Eyeworld

EW FEATURE 56 byline goes here plus fade AT A GLANCE • text goes here. • text goes here. • text goes here. would traditionally undergo trabe- culectomy and have found this to be successful in the majority of cases," Dr. Kahook said. "I think that the less invasive procedures should be given a chance prior to full-thick- ness procedures except in rare circumstances, including patients with high episcleral venous pressure, patients with clotting disorders, or in patients with severely elevated pressure in the setting of active uve- itis or neovascular glaucoma." Microinvasive glaucoma surgery also offers a bridge between starter treatment, such as the use of topical medications or laser trabeculoplas- ty, and more advanced treatment, such as trabeculectomy, Dr. Shareef said. "This is like someone being placed on heart medications and if this intervention failed, they would undergo open heart surgery. Bal- loon angioplasty now provides an intermediate step for such patients. Similarly, MIGS provides a more practical intervention for those with mild to moderate glaucoma while avoiding potentially serious compli- cations from ab externo glaucoma procedures," he said. The surgeons interviewed agreed that all the currently available MIGS procedures are equally challenging but straightforward—provided the surgeon is proficient in intraopera- tive gonioscopy. To assist surgeons in gaining familiarity with surgical gonioscopy, Dr. Shareef has pub- lished articles on the topic and has a nonprofit educational website at www.anglesurgery.org. Also important is use of the go- nioscopy lens in the nondominant hand and familiarity with angle anatomy, Dr. Kahook said. EW Editors' note: Dr. Brown has financial interests with Glaukos. Dr. Francis has financial interests with Allergan (Dublin, Ireland), Endo Optiks/Beaver Visitec (Waltham, Massachusetts), Lumenis (Yokneam, Israel), and NeoMedix. Dr. Kahook has financial interests with Alcon (Fort Worth, Tex- as), Allergan, and New World Medical. Dr. Shareef has no financial interests related to his comments. Contact information Brown: reaymary@comcast.net Francis: bfrancis@doheny.org Kahook: malik.kahook@ucdenver.edu Shareef: shakeel_shareef@urmc.rochester.edu • Patient preference. Occasionally, patients have undergone an ab externo invasive surgery in one eye with a subsequent adverse outcome, Dr. Shareef said. They experienced foreign body sensa- tion from conjunctival sutures, bleb dysesthesia, or found it difficult to use postop eye drops with a tapering dose over several weeks and preferred to have MIGS in their second eye, he said. Performing standalone, combined MIGS Surgeons well-versed in MIGS per- form both standalone MIGS as well as MIGS with phacoemulsification. However, the combined approach is fairly common. "In my academic tertiary care hospital system, the ma- jority of my surgeries are now in this category," Dr. Shareef said. "I per- form at least a dozen such surgeries in a month, many with two iStents or combined with endocyclophoto- coagulation depending on the target IOP I want to achieve." If a patient is phakic and has any degree of a cataract, Dr. Francis usually opts for a combined proce- dure, even if the patient is 20/30 or 20/40. In patients who are phakic but 20/20 or 20/25, Dr. Francis will do a standalone MIGS. "I think a combined procedure does give a little extra pressure low- ering, but there's still good efficacy with the standalone procedure," Dr. Francis said. Dr. Shareef sometimes combines two MIGS procedures to help lower IOP and halt or slow glaucoma pro- gression. "This is especially the case in someone who may not tolerate a more invasive surgery or is unable to return for frequent postop follow-up visits," he said. Combined MIGS can help lead to less frequent drop use over a patient's lifetime, he added. For his part, Dr. Brown does not combine MIGS procedures. "I gener- ally only do iStents in conjunction with cataract surgery. In standalone procedures, I would do a goniosco- py-assisted transluminal trabeculoto- my or a goniotomy with the Kahook Dual Blade [New World Medical, Rancho Cucamonga, California] or Trab360 [Sight Sciences, Menlo Park, California]," he said. The entry of MIGS into the treatment armamentarium has generally reduced the number of trabs/tubes cases. "I have been performing angle-based surgery on more advanced glaucoma cases that Selecting continued from page 54

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