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EW GLAUCOMA 34 November 2018 YES connect by Liz Hillman EyeWorld Senior Staff Writer tives. Likewise, those still in resi- dency are being exposed to them in similar settings, but Dr. Greenwood said there is probably more being taught in training than just a few years ago. "The momentum is building a little bit. The education had come in PowerPoint form for the last couple of years, and now it's starting to be- come more and more of a hands-on thing," he said. That said, both Dr. Greenwood and Manjool Shah, MD, clinical as- sistant professor, Kellogg Eye Center, University of Michigan, Ann Arbor, think training programs still have yet to fully catch up. "I think the community is rec- ognizing that this class of interven- tional glaucoma is here to stay," said Dr. Shah, who received very little exposure to MIGS in residency but had the opportunity to learn more in a fellowship with Iqbal "Ike" Ahmed, MD. He added later that he thinks "we're going to continue to see more and more exposure for resi- dents, but it's a slow transition." So with those in residency still receiving limited exposure to MIGS, how should one in training or newer in practice step into the MIGS sphere? In terms of formal training, both Dr. Greenwood and Dr. Shah said wet labs are often held at meet- ings around the country. Richard Lewis, MD, Sacramento Eye Consul- tants, Sacramento, California, said interested ophthalmologists should contact companies about resident training. "They would love to get res- idents trained and involved," he said. "After that, consider a mini-fel- lowship with a glaucoma specialist." Dr. Greenwood also encouraged contacting industry representatives for training and said observing a trusted colleague as they perform their procedures is helpful as well. When you're ready to get start- ed with any MIGS procedure, you first have to be comfortable with angle anatomy. "Dust off that goniolens in your pocket, if you have it still, and use it a lot with your patients [in clinic]," Dr. Shah said. Dr. Greenwood said perform- ing gonioscopy in clinic, which is recommended and is reimbursable for glaucoma patients, allows you to see what is normal and what the different variances are. Getting on board with MIGS The iStent inject Source: Michael Greenwood, MD How to get up to snuff with MIGS when you've had little exposure in training "I feel like I'm growing up with MIGS." That's the perspective of Michael Greenwood, MD, Vance Thompson Vision, Fargo, North Dakota, and it's likely the sentiment of many others as well. As a resident from 2012–2015, Dr. Greenwood had minimal ex- posure to microinvasive glaucoma surgery (MIGS). The iStent (Glaukos, San Clemente, California) had only just received approval from the U.S. Food and Drug Administration, so his exposure to MIGS mostly con- sisted of this device. He got more exposure during fellowship with John Berdahl, MD, and has since adopted all MIGS devices as they become available on the market. Established surgeons and those still in training are almost in the same boat with many MIGS options becoming approved within the last few years. Established surgeons are learning about them at ophthalmol- ogy meetings, participating in wet labs, observing their colleagues, and working with industry representa- continued on page 36 W ith the aging U.S. population, both cataracts and glaucoma are increasing in prevalence. Until recently, when patients had both diseases, the option was to perform cataract surgery alone if the glaucoma was mild, or combine cataract surgery with a trabeculectomy or tube shunt if the glaucoma was severe. Patients had nothing beyond the potential IOP improvement with cataract surgery alone, or they were put at risk for the many short- and long-term complications of those procedures. While there is no doubt that many patients still need a full thickness procedure, with the ever-expanding portfolio of microinvasive glaucoma surgery (MIGS) options, we have the potential to improve the control for many patients without many of the risks associated with traditional filtering procedures. In this month's "YES connect" column, Michael Greenwood, MD, Richard Lewis, MD, and Manjool Shah, MD, discuss how to incorporate MIGS into your practice. The most crucial aspects of MIGS procedures are good clinical and surgical gonioscopy skills and a solid understanding of angle anatomy and landmarks. These should be honed before proceeding to the full procedure in your patients. Begin with patients with clear corneas and clear landmarks until you are comfortable with the process. David Crandall, MD, YES connect co-editor

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