Eyeworld

28 | EYEWORLD BONUS ISSUE | FEBRUARY 2025 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Cathleen McCabe, MD Medical Director The Eye Associates Bradenton, Florida Rachel Simpson, MD Vice Chair of Education John A. Moran Eye Center University of Utah Salt Lake City, Utah Dr. McCabe thinks there are certain proce- dures that everyone should know how to do. "The first step is that everyone, any comprehen- sive or anterior segment surgeon, should know how to look at the angle. We should know how to do a gonioscopy. We know that it's important just in the clinical care of our patients, so we should be able to look at the angle and identify structures. That's the baseline." It's what we should be able to do regardless of whether or not we're going to do MIGS, she said. That means being able to position the mi- croscope, the patient's head, a gonioprism, and the illumination and magnification, and focus in a way that optimizes a view of the angle structures, Dr. McCabe continued. It's some- thing physicians can practice in the operating room at any time, even without doing a MIGS procedure. Dr. McCabe said there are many differ- ent gonioprism designs, including those that sit on the eye and one that will attach to the microscope for a hands-free approach with the view managed with the microscope foot pedal. She suggested using something where you can be hands-free or one that you hold in your non-dominant hand, adding it's important to be comfortable with the viewing technique and find the prism that you like. Being comfortable in identifying those angle structures, which is the critical part of do- ing any MIGS procedure, is the biggest hurdle because it's not a place that we normally look Who should be performing glaucoma surgery in 2025? W ith the variety of MIGS proce- dures and devices available, and with use both as a standalone option and in conjunction with cataract surgery, there is more interest than ever. Many of these procedures are proving useful and accessible not just to the glaucoma specialist but to comprehensive ophthalmologists as well. Cathleen McCabe, MD, and Rachel Simpson, MD, discussed who should be performing glaucoma surgery, as well as ways to learn and stay fresh with some of these techniques. Many patients, an estimated 20% of cataract patients, have a co-diagnosis of glau- coma and are on medication, Dr. McCabe said. Being able to provide microinvasive surgery at the time of cataract surgery doesn't change the postoperative course, other than allowing them to be potentially free of their glaucoma medication and the negative side effects of that, she said. "I'm a cataract refractive surgeon who got involved with MIGS early on, and I think it's well within the skillset of anterior segment surgeons," Dr. McCabe said. She thinks glauco- ma treatment in the setting of cataract surgery is part of comprehensive care offered to patients that improves their quality of vision as well as their quality of life. "There's strong agreement among most glaucoma surgeons [that] there's going to be more glaucoma in the world in 20 years than we are able to treat and that there is a critical role for comprehensive ophthalmologists to be performing MIGS," Dr. Simpson said. "I even encourage our cornea fellows if they didn't get a lot of MIGS exposure; I tell them being able to perform MIGS is going to be helpful, espe- cially in private practice." Dr. Simpson thinks anyone who works in the anterior segment of the eye should feel empowered to be able to perform MIGS. "I think it is incumbent on them to make sure that they are getting the training in residency that allows them to be comfortable working in that space and, maybe even more importantly, to be comfortable making the decision on which procedure is right for each patient." Understanding the decision-making flow is key, she said. " Stay informed because this is a very fast-paced and evolving space right now; it's exciting to see what's coming, and there's good data coming out." —Cathleen McCabe, MD

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