Eyeworld

86 | EYEWORLD | DECEMBER 2022 G HOT TOPICS IN OPHTHALMOLOGY UCOMA lower target IOP, or discontinuing of some of the medications," Dr. Razeghinejad said. "We do not have any evidence-based data on combined MIGS efficacy and safety; currently physicians are combining MIGS based on their personal experience and the current literature on stand- alone MIGS." Dr. Murphy said there are cases in which it would be acceptable to perform MIGS if the patient is properly counseled that while MIGS offers an attractive risk profile, they are less likely to achieve target IOP, and the chances are higher that additional, more invasive glaucoma surgery will be required in the future. "I tend to take the team approach (surgeon and patient) when it comes to decision making, as many patients are reasonably well informed even before our surgical consultation, have often seen several other glaucoma surgeons, and I'm the second, third, or fourth opinion," he said. "If one performs a MIGS procedure and it fails, the option to go more invasive is available, whereas if one proceeds with more invasive surgery right away, there is no role for most MIGS procedures at that point." The main reason Dr. Murphy chooses to combine MIGS is additional IOP-lowering pow- er, targeting aqueous production and resistance to conventional outflow simultaneously, for example. "We as glaucoma surgeons know that sometimes a MIGS procedure fails, but if you perform two or three MIGS, it is theoretically by Ellen Stodola Editorial Co-Director About the physicians James Murphy, MD Adjunct Clinical Instructor Yale New Haven Hospital New Haven, Connecticut Reza Razeghinejad Director Glaucoma Fellowship Program Wills Eye Hospital Philadelphia, Pennsylvania Combining MIGS procedures Using the RPT forceps (MicroSurgical Technology) to maneuver the iTrack (Nova Eye Medical) LED lighted tip microcatheter into Schlemm's canal for 360-degree canaloplasty Source: James Murphy, MD C ombining MIGS procedures is some- thing James Murphy, MD, considers if he wants to get the most IOP-lowering effect balanced with a minimal surgi- cal risk profile. "I routinely combine MIGS procedures that target different contribu- tors to the conventional inflow/outflow system of the eye," he said. As an example, he described combining a canaloplasty with a MicroPulse CPC (Iridex) laser treatment or canaloplasty with goniotomy and a trabecular microbypass stent. "I some- times combine subconjunctival MIGS with MicroPulse CPC as well," he said. "Typically, I am targeting patients with mild to moderate open-angle glaucoma, patients with additional risk factors for complications from shunts or blebs, and patients for whom having one of the traditional glaucoma procedures may not fit well with their lifestyle. Sometimes patients present with an already well-informed im- pression of what types of glaucoma surgeries fit with their lifestyle and risk tolerance." Dr. Murphy added that there are patients who have already had a tube shunt or trabeculectomy in the fellow eye, had a bad experience, and are therefore resistant to having the same or a similar procedure in the second eye, even if that procedure may be the most likely to achieve target IOP. "As a glaucoma surgeon, I use the preoperative counseling session as my opportu- nity to gauge what the patient's acceptance of partial success or tolerance for failure would be. I want to avoid a patient who fails a MIGS pro- cedure and is unwilling to follow through with an escalation in surgical care if the need arises." Reza Razeghinejad, MD, said that he would be more inclined to combine MIGS procedures in those patients with higher IOPs when it is preferable to avoid filtering procedures or in those needing lower target IOPs. Generally, MIGS is used in mild and mod- erate glaucoma patients, he said, but it may be used in severe glaucoma patients requiring a decrease of a few points of IOP, especially those patients with unfavorable outcomes with filter- ing surgery in the contralateral eye. "When we plan to combine MIGS, we are looking for more IOP reduction due to higher baseline IOP, more optic nerve damage requiring

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