Eyeworld

APRIL 2023 | EYEWORLD | 93 G Hydrus (Alcon), you have the ability to access at least a few collector channels with the way it is placed. Compared to the first-generation iStent (Glaukos), Hydrus has a better pressure reduction and less need for secondary surgical intervention, he said. Dr. Sheybani also said he will not go back in the angle if he's already been there because he wants to do as much as he can at the time of the procedure in the angle. "If I'm doing an iStent or a Hydrus, I'm trying to pick the cases where it's going to get the maximum efficacy with that device," he said. "We're not going to try to push it in someone with advanced disease or some- one with high pressure looking to get a dramatic pressure reduction." Sameh Mosaed, MD, has been performing MIGS since 2003. "The IOP levels you can ex- pect with someone on medications in whom you do MIGS in combo with phaco or even stand- alone is in the mid-teens, and if you supplement it with medications, you can get it to the low teens," she said. When performing MIGS in combination with cataract surgery, Dr. Mosaed thinks it's a good trade-off to have moderate IOP lowering with less medications. But she noted that she won't typically perform MIGS as a standalone procedure just to reduce the medication bur- den. "The place where it fits into my practice as a standalone procedure is in the setting of steroid-induced glaucoma where the patient will come in with a very high pressure in the 30s–40s, sometimes 50s; the trabecular bypass procedures work well for steroid-induced glaucoma," she said. When Dr. Singh chooses a MIGS procedure, he looks for options where there is high quality data to support the use. He noted that many of the implantable MIGS devices went through rigorous review processes for approval, so there is a lot of data on safety and efficacy. "Some of the most robust trials done by the glaucoma community were for implantable MIGS proce- dures," Dr. Singh said. He thinks that the quality of long-term efficacy and safety data available for adult goniotomy is insufficient presently, thus he has not incorporated this procedure in his practice. Dr. Singh also said that reimburse- ment plays no role in his decision making, and he has been disappointed by trends suggesting continued on page 94 Creation of the needle bend for a goniotomy Source: Arsham Sheybani, MD that the use of various MIGS devices in the U.S. has been influenced by levels of and changes in reimbursement. Determining if a MIGS procedure worked or if it's necessary to try a different approach de- pends on a couple of factors, Dr. Sheybani said. First is the severity of the patient's glaucoma. "I tell patients that we might not know where the pressure will settle until a couple months after the procedure because then I've been able to taper steroids," he said, explaining that you need 4–6 weeks to know the steroid effect is washed out. The earliest Dr. Sheybani said he would go back in would be around 2 months after a procedure, though it's uncommon. These would be cases where the patient's collectors weren't

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