Eyeworld

I MIGS UPDATE N FOCUS 42 | EYEWORLD | JULY 2019 by Ellen Stodola EyeWorld Senior Staff Writer/ Meetings Editor Contact information Brubaker: jacobbrubaker@me.com Patrianakos: tpatrianakos@yahoo.com Dr. Brubaker also noted that although the CyPass (Alcon) is no longer being implanted, it could be associated with such issues as hypot- ony, myopic shifts, uveitis, and endothelial cell damage. Rare complications such as iridodialysis, cyclodialysis, or Descemet's detachment can oc- cur, Dr. Brubaker said. Descemet's detachment may be seen more commonly with incisional procedures. The trabecular meshwork may be more adherent to the endothelium, he said, and it could detach as you ablate or remove it. It's important to recognize this early and cut it rather than continuing to pull. Though many associated MIGS complica- tions will resolve on their own, Dr. Brubaker said they may need some sort of intervention. If there is cyclodialysis or iridodialysis, that will often need repair, he said. Hyphema will usually resolve on its own. Thomas Patrianakos, MD MIGS in general is meant to be safer and have fewer complications than traditional glauco- ma filtration surgery, Dr. Patrianakos said. He stressed that these procedures are not compli- cation-free, but they don't see complications as frequently. One of the first issues he discussed was gaining familiarity with the procedure. Since they're all relatively new, these procedures are either self-taught or someone from the industry works with surgeons to train them on the prod- uct. Training may also include watching videos. "Being familiar with intraoperative gonios- copy is essential to minimize complications," Dr. Patrianakos said, adding that being familiar with angle structures is also important. To make these procedures safer and have a better target in terms of outcomes, make sure you have a clear view of the angle before proceeding with any of the devices that use gonioscopy, he said. One cause of complications in MIGS procedures is blood reflux. "If your view is not crystal clear, then you're not going to be able to perform the procedure correctly," he said. T hough MIGS is generally considered safer than traditional glaucoma pro- cedures, complications can still occur. Two surgeons discussed potential complications, how to speak to pa- tients about them, and how to remedy these situations. Jacob Brubaker, MD One point that Dr. Brubaker said he is sure to mention to patients is that sometimes these de- vices are not effective for some people. It's im- portant to make sure patients are aware upfront that the collector systems may not function in a particular individual. "We're not aware of that until we're doing surgery," he said. As a result, a common "complication" may be that it's just less efficacious in some patients. Dr. Brubaker said that one of the most common surgical complications that can occur is bleeding. This is more likely with trabecular bypass ablating procedures. In procedures like the Kahook Dual Blade (KDB, New World Medical) or gonioscopy-as- sisted transluminal trabeculotomy (GATT) or OMNI Glaucoma Treatment System (Sight Sciences), there is a common hyphema risk, he said. Depending on how much you excise, with KDB, you may have around a 5–10% chance that there will be a little hyphema, he said. Dr. Brubaker has seen hyphema in some iStent (Glaukos) cases that may take up to 2–4 weeks to resolve. Complications in MIGS At a glance • Hyphema and blood reflux are two complications that can occur with MIGS procedures. These tend to resolve on their own. • More serious complications can include cyclodialysis or Descemet's detachment. • Other MIGS "complications" could be connected to gaining familiarity with the procedures or the devices being less efficacious in some patients. "While each MIGS has its own possible complications, we as surgeons continue to modify our technique to minimize these and to better manage them when they arise." —Thomas Patrianakos, MD

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