Eyeworld

92 | EYEWORLD | APRIL 2023 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Sameh Mosaed, MD Director of the Glaucoma Service Gavin Herbert Eye Institute University of California Irvine Irvine, California Arsham Sheybani, MD Associate Professor, Ophthalmology and Visual Sciences Washington University School of Medicine in St. Louis St. Louis, Missouri Kuldev Singh, MD Professor and Chief of the Glaucoma Division Stanford University School of Medicine Palo Alto, California and tube implants. These, he said, "are the ones that can sometimes prevent patients from going blind from glaucoma." He sees MIGS as an op- tion for patients with mild to moderate disease or controlled glaucoma and a need for cataract surgery. "But for patients who have a substan- tial risk of blindness from glaucoma, MIGS are much less likely to get you to the pressure goal, and you often need to accept the risks that come with trabeculectomy to have a reasonable chance of preserving vision," Dr. Singh said. "I think the greatest value of canal-based MIGS is that each eye undergoes cataract surgery only once, presenting an opportunity to adjunctively do something good for the glaucoma. … You can piggyback onto cataract surgery, which alone results in IOP lowering, and get an addi- tional benefit from the MIGS procedure." With a variety of MIGS devices and proce- dures available, Dr. Sheybani said the choice depends on the disease. First, he mentioned partial goniotomies, which he expects would be done at the time of cataract surgery and can get pressure to 14–15 mm Hg. Dr. Sheybani added that you should be able to get patients off one or two classes of medications with this. "If they started at two to three, they might be down to a drop at 1 year," he said. If using partial goniotomy as a standalone procedure, Dr. Sheybani said it's unlikely to show a large pressure drop. When he performs goniotomy as a standalone, he said it's usually 180–360 degrees. "We have the iTrack catheter [Nova Eye Medical], OMNI Surgical System [Sight Sciences], sutured GATT, and they can get pressure down as a standalone procedure." However, there is a risk of bleeding. Secondary open-angle glaucoma patients do much better in those cases, he explained. "We've had uveitics with pressures in the 40s who you can get down into the teens and off their drops, if you get to them early enough," he said. Dr. Sheybani said if he's already worked in the angle, he will not go back in if the patient isn't where they need to be. He will engage a subconjunctival option if he's already tried an angle procedure, like stenting or goniotomy. That's where the conversation gets a little more nuanced, he said. With a stent, like MIGS and IOP control M IGS procedures have become a mainstay in the surgical treatment of mild to moderate glaucoma, but what pressures can physicians real- istically expect with these? Several physicians discussed this, as well as how MIGS can fit into the overall glaucoma management process and what to do if MIGS procedures don't achieve the desired IOP. Before getting into the discussion about IOP levels attainable with MIGS, Arsham Sheybani, MD, stressed the importance of case selection from the beginning. "You're trying to avoid hav- ing the MIGS fail, and in general, patients who have been on medications for years or who have more advanced disease aren't going to do well with angle procedures," he said. "[With] MIGS in general, if you need pres- sures that are consistently going to be in the low-teens without medications, angle surgery is not going to be a great option," Dr. Sheybani said. "On average, the way to avoid failure is to do [MIGS] in patients where your goal pres- sures are in the mid-teens, and they have some tolerability to at least one class of medications." If you are operating on a patient's cataract and that's the main reason for surgery, Dr. Sheybani said it may be reasonable to try an angle surgery, but for advanced disease, if the pressure is high, there's unlikely to be a signifi- cant reduction with angle surgery. Kuldev Singh, MD, said the IOP levels that can be expected after angle-based MIGS surgery are usually similar to preoperative IOP but with reduced dependence on medications. "I think that's the most achievable goal of MIGS—to reduce the number of medications," Dr. Singh said, adding that there will be some patients who can get lower pressures if they were not on medications previously, but the main goal is to get patients off as many medi- cations as possible. Dr. Singh thinks there will be data forthcoming that will show that if you achieve the same IOPs with or without IOP-low- ering medications in similarly diseased patients, eyes that are off medications will do better in terms of visual field preservation than those where medications continue to be needed. Dr. Singh said he mostly performs tradition- al glaucoma procedures, like trabeculectomy

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