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G Contact Herndon: leon.herndon@duke.edu tubes. MIGS, in more recent years, has also taken up some of this space, Dr. Herndon added. "It depends on your practice. My practice is typically a very advanced glaucoma practice, and these aren't the types of patients you are going to be doing MIGS on and in some cas- es tubes. If you need pressures in the single digits, there is only one way you're going to get there—trabeculectomy," he said. "I think nationwide the numbers are going down with trabeculectomy, but I think there are several pockets in the country where providers see a lot of advanced glaucoma, and you still need to do a trabeculectomy. I think any glaucoma surgeon in his or her practice can't get away from severe glaucoma, and the concern is that if you're not training and getting your fingers wet doing trab- eculectomy, once you get out in practice, you're going to do a disservice to patients with severe disease if you do [a MIGS] because it's the only thing you know how to do." Dr. Herndon reiterated that he's a believer in doing fewer trabeculectomies, but "there are patients who clearly need a trabeculectomy, and they might not be getting the care they need in the next 10–15 years." Dr. Herndon said a "cataract cowboy or cowgirl" is not likely going to do trabs, leaving the procedure within the purview of glaucoma trained surgeons or comprehensive ophthal- mologists who don't otherwise have glaucoma specialists nearby. MIGS, Dr. Herndon contin- ued, are mainly indicated for mild to moderate disease. If the glaucoma is more advanced, performing a MIGS procedure rather than a filtering procedure, which can achieve lower pressures, could be a disservice to the patient. If patients truly have severe disease and need significant pressure lowering, Dr. Herndon's message is: If you can't do a trab- eculectomy and its postop management, it's important to refer. "Trabeculectomy is not dead. It's a sight-saving procedure, and if someone isn't comfortable doing it, please find someone who is," he said. In terms of when he, as a surgeon trained in filtering procedures, is comfortable returning a patient to a referring physician for care post-tra- beculectomy, that's generally after 2 months. Trabeculectomy flap being created Source: Leon Herndon, MD "Ideally, I like to make sure pressures are well controlled and the bleb is functioning fine, and many of my patients are referred in from glaucoma specialists who know how to handle this postop period. The most crucial period of time is the first 2 months. I like to get them through that time, then I am comfortable refer- ring them back," he said. Dr. Herndon said that glaucoma is a prac- tice that builds over time with long-term patient relationships. He knows he can't hold on to all of his patients, and this is why he thinks it's important for more ophthalmologists to get comfortable handling the common postop issues that these patients might face. The two main complications are pressures being too low or too high. As a takeaway, Dr. Herndon said to not be scared of trabeculectomy. "[Trabeculectomy] requires a lot of follow up. It's not a money maker in many cases," he said. "But it's what's in the best interest of the patient in saving sight. Don't be afraid to consider trabeculectomy if there is no one in the near vicinity who can do it for the patient. You have to put the patient first and strive to get low pressures for these more severe patients." SEPTEMBER 2022 | EYEWORLD | 81

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