaucoma patients—such as those with neovascular glauco- ma, angle closure, or iridocorneal endothelial syndrome—cannot be considered for MIGS, Dr. Kim said. What specific MIGS procedures are surgeons combining right now, and how effective are they? MIGS combinations expand surgical options for glaucoma patients Figure 1. Trab 360 handpiece is used to perform GATT, which is followed by ECP.

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