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71 EW GLAUCOMA May 2017 by Liz Hillman EyeWorld Staff Writer In addition to being comfort- able with gonioscopy, angle anat- omy, and using a single hand to perform the procedure, Dr. Berdahl added that the manufacturers of the MIGS devices have "excellent train- ing programs." "So, don't rush through the on- line and wet lab training. It's helpful so do it well," he said. On the conceptual side, Dr. Condon said, young ophthalmolo- gists have to recognize the advantag- es—and limitations—of MIGS. "[Understand] what strata it fits in in the different levels of interven- tions and what you can expect from it," Dr. Condon explained. Dr. Berdahl said another barrier for young eye surgeons on the MIGS front could just be surgical volume. "As you're growing your practice, you may not get as many shots on goal because you just don't have quite the same level of volume as you're building your surgical prac- tice," he explained. adaptable. It's a lot easier to adopt new technologies, and it's probably easier to develop a habit of adopt- ing new technologies when you're young than trying to do it later in your career," he said. Overcoming barriers to MIGS Barriers that young eye surgeons might face when first getting into the MIGS space in general can be similar to that of more seasoned ophthalmologists. First and foremost for angle-based procedures is being comfortable with angle anatomy, said Garry Condon, MD, associ- ate professor, College of Medicine, Drexel University, Pittsburgh. From a surgical standpoint, it takes some practice to get comfortable with the two-handed approach—with one hand holding the gonioprism and the other manipulating the device, Dr. Condon said. He actually advised practicing gonioscopy at the end of a standard cataract surgery to get a feel for angling the patient's head and microscope, using the gonio- prism and viewing the angle in the operating room. M icroinvasive glaucoma surgery (MIGS) is still a new kid on the block in the world of ophthalmic surgery. Only 30% of surgeons responding to the 2016 ASCRS Clinical Survey reported using MIGS in their practice. In echoing the sentiments of our interviewed experts, I would contend that young eye surgeons are particularly well positioned to incorpo- rate MIGS into their surgical skill set. Even if newly practicing ophthalmologists did not receive significant exposure to MIGS during their training, these surgeons are not far removed from needing to meet the disparate demands placed upon them by attending surgeons to constantly alter and refine their surgical techniques. Maintaining this nimbleness in clinical practice lowers the barrier to adopting unfamiliar tech- niques, including MIGS. Surgical devices and techniques falling under the category of MIGS will continue to grow in number in the coming years, and familiarity with these techniques will be a necessity for all cataract surgeons seeing patients with coincident glaucoma. In this month's column, we call upon John Berdahl, MD, Garry Condon, MD, YES Clinical Committee member David Crandall, MD, and Yao Liu, MD, for their insights into adopting MIGS in clinical prac- tice, including tips on overcoming barriers to implementing MIGS, patient selection, and postoperative care. Charles Weber, MD YES connect co-editor Emerging technologies: MIGS continued on page 73 YES connect Inserting the iStent into the trabecular meshwork Source: John Berdahl, MD What you need to know about adopting newer surgical glaucoma treatment options W hen it comes to the emergence of mini- mally invasive glau- coma surgery (MIGS), ophthalmologists are continually refining their approach to these relatively new devices and techniques and how different strat- egies could fit together to improve patient care. While there are some common challenges for all ophthal- mologists starting to adopt MIGS, young eye surgeons, in some ways, might have an upper hand. "I think the barriers are lower for young eye surgeons than for some who are older," said Yao Liu, MD, assistant professor, Depart- ment of Ophthalmology and Visual Sciences, University of Wisconsin, Madison. "As a younger surgeon, your experience of doing procedures that are relatively new to you is still fresh." John Berdahl, MD, Vance Thompson Vision, Sioux Falls, South Dakota, expressed a similar senti- ment. "As a young eye surgeon, you learn to adapt to each attending's nuances and try to pick up the best things from each attending, and you become a very flexible surgeon. When you get out into practice, the natural tendency is to get into a rut, determine your favorite style, and not deviate from that. I'd encourage young surgeons to (1) continue to do things that aren't your natural comfort zone and (2) leverage the advantage that you're still very

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