EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/407647
World view Glaucoma surgery for the other 95% A lthough the term "MIGS" brings to mind a variety of procedures and devices, the core of MIGS is a new way of thinking about glaucoma surgery. In the past, glaucoma sur- gery was either a trabeculectomy or tube shunt and often performed by glaucoma specialists on patients with uncontrolled pressures who were losing vision. But this is a very small minority of glaucoma patients (less than 5%), and MIGS has not changed this. The other 95% of glauco- ma patients have controlled pressures on topical treatment. What MIGS has done is dramatically expanded the possible candidates for glaucoma surgery to include those patients who need cataract surgery and have controlled or nearly controlled pressures. MIGS is glaucoma surgery for the other 95%. In this EyeWorld issue we are focusing on combined surgery for glaucoma, and this immediately brings up the topic of MIGS. Since the approval of the iStent (Glaukos, Laguna Hills, Calif.)—the first MIGS device approved for use in the U.S.—it has become an increasingly popular component of combined cataract and glaucoma surgery. One fundamental question is whether the term "MIGS" is helpful. We are grateful to have Iqbal "Ike" K. Ahmed, MD, Malik Kahook, MD, and Richard A. Lewis, MD, share their opinions on this. As surgeons begin implanting the iStent with cataract surgery, there are many important considerations that can improve success. We have Dr. Kahook, Gary Condon, MD, and Douglas Rhee, MD, discussing their pearls for getting started. The safety of MIGS has opened up glaucoma surgery to general cataract surgeons, but this means learning some new skills, such as intraoperative gonioscopy. Cataract surgery alone can be a powerful treatment for lowering pressure. We have Steven Mansberger, MD, Dennis Lam, MD, David S. Friedman, MD, and Parag Parekh, MD, giving us their thoughts on cataract surgery in glaucoma. The finding that cataract surgery can lower pressure has led to the concept of "lens-based" glaucoma surgery. Cataract surgery is particularly beneficial in angle closure, and the possibility of clear lens extraction is an important consideration for patients with uncontrolled pressures who otherwise would need a much higher-risk trabeculectomy. The near-MIGS procedures—such as ECP (endoscopic cyclophotocoag- ulation, Endo Optiks, Little Silver, N.J.) and Trabectome (NeoMedix, Tustin, Calif.)—are discussed by Robert J. Noecker, MD, Nathan M. Radcliffe, MD, and Brian A. Francis, MD. These procedures offer most of the advantages of MIGS but depend on some degree of tissue ablation and so do not quite meet the classic definition of MIGS. Whether this is an important distinction remains to be seen as these treatments continue to be refined. Despite the excitement over MIGS, we still have patients who need their pressures lowered to levels beyond what can be expected with MIGS. In these challenging cases, combining cataract surgery with a trabeculectomy may be the best option. Jeffrey A. Kammer, MD, and Uday Devgan, MD, share their insights. They provide suggestions for steps to increase the safety of traditional trabeculectomy surgery. The approval of the XEN Glaucoma Implant (AqueSys, Aliso Viejo, Calif.) will move trabeculectomy surgery much closer to a MIGS-like procedure. Cataract surgery is eventually part of the treatment plan for most glaucoma patients. But where cataract surgery was previously put off as long as possible, it has become an option to embrace. It can lower pressure by itself, or when combined with a MIGS, near-MIGS, or trabeculectomy, it can improve pressure and reduce the need for medications. MIGS devices—with their increased safety—will present a growing opportunity to use combined surgery to help the majority of glaucoma patients who otherwise would not be candidates for a riskier glaucoma surgery. EW Reay H. Brown, MD, glaucoma editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S November 2014 Volume 19 • No. 11 Publisher Donald R. Long don@eyeworld.org Editorial Editor Erin L. Boyle erin@eyeworld.org Managing Editor Stacy Majewicz stacy@eyeworld.org Staff Writer Ellen Stodola ellen@eyeworld.org Staff Writer Lauren Lipuma lauren@eyeworld.org Production Graphic Designer Julio Guerrero julio@eyeworld.org Graphic Design Assistant Susan Steury susan@eyeworld.org Production Manager Cathy Stern cathy@eyeworld.org 703-383-5702 Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Vanessa Caceres Lakeland, Fla. Michelle Dalton Reading, Pa. Matt Young Malaysia Enette Ngoei Dublin Rich Daly Arlington, Va. Senior Contributing Writer Maxine Lipner Nyack, N.Y. Advertising Sales ASCRSMedia 4000 Legato Road Suite 700 Fairfax, VA 22033 703-591-2220 fax: 703-591-0614 eyeworld@eyeworld.org www.eyeworld.org Advertising Sales Jeff Brownstein jeff@eyeworld.org 703-788-5745 Paul Zelin paul@eyeworld.org 703-383-5729 Classified Sales Cathy Stern cathy@eyeworld.org 703-383-5702 EyeWorld Special Projects and Events Jessica Donohoe jessica@eyeworld.org 703-591-2220 ASCRS Publisher: EyeWorld (ISSN 1089-0084) is published monthly by ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; telephone: 703-591-2220; fax: 703-591-0614. Printed in the U.S. Editorial Offices: EyeWorld News Service, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Advertising Offices: ASCRSMedia, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. Copyright 2014, ASCRS Ophthalmic Services Corp., 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055. All rights reserved. No part of this publication may be reproduced without written permission from the publisher. Letters to the editor and other unsolicited material are assumed intended for publication and are subject to editorial review and acceptance. Subscriptions: Requests should be addressed to the publisher. Annual subscription prices: Individual: 1 year, $120; 2 years, $220; 3 years, $320. Institutional: 1 year, $250; 2 years, $330; 3 years, $425. Foreign: 1 year, $240, 2 years $470, 3 years, $700. Back copies: Subject to availability. Contact the publisher. Cost per copy is $15; $30 foreign. All orders for individual or back copies must be accompanied by payment. Requests to reprint, use, or republish: Requests to reprint or use material published herein should be made in writing only to Cathy Stern, EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: eyeworld@eyeworld.org. EyeWorld reprints: To order reprints of material published in EyeWorld, contact Cathy Stern, EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033-4055; toll-free: 800-451-1339, 703-591-2220; fax: 703-591-0614; email: cathy@eyeworld.org or your salesperson. Change of address: Notice should be sent to the publisher six weeks in advance of effective date. Include old and new addresses and label from recent issue. The publisher cannot accept responsibility for undelivered copies. POSTMASTER: Send change of address to EyeWorld, 4000 Legato Road, Suite 700, Fairfax, VA 22033. Periodical postage paid at Fairfax, VA 22033 and at additional mailing offices. The ideas and opinions expressed in EyeWorld do not necessarily reflect those of the editors, publisher, or its advertisers. P U B L I S H I N G S T A F F