Eyeworld

EW FEATURE 126 New technology in cataract surgery • April 2016 AT A GLANCE • MIGS are likely to become standalone surgical procedures in the near future. • Patient selection remains the primary factor in determining MIGS surgical success. • Preop washout is not necessary, but keep patients off meds for 1–2 months postop. by Michelle Dalton EyeWorld Contributing Writer straightforward procedure, but keep in mind "the importance of setting yourself up for success with the right position and the right visualization," Dr. Ahmed said. The best way to approach these various options to patients is to have unique informed consent forms for each of the potential MIGS therapies, Dr. Vold recommended. Consider the refractive status of the patient as well, Dr. Lewis said. "Are they wearing contact lenses? That changes my thinking a lot. If they're high myopes, I don't "It's always been a balance in glaucoma surgery of risk and benefit, and unfortunately the older tech- niques have more complications," he said. "That's what drove the de- sire for the MIGS-based procedures. The safety of these devices is what has driven the field." The "initial foray" into MIGS made sense to combine with cataract surgery "being that we're already in the eye, so we get an extra boost in IOP-lowering using MIGS," said Iqbal "Ike" Ahmed, MD, assistant professor of ophthalmology, Univer- sity of Toronto, and clinical assistant professor, University of Utah, Salt Lake City. These devices "definitely will be standalone procedures," said Steven Vold, MD, founder and chief exec- utive officer, Vold Vision, Fayette- ville, Arkansas. "Some of these may ultimately end up being performed in an office setting." There are ongoing clinical studies evaluating the use of MIGS devices as standalone procedures in phakic eyes and studies investigat- ing multiple simultaneous iStent implantations, Dr. Vold said. For pa- tients who may have more moderate than mild glaucoma, multiple stents may be most beneficial, he said. In some patients, phaco alone may be enough to lower IOP; "pha- co plus MIGS often is even better than phaco alone. That's the sweet spot," Dr. Ahmed said. "I try to avoid phaco-trabs because they're harder to manage." The devices that will gain rapid market acceptance are those with the highest safety and most robust IOP lowering; those that are less "cost involved" are likely to gain ac- ceptance quicker than those that are not reimbursed, Dr. Ahmed said. Implantation pearls The key to successful MIGS is patient selection, the experts say. Implanting the devices is a relatively Newer devices and more experience may lead to MIGS becoming a standalone procedure— in the right patient W hen glaucoma pa- tients present with visually significant cataracts, more and more surgeons are considering combining the cataract surgery with microinvasive glauco- ma surgery (MIGS); in the U.S., only the iStent (Glaukos, Laguna Hills, California) is an approved MIGS device. Its approval is in combina- tion surgery, but it's only a matter of time before MIGS devices "are approved as standalone procedures," said Richard Lewis, MD, in private practice, Sacramento, California. MIGS and cataract surgery Monthly Pulse New technology in cataract surgery T he topic of this Monthly Pulse survey was "New technology in cataract surgery." We asked, "In what percentage of patients do you implant MFIOLs?" and more than half of respondents said <10%. The majority of respondents to this survey said they do not currently perform femtosecond laser cataract surgery. When measuring corneal astigmatism in cataract patients, the majority of respondents use a combination of IOLMaster Ks, corneal topography, preoperative/intraoperative cataract suites (Verion or Callisto), and intraoperative aberrometry (ORA). Finally, we asked about mild to moderate glaucoma patients with cataracts, and the majority of respondents to the survey said they perform phaco alone and then reassess IOP. " It's always been a balance in glaucoma surgery of risk and benefit, and unfortunately the older techniques have more complications. That's what drove the desire for the MIGS-based procedures. " –Richard Lewis, MD

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