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41 EW FEATURE November 2014 "I think the term 'MIGS' is here to stay, but I think it will apply to many different devices in the next 10 years," he said. In the future, the devices that are developed will be more effective, will apply to different tissues in the eye, and will be coupled with drug delivery and IOP monitoring, he said. "We have a great deal of work to do to make MIGS more success- ful and to have it apply to more of our patients, especially those with advanced disease who require drastic lowering of their IOP," Dr. Kahook said. "I do think we will get there in the next 10 years, and I am excited to be part of a community of doctors who are innovating and not settling for the status quo." Dr. Lewis believes that MIGS will definitely still be spoken about in 5 or 10 years. While there is only one approved MIGS procedure, there are more coming, he said. When other procedures besides the iStent are approved, the MIGS term may transition to the anatomic area where the procedures work. "I think it's an exciting time that's long overdue in glaucoma, and I hope glaucoma physicians will be open minded to the good and bad of this," he said. MIGS is clearly a different type of surgery, Dr. Ahmed said, and it is a different approach to treating glaucoma, as well as an earlier intervention. "I see glaucoma [treatment] changing over the next several years to moving toward more of a dynamic interventional approach," Dr. Ahmed said. EW Editors' note: Dr. Ahmed has financial interests with Abbott Medical Optics (Santa Ana, Calif.), Alcon, AqueSys, Glaukos, Ivantis, and Transcend Medical. Dr. Brown has financial interests with Glaukos, Ivantis, and Transcend Medical. Dr. Kahook has financial interests with Glaukos and Ivantis. Dr. Lewis has financial interests with Alcon, AqueSys, Glaukos, and Ivantis. Contact information Ahmed: ike.ahmed@utoronto.ca Brown: reaymary@comcast.net Kahook: malik.kahook@gmail.com Lewis: rlewiseyemd@yahoo.com "invasiveness" of the procedure, which disrupts the normal physiol- ogy of the eye. Trabectome, while destructive in a sense, is removing disease pathology and therefore is differentiated from ECP and could be considered a MIGS procedure, Dr. Ahmed said. A continuum of MIGS Dr. Ahmed has previously described a range of MIGS procedures starting with the iStent, CyPass (Transcend Medical, Menlo Park, Calif.), Hydrus (Ivantis, Irvine, Calif.), and the XEN Gel Stent (AqueSys, Aliso Viejo, Calif.). The latter is what he calls "MIGS plus," considering the more aggressive IOP-lowering the XEN achieves comparability, which is also accompanied by slightly more risk (i.e., bleb creation). Although the XEN Gel Stent creates a bleb, it is made with a controlled lumen ab in- terno delivery with no conjunctival incisions. In Dr. Ahmed's opinion, it differentiates itself from ab externo bleb procedures such as trabeculectomy and the EX-PRESS Glaucoma Filtration Device (Alcon, Fort Worth, Texas). Thus, he feels it warrants inclusion as a MIGS procedure. Dr. Lewis said the spectrum includes a whole slew of procedures that could fit within the MIGS umbrella. "Ultimately, I don't think it's going to matter because I think we're going to move on to defining these procedures anatomically," he said. "Dividing surgeries from min- imally invasive to most invasive is not a new concept, and Ike has done an excellent job in clarifying some of these issues for the global oph- thalmic community," Dr. Kahook said. The XEN stent should be in the same category as the EX-PRESS Glaucoma Filtration Device, trabe- culectomies, and glaucoma drainage devices, according to Dr. Kahook. "The only difference is that it might be faster, but it has the same risk factors of the most invasive surgeries we do." In the future Although MIGS devices are still in the early stages, Dr. Kahook thinks they will be around for a number of years.