Eyeworld

10 | EYEWORLD BONUS ISSUE | FEBRUARY 2025 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Deborah Ristvedt, DO Vance Thompson Vision Alexandria, Minnesota Inder Paul Singh, MD The Eye Centers of Racine and Kenosha Racine and Kenosha, Wisconsin Arkadiy Yadgarov, MD Omni Eye Services Atlanta, Georgia said Deborah Ristvedt, DO. "Our goal is taking on a proactive instead of a reactive approach, with the vision of 24/7 IOP control, effective pressure reduction, less drop dependence, and improved quality of life," she said. "MIGS has greatly expanded over the last 12 years, includ- ing stents that bypass the trabecular meshwork, cutting techniques that remove trabecular meshwork, and viscodilating to reduce herni- ations of tissue into the collector channels and expanding Schlemm's canal. Cyclophotocoagu- lation has been used to reduce aqueous produc- tion, working on the inflow pathway. Minimally invasive bleb surgery (MIBS) has also become available, bypassing the angle. With all of these options, we are now seeing more of a staged approach to treating glaucoma, starting earlier in the disease process." Dr. Ristvedt added that SLT and pharma- ceutical procedures that reduce drop depen- dence are becoming more first line. "In the MIGS space, with having options for interven- tions in phakic eyes, in combo with cataract surgery, and in pseudophakic eyes, I am always looking and evaluating IOP goal, stage of dis- ease by visual field loss, quality of life issues, drop compliance, and determining the best plan based on the individual in front of me," she said. "Our new algorithm is starting to look like this: SLT<–>Drug delivery<–>MIGS–>Second MIGS–>MIBS–>Tube or Trab." Expansion of MIGS and options The expansion of MIGS use is due to evidence that shows they work and that they are safe MIGS expansion and where it fits in interventional glaucoma M IGS has continued to expand in its application for a large number of patients with varying degrees of glaucoma. Several physicians discussed where various MIGS procedures fit into interventional glaucoma, including applications for standalone MIGS and how it continues to play a role in conjunction with cataract surgery. For many years, MIGS was thought about only at the time of cataract surgery, said Inder Paul Singh, MD, adding that this was because of the way the FDA regulated the initial studies of devices like the iStent (Glaukos) and Hydrus (Alcon). "These studies were designed based on the FDA guidelines saying that you have to do these with cataract surgery because no one knew how safe they were," he said. "But once we realized that these MIGS procedures are very safe and thus safety became a moot point, now we see a lot more studies being done with standalone indications." Where does MIGS fit in interventional glaucoma? MIGS has typically been discussed at the time of cataract surgery, but that discussion has more recently expanded. "We no longer have to only offer MIGS at the time of cataract extraction. Therefore, from an interventional glaucoma perspective, MIGS is a big part of the picture alongside SLT," said Arkadiy Yadgarov, MD. Dr. Yadgarov offers MIGS for patients who have failed one or two drops due to compliance issues, difficulty with instilling drops, intoler- ances to drops, fluctuating IOPs that exceed target IOP, and those in whom SLT has failed to control IOP. "I also offer MIGS to patients who are showing mild progression on testing despite medications. Typically, in those patients, we would add more drops to avoid the need for major incisional surgery, but due to MIGS safety, I highly recommend MIGS to every patient who shows signs of progression on testing," he said. Interventional glaucoma is gaining famil- iarity and redefining the treatment paradigm as we have multiple ways to intervene earlier in the disease process, with less drop burden, iStent infinite in the canal with reflux of heme Source: Inder Paul Singh, MD

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