Eyeworld

DECEMBER 2022 | EYEWORLD | 83 G Contact Francis: bfrancis@doheny.org Noecker: noeckerrj@gmail.com Relevant disclosures Francis: Alcon, Allergan, BVI, Iridex, iSTAR Medical, MicroSurgical Technologies, Santen Noecker: Allergan, Alcon, Glaukos, Iridex, MicroSurgical Technologies, New World Medical, Nova Eye Medical, Santen, Sight Sciences "You don't have to become proficient in multiple procedures that are in the same cate- gory. It makes more sense to span two or three different categories within your armamentari- um," he said. Dr. Francis said it's helpful to know the different categories and what they address to customize choices for patients based on their disease and anatomy. "That can sometimes give you an idea of what procedures might be more successful depending on how they work," he said. "The categories also help if you're thinking about combining different procedures. You want to combine procedures that are from a different category. For instance, you might not want to do two trabecular bypass stents. That's not going to be as helpful as combining a trabecular bypass with something that reduces aqueous humor production or opens up the canal 360 degrees." Dr. Noecker said that the variability in eye anatomy influencing MIGS efficacy makes un- derstanding the different categories important. It also highlights the need to have experience across the different categories. Both Dr. Noecker and Dr. Francis said insur- ance coverage can play a role in why a surgeon might want to have experience in different MIGS categories as well. "It's about having backup options. Some patients don't want to have a device put in their eye. It's nice to have another option," Dr. Noecker said. "I like to hedge my bets, so I do a lot of combining of these procedures and understanding what makes sense to combine, what complements each other vs. doing the same thing." In terms of choosing an option within each category, Dr. Noecker said to go with what you're good at. "Figure out which one works best in your hands and go with it," he said. Dr. Francis said without head-to-head data show- ing which MIGS is better, it boils down to what you're comfortable with. "Within the same cate- gory, generally, they are similar in terms of their mechanism of action and efficacy. I don't think it matters that much which you choose," he said. Dr. Francis said trabecular bypass stents are the first step for most cataract surgeons. As a second step, he advised a goniotomy/trabecu- lotomy or combined canaloplasty-goniotomy/ trabeculotomy procedure. "The reason those are nice is you can do them without cataract surgery," he said. "The other category you might want to consider is an aqueous humor reduction procedure. Those can be combined with any procedure along the way." Dr. Noecker said that each of these spaces has evolved and gotten better, but there is still room for improvement. "The techniques got better. The instrumen- tation got more elegant. It's all with the goal of decreasing side effects, which in this case is primarily bleeding. I think all of the technolo- gies have improved, but they all could continue to be better," he said. "There is always room for improvement to [reduce the] chance of sticking a device in the wrong place." Dr. Francis said he'd like to see a supracho- roidal stent come back to the market. "I know there are a couple in the pipeline that are being studied right now; they're in trials that are ongoing. I think that is an area that will be reopened in the near future. It's not necessarily better than the other procedures but it's different. We're accessing a different outflow pathway than the traditional trabecular outflow," he said, adding "it can be nice to have access to a different outflow pathway to try to enhance the aqueous outflow rate." "You don't have to become proficient in multiple procedures that are in the same category. It makes more sense to span two or three different categories within your armamentarium." —Brian Francis, MD

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