Eyeworld

DECEMBER 2022 | EYEWORLD | 87 G Contact Murphy: jamestmurphyiiimd@ gmail.com Razeghinejad: reza@willseye.org Relevant disclosures Murphy: Nova Eye Medical, Sight Sciences Razeghinejad: None less likely for all of them to fail simultaneously," he said. In terms of which procedures might work best together, Dr. Murphy prefers to combine MIGS procedures that target different aspects of aqueous production and outflow. Reducing resistance to outflow at the level of the trabecu- lar meshwork can be performed in several ways, including canaloplasty, goniotomy, and stenting procedures. "Often I will implant a stent in the nasal quadrant and perform a goniotomy in an adjacent quadrant, as well as perform a 360-de- gree canaloplasty," he said. "You're throwing multiple strategies at the conventional outflow pathway to try to jumpstart the system as much as you can." Dr. Razeghinejad said with the CyPass (Alcon), which was voluntarily recalled in 2018, it was easy to combine two different mechanisms of MIGS: conventional and uveo- scleral pathway. "Currently, we do not have any FDA-approved supraciliary MIGS devices, and procedures aimed at the conventional pathway may be used together or with cyclodestructive procedures," he said. For example, he said the OMNI Surgical System (Sight Sciences) may be combined with goniotomy to bypass the trabecular meshwork and dilate the distal outflow. Other trabecular meshwork bypassing procedures could also be combined, such as the Hydrus (Ivantis) and the iStent (Glaukos) or goniotomy. These could be done on different parts of the angle, as the col- lector channels and aqueous veins may not be functioning well in four quadrants. Performing two MIGS procedures on different parts of the conventional pathway may increase the chance of successfully lowering IOP, Dr. Razeghinejad said. Cyclodestructive procedures could also be combined with any of the conventional pathway MIGS, he added. In order to partially mitigate the risk of entering the eye for surgery, Dr. Murphy will perform ab interno MIGS procedures simulta- neously. If one is performing a non-incisional procedure or an ab externo procedure, those are very different risk profiles, he said. "But if I'm going to take on the risk of creating an incision and entering the anterior chamber with instru- mentation, I am compelled to take as many surgical steps as possible to lower IOP for that patient. "In my mind, the main drawback is the additional cost to the healthcare system be- cause these devices are expensive, and if you use more than one, there's no discount. There is negligible change to surgical risk, and if anything, OR time utilization is more efficient when combining MIGS," he continued. "I tend to prefer non-implant MIGS over implant MIGS because while there is good data to support safety and efficacy of implants, they do come with a unique set of risks, and frankly, some patients have an aversion to the word 'implant,' especially if they've had a bad experience with an unrelated implant in the past. When one is discussing surgery to save a patient's vision, I find that they are much less concerned with what the surgery costs and very interested in a spare-no-expense approach." Each MIGS procedure has its own set of risks, Dr. Murphy added. Many of these proce- dures' risk profiles overlap, though not entirely. "You can think of it like a Venn diagram; there may be two or three overlapping circles, but there are always additional risks or an increased risk of one particular adverse event when com- bining procedures. But in my experience, the additive risk is minimal." If one is performing canaloplasty, for ex- ample, there is a fairly low risk of bleeding and hyphema; however, if you add goniotomy to this, as many MIGS devices do, there is a higher risk of bleeding and hyphema, he said. If you perform a stent and goniotomy, there may be a higher risk of implant movement, at the time of surgery or later. If one is using a laser, there are risks associated with additional anesthesia required. While MIGS procedures have a lower risk profile compared to their more invasive counterparts, in Dr. Murphy's opinion, com- bining MIGS does marginally increase risk compared to standalone. In his experience, the added benefits outweigh the risk. Dr. Razeghinejad said to decrease the chance of complications and the cost, combin- ing the MIGS procedures in one session seems to be a reasonable approach. "Because of the continued on page 89

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