EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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58 EW GLAUCOMA February 2011 October 2012 Glaucoma editor's corner of the world Meeting of the minds: Glaucoma at the cutting edge by Maxine Lipner Senior EyeWorld Contributing Writer Leading practitioners convene to discuss innovations s MIGS technology is developed for glaucoma, there is an increasing need for a forum focused specifically on surgical issues unique to MIGS. The Cutting Edge: Innovative Glaucoma Surgery Symposium was started by Ike Ahmed, M.D., and Rick Lewis, M.D., to fill this need, and we are fortunate to have their insights in this month's "Glaucoma corner of the world." We also have the reflections of Malik Kahook, M.D., and Randy Craven, M.D., on topics covered at this year's 4th annual symposium. A The Cutting Edge symposium brings together surgeons and basic scientists who are working in the MIGS area and also inter- ested industry representatives. The agenda aims to encourage open discussion among all the stakeholders in these exciting new technologies. The history of other break- through technologies—like IOLs or vitrec- tomy—shows that new organizations based around them are critical to their develop- ment and dissemination. There currently is just one national glaucoma organization, the American Glaucoma Society (AGS). While the AGS has surgical issues on its program at its national meeting, it covers all glaucoma topics— medical treatment, imaging, visual fields, diagnosis, screening, etc. There simply is not enough time within the broad AGS framework for the in-depth discussion of MIGS that surgeons and industry need for this emerging group of technologies. This relative vacuum creates a huge opportunity for a symposium like Cutting Edge to become the focal point for MIGS discussion and development. Reay Brown, M.D., glaucoma editor M IGS (micro-invasive glaucoma surgery) was one of the watchwords at the fourth annual Cutting Edge: Innova- tive Glaucoma Surgery Symposium held this summer, in Newport Beach, Calif. This think tank-like gathering took place just prior to the FDA approval of the iStent (Glaukos, Laguna Hills, Calif.), a glaucoma device heralded for being minimally invasive. Those attending included 30-40 leaders in the field, according to Richard A. Lewis, M.D., Sacra- mento, Calif., who co-founded the meeting along with Iqbal "Ike" K. Ahmed, M.D., assistant professor of ophthalmology, University of Toronto. "We wanted to get together a group of clinicians, researchers, and industry people who were in- volved and interested in the latest glaucoma devices," Dr. Lewis said. Dr. Ahmed described the envi- ronment here as one replete with roundtable discussion on sometimes difficult topics. "This time we talked a lot about MIGS, which is a term that I had coined 4 years ago," Dr. Ahmed said. "We had a good healthy discourse on how do we define MIGS," he said. "When I first came up with the term, I had a very loose idea, and I think that we tried to nail it down a little bit more in terms of what this means." Talking MIGS One of the presentations that Dr. Ahmed gave was on the cardinal fea- tures of MIGS. "These are procedures that are micro-incisional," he ex- plained. "They're small, typically clear corneal incisions, not involved in the conjunctiva, so the invasive- ness of the procedure into the eye is minimal." He described the proce- dure as one that is minimally trau- matic with very little disruption to physiologic function of the eye. Safety of MIGS was another feature discussed and is something that Dr. Ahmed terms "second to none." An iStent going into the angle Source: E. Randy Craven, M.D. Also, the efficacy of MIGS devices and their ability to continue to work were considered. Furthermore, he stressed that adaptability is the final cardinal feature, describing this as the flexibility to combine MIGS with other approaches such as cataract surgery. Such adaptability also involves considering how easily surgeons of different skill levels in varying environments are able to use this technology. "Anything that would involve cutting the conjunctiva, scleral dissection, wouldn't be part of MIGS, in my opinion," Dr. Ahmed said. "All of the work to do those procedures would be quite trau- matic." One final hallmark of MIGS is the fact that it doesn't burn any bridges for future procedures. "By not having to open up the conjunc- tiva, MIGS procedures leave the door open if there needs to be further, more aggressive surgical procedures, for example, trabeculectomy," Dr. Ahmed said. Among those devices that Dr. Ahmed thinks fit the MIGS bill are the iStent, the Trabectome (NeoMedix, Tustin, Calif.), the CyPass glaucoma implant (Tran- scend Medical, Menlo Park, Calif.), the Hydrus device (Ivantis, Irvine, Calif.), and the AqueSys implant (AqueSys, Irvine, Calif.). Malik Y. Kahook, M.D., profes- sor of ophthalmology, University of Colorado, Aurora, who spoke at the meeting on the iStent, describes the recent FDA approval of the device as having ushered in a new era in the way mild to moderate glaucoma can be managed. "Being the first MIGS implant that the FDA has approved certainly has brought a lot of excite- ment to the field of glaucoma where in the past we have not seen much advancement in how we manage patients surgically," Dr. Kahook said. "The big question at this point will be how this device performs in real-world settings." In his talk, Dr. Kahook reported results from a study in which com- puter software was used to simulate how the iStent might act after im- plantation in a model of the human eye. Investigators also considered how multiple iStents would perform. "We compared one versus two iStents and tried to understand device efficacy—to tease out some of the subtle findings using the com- puter software," Dr. Kahook said. "What we found was that one iStent was fairly effective in decreasing