Eyeworld

World view Accelerating innovation in glaucoma surgery with MIGS T he pace of innovation in technology may be exponential. Ray Kurzweil, inventor, futurist, and director of engineering at Google, gave a TED Talk in which he described exponential progress in many areas of technology. He makes a strong case that by any measure we choose—computing power, band- width, price performance, adoption rates, etc.—we find exponential advancement. This exponential growth has been remarkably robust, continuing despite changes in technologies, paradigms, and even through economic depressions and world wars. Innovation is like a ball rolling down a hill. The MIGS revolution has brought hope that innovation in glaucoma surgery—while not expo- nential—is definitely accelerating. In this month's feature articles, we exam- ine the MIGS landscape. The iStent—the first MIGS device approved—has been available for 4 years. What have we learned? After a breakthrough like the iStent, there is always a time of consolidation when the new device finds its place. Improvements in our understanding of indications and how best to use the iStent are reviewed by Jason Bacharach, MD, Quang Nguyen, MD, and Paul Harasymowycz, MD. Mr. Kurzweil makes the point that new technology may fail not because of the worth of the idea, but because of an absence of enabling tools and know-how. For example, the success of phaco and IOLs has depended on enabling technology like the capsulorhexis and viscoelastics. Finding the canal is a critical step to implanting the iStent. Ronald Fellman, MD, and I describe our techniques for identifying the canal. The use of trypan blue is one enabling technology, but there will be others that will continue to improve our placement skills. The non-device MIGS approaches are very creative. A benefit to non-de- vice alternatives is that all MIGS devices so far are only approved for implan- tation at the time of cataract surgery. So we desperately need surgical options for patients who are pseudophakic. These non-device MIGS alternatives are reviewed by George Tanaka, MD, Nathan Radcliffe, MD, Arthur Sit, MD, and Arsham Sheybani, MD. The MIGS pipeline is filled with new devices, and this also demonstrates the accelerating innovation. These new devices explore alternative strategies for controlling pressure surgically—trabecular bypass, suprachoroidal drain- age, and an internal approach to external filtration. These new strategies and devices are reviewed by Rick Lewis, MD, Sean Ianchulev, MD, Davinder Grover, MD, and Husam Ansari, MD. Although not talking about glaucoma devices, Mr. Kurzweil acknowledges that it is usually not possible to predict which specific technology will be successful. However, he is confident that the overall goal sought by the competing technologies will be achieved. In other words, he would say that MIGS (and patients and surgeons) will win. These technologies are already helping patients, and it will only get better. This issue also reviews relevant information from the 2015 ASCRS Clinical Survey. The survey found that 50% of U.S. respondents were either implanting the iStent or planning to. Adoption rates for new technology were also reviewed by Mr. Kurzweil, and he concluded that they follow the exponential rule. For example, the telephone took 50 years for adoption. The cell phone was only 8 years. As someone who has been disappointed at how reluctant surgeons are to try new glaucoma approaches, 50% looks amazing to me. It shows how fast the MIGS ball is already rolling down the hill. EW Reay Brown, MD, glaucoma editor The official publication of the American Society of Cataract & Refractive Surgery A S C R S May 2016 Volume 21 • No. 5 Publisher Donald R. Long don@eyeworld.org Editorial Editor Amy Goldenberg amy@eyeworld.org Managing Editor Stacy Jablonski stacy@eyeworld.org Senior Staff Writer/Digital Editor Ellen Stodola ellen@eyeworld.org Staff Writer Liz Hillman liz@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 Production Assistant Carly Peterson carly@eyeworld.org Contributing Writers Stefanie Petrou Binder, MD Germany Vanessa Caceres Bradenton, Florida Michelle Dalton Reading, Pennsylvania Rich Daly Arlington, Virginia Lauren Lipuma Washington, D.C. 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