Eyeworld

WINTER 2025 | EYEWORLD | 67 G MIGS procedures are a good place to start, Dr. Kamat agreed, and within that category, she said canal-based stenting or goniotomy are likely the most approachable. These include trabecular bypass stents such as the iStent or Hydrus (Alcon) or goniotomy procedures such as the Kahook Dual Blade (New World Medi- cal). "These procedures have a favorable safety profile, comparable postoperative management to cataract surgery alone, and have a similar recovery period as a typical cataract extraction." Dr. Kamat said it's within the wheelhouse of a comprehensive ophthalmologist to master a couple of MIGS techniques. "If one wanted to expand his or her MIGS armamentarium, I would consider viscocanaloplasty, as I person- ally find that to be a highly effective and useful tool for glaucoma." She added that while sub- conjunctival bleb-forming procedures such as the XEN Gel Stent (AbbVie), trabeculectomy, or glaucoma drainage devices are all important in the surgical management of glaucoma, they are not critical for the comprehensive ophthalmolo- gist to master. Dr. Kandavel encouraged surgeons to for- mulate their own algorithm for recommending and performing these glaucoma procedures (as standalone procedures or in conjunction with cataract surgery) as they gain experience and as more data is published. But he said surgeons should not feel limited because they can all be learned and mastered by any committed cata- ract surgeon. "For instance, we would not prescribe only one medication drop to a patient because we are only comfortable with that drop; rather, we want to be familiar with the benefits of all medications and offer the best combination of medication available," he said. "Similarly, MIGS procedures should be performed in a logical algorithm and should not be limited by experi- ence or effort." Dr. Kandavel agreed with Dr. Kamat that surgeons can start with a limited number of pro- cedures that they are comfortable with and then expand to others as they become more familiar with the techniques. "At this point in time, we can break down angle-based procedures into the following larger categories: stenting procedures such as Hydrus and iStent, viscodilation and goniotomy proce- dures, and the last, for now, is pharmaceutical implantation," he said. Dr. Kandavel suggested starting with the iDose TR to get the surgeon prepared for angle-based visualization. Then, he suggested expanding to iStent, which he said leverages that same visualization for an angle stenting procedure. "The surgeon will have to be com- fortable with retrieving and rethreading the stent for reimplantation in case the first pass is not successful and the target is more narrow," he said, adding that this is an additional skillset. "Having microsurgical forceps for intracam- eral use is necessary. However, with practice, continued on page 68 Dr. Kamat performs a MIGS procedure. Source: Shivani Kamat, MD

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