Eyeworld

EW GLAUCOMA 36 November 2018 the safety and efficacy with what the patient wants." In terms of skills, Dr. Shah said once you have the intraoperative gonioscopy skillset, it can be applied broadly to almost all MIGS devices and techniques. Most of the chal- lenges with these procedures, he added, come with aspects of intra- operative gonioscopy, not the MIGS device or insertion procedure itself. Now is the time, early in one's practice, to establish this new skill- set, Dr. Shah said. "Glaucoma is everyone's prob- lem. Whether you are cornea, retina, or comprehensive, you are going to see and manage glaucoma in your practice," he said. "At the very least, it's all of our responsibilities as eye care providers to have an awareness. In terms of actual utilization and implementation, I think it's individ- ual in whether you want to jump in." Dr. Greenwood said he thinks MIGS is here to stay, making a huge quality of life impact for patients, and it's something he thinks cata- ract surgeons need to know how to do. "If you're not performing MIGS and a patient has glaucoma, pa- tients should know that MIGS is an option. Your job as a surgeon should be to get these patients to someone who does it. You'd be doing a big disservice not to," Dr. Greenwood said. EW Editors' note: Dr. Greenwood has finan- cial interests with Alcon (Fort Worth, Texas), Equinox (Sioux Falls, South Dakota), Glaukos, New World Medical (Rancho Cucamonga, California), and Staar (Monrovia, California). Dr. Shah has financial interests with Glaukos and Allergan (Dublin, Ireland). Dr. Lewis has financial interests with Aerie Pharmaceuticals (Durham, North Car- olina), Alcon, Allergan, AVS (Goleta, California), Glaukos, Ivantis (Irvine, California), Sight Sciences (Menlo Park, California), Kedallion (Palo Alto, Cal- ifornia), and MicroOptx (Maple Grove, Minnesota). Contact information Greenwood: michael.greenwood@vancethompsonvision. com Lewis: rlewiseyemd@yahoo.com Shah: manjool@med.umich.edu After you're comfortable with that, it's time to start practicing intraoperative gonioscopy. "Surgical gonioscopy is a unique skillset. Once you have comfort with the landmarks, in general, then you want to try applying them in the operating room," Dr. Shah said. "Achieving a good surgical intraop- erative gonio view can be challeng- ing. Having seen trainees struggle with some of the MIGS techniques and devices, the struggle is not with the device itself; it's due to an inabil- ity to achieve a good view. "To get that view, you have to be light with your hands, you have to tilt the head of the patient, you've got to tilt the microscope, you've got to position your chair. It's by no means impossible, but it is something that is often a limiting factor when starting off." For Dr. Greenwood, turning the patient's head 30 degrees and tilting the microscope about 30 degrees is a good place to start. Viscoelastic should be placed on the eye before setting the gonioprism, he noted. In addition to the setup of intraopera- tive gonioscopy being different than in the clinic, Dr. Greenwood said it is direct gonioscopy, whereas in the clinic, it is indirect, giving a slightly different view. Practicing intraoper- ative gonioscopy also allows you to get comfortable using your non- dominant hand to view the angle. Once you're comfortable with intraoperative gonioscopy, in gen- eral, Dr. Greenwood and Dr. Lewis suggested adding an instrument in your dominant hand. "Take a straight instrument, a straight Sinskey or a 27-gauge can- nula that you've straightened out on a [balanced salt solution] syringe, learn how to keep your gonioprism on the eye and go in and out of your cataract incision. Learn how patients behave and what you need to do to get that comfortable view," Dr. Greenwood said. "Once you're comfortable with that, you can take that same instrument and you don't want to touch anything, but go through the motion of moving those instruments within the eye." Next comes the task of choos- ing a MIGS procedure to start with. Both Dr. Greenwood and Dr. Shah said you should pick one to focus on before adding others to your repertoire. "It's dependent on your com- fort level as a surgeon, your level of comfort managing the broader picture, and what kind of patients you're hoping to take care of and treat with this sort of growth in your practice," Dr. Shah said. Dr. Shah tends to favor Schlemm's canal-based surgical tech- niques as a safe introduction to the MIGS family. "There is a physiologic safety net and there are a number of options, either with microstents or microincisions, that allow surgeons to reach a broad segment of pa- tients." Dr. Greenwood said MIGS that target the trabecular meshwork are generally a good starting point be- cause of the low risk for hypotony. "You've got your safety net with the backstop of episcleral venous pressure," he said. Dr. Greenwood thinks MIGS are good for almost any patient who has uncontrolled glaucoma. "There are MIGS devices you can use in very advanced, very severe glaucoma that can hopeful- ly eliminate or hold off the need for a tube or trab for a few years," Dr. Greenwood said, adding that exceptions for MIGS devices in- clude patients with neovascular or pro-inflammatory glaucoma, such as uveitic glaucoma. Dr. Lewis said he would avoid MIGS in patients on anticoagulants or with vessels in the angle. After you have experience with various MIGS devices comes what Dr. Greenwood said is the most common question he gets from staff and industry: How do you decide which device to use? "We have a whole bunch of tools in our toolbox and our job as surgeons is to decide what is the best technology to fit to this patient, rather than forcing them into one certain technology," he said. As Dr. Shah put it, "we are blessed now in this time and in this country with a number of devices, a number of options, that we will con- tinue to refine and figure out which patients are best suited for what." Some decisions might be based on a patient's insurance coverage, the patient's level of disease, and even constraints from one's prac- tice, Dr. Shah said. In general, Dr. Greenwood said each surgeon has their own internal algorithm for deciding what MIGS to perform with what patient, but, he added, "it boils down to how do you balance Getting continued from page 34 Dr. Greenwood demonstrates how he tilts his microscope. Source: Michael Greenwood, MD

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