Eyeworld

FEBRUARY 2025 | EYEWORLD BONUS ISSUE | 29 G Relevant disclosures McCabe: AbbVie, Alcon, Glaukos, Spyglass Pharma Simpson: AbbVie, Alcon, Glaukos, Nova Eye Medical those skills. Dr. Simpson noted that when she was in residency, she was not trained on the iStent (Glaukos). "It's interesting how much has changed," she said. In terms of other important testing and diagnostic skills for glaucoma, Dr. McCabe said there are some basic skills around anterior seg- ment pathology and glaucoma pathology. She noted being able to grade the severity of the glaucoma. To do that, you need to know how to perform an OCT and get RNFL data so you can look at the health of the optic nerve and be able to interpret a visual field test as well. Many reimbursement schedules are built around reimbursing for certain grades of glaucoma, so you must be able to adequately and accurately grade the severity of the disease. Because of the nature of the disease, what- ever intervention we do at the time of the MIGS procedure won't be the last invention the pa- tient needs, Dr. McCabe said, and it's important to leave options available on the journey for the patient. It gives them room to have additional treatments before we go to treatments that at as an anterior segment or comprehensive sur- geon, Dr. McCabe said, and it is a bit of a skill making sure you have good visualization. But once you're comfortable with that, acquiring the skills to do any of the techniques is much easier. Dr. McCabe warned against creating folds in the cornea because you're pushing too hard or a bubble underneath the lens because you're not holding it steadily in the middle. Another important thing is to have several different categories of MIGS with which you're comfortable. "You don't have to be comfortable with every single trabecular meshwork bypass stent. As time goes on, we'll have more and more options. You don't have to master every single option, but you should have one at least that you're familiar with." Dr. McCabe suggested knowing how to do a trabecular meshwork bypass stent, a canaloplas- ty technique, and a goniotomy device. "I think those three categories are accessible to every- one," she said, adding that some physicians might want to expand to learning applications for a suprachoroidal stent as well. Things become a bit more complicated when a bleb is required in the postop period. "For me, as a cataract and refractive surgeon, I don't do any procedures that involve bleb formation," she said. "I think, if you're interest- ed, it's an accessible skill, but I don't want to be involved in the more complicated postoperative care for those." Training requirements are continually evolving. Dr. McCabe said when she came out of training, LASIK was just taking off. "It was to the point where as a resident, you could do a few PRKs and maybe a LASIK or two, but it wasn't routinely part of training. That all changed, and that kind of evolution has hap- pened with MIGS, too, because it is something that training programs realized that their train- ees should have exposure to and should have some of those basic skills." Dr. Simpson agreed that updated train- ing requirements are reflecting the trends in ophthalmology, particularly the requirement to include more MIGS in training. Trabs and tubes are not happening nearly as often, and you have to do a glaucoma fellowship to get continued on page 30 Mary Qiu, MD, EyeWorld Glaucoma Editorial Board member, shared her thoughts on interventional glaucoma: "In the era of angle-based surgeries, the treatment paradigm for secondary open angle glaucoma has changed dramatically in the past decade. Eyes with uncontrolled pseudoexfoliation or steroid-induced glaucoma, for example, would historically undergo a trabeculec- tomy or tube shunt, but now those same eyes may be able to achieve excellent IOP control with a goniotomy/GATT procedure, which has a significantly better safety profile." INTERVENTIONAL GL AUCOMA

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