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59 EW GLAUCOMA December 2017 standalone procedures or in com- bination with phaco, and we can target the conventional outflow pathway, the non-conventional outflow pathway, and the subcon- junctival pathway. Different patients will be better served by different procedures, which is why I think surgeons should get comfortable with multiple devices and tech- niques. Also, being comfortable with multiple devices means you can treat the same patient multiple times over the course of his or her life. For instance, in the phakic patient you could perform a goniotomy proce- dure, and when that patient devel- ops a cataract, you could remove it and place a stent in the uveoscleral space at the same time. Down the line if more IOP lowering is needed you could place a subconjunctival stent. At any point, you could also consider performing ECP to decrease aqueous production. With several techniques in your toolbox, you get to a point where most of your glau- coma patients become eligible for a MIGS procedure." EW Editors' note: Dr. Craven has finan- cial interests with Alcon (Fort Worth, Texas), Allergan (Dublin, Ireland), Ivantis (Irvine, California), Pfizer (New York, New York), and Santen (Osaka, Japan). Dr. Williamson has financial interests with Alcon, Allergan, Glaukos (San Clemente, California), and New World Medical (Rancho Cucamonga, California). Contact information Craven: ercraven@yahoo.com Williamson: blakewilliamson@weceye.com to see miserable cases because we did not have it sorted out yet, but now, most patients walk out happy." Dr. Craven said that patients visit their eye doctor for one of two general reasons: a visual complaint or high IOP. Patients who present with early glaucoma may not fit the profile for MIGS, with many MIGS insurances and label eligibilities being linked to cataract surgery. This may keep them from getting MIGS, even though it would benefit them. "In the U.S. we tend to do cataract surgery at a different time than in other parts of the world," Dr. Craven said. "Cataracts tend not to be as visually debilitating as they are in Europe. Patients will visit their eye doctor with early glaucoma, for in- stance, complaining about the cost of the medication and will be con- sidered for MIGS, before cataract is necessarily a major issue. Frequently, the surgeon considers MIGS first and cataract surgery second, whereas in Europe, it has more of a visual de- bilitation cause, which is why MIGS is less often done combined there. Outside of the U.S., several of the MIGS have a standalone indication. I suspect that is going to come here in the next few years, which will change the way we use MIGS." Investing in your eyes Most eye doctors identify MIGS as part of the future of glaucoma treatment, whether they are using it or not. "I often say that MIGS is about buying time and saving real estate," Dr. Williamson said. "Lucki- ly, we now have devices that can be used in every stage of glaucoma as "There are ways to recommend surgery for someone when a proce- dure is off label," Dr. Craven said. "We do an advanced beneficiary notice, in which we speak with the patient about paying out of pocket. Depending on the costs of surgery and the finances of the patient, the patient may elect to proceed with an out-of-pocket procedure. But the vast majority of patients, at least in the academic center where I work, want to stick with whatever treat- ment is covered by the insurance. The insurance companies label new things as 'experimental.' This makes it sound as if we are experimenting on patients, which is not true. They use this wording to set the patient off from our recommendations and to have a way of validating their rejection. But with all of those forces swirling around out there, some of us still choose to go off label because we think it is better for the patient. Other times we will choose a different option. Or we will intervene with the cataract surgery and include a MIGS, since if the patient has a glaucoma issue, it tips our hand." Get prepared The more MIGS the eye surgeon is comfortable performing, the better prepared he or she will be. Dr. Craven performs MIGS regular- ly and thinks it is important that his fellows learn how to implant different MIGS devices. "We implant a mixture of MIGS devices because all of them have their place in glaucoma surgery to some degree," he said. "I am getting a little more clarity on who needs which one and under which circumstances. MIGS is always the initial consideration. I don't know how many thousands of trabeculectomies I performed and dealt with for years, with all the problems that came along with that, like mitomycin-C and leaking blebs. Trabs, however, give us low pres- sures, and I am still trying to figure out how to push MIGS as far as I can to get pressures close to what I see with a trab. I still do trabs regularly. I think everything still has its place. Maybe the miracle procedure will come along and replace the filtering surgeries, but I have not found it yet. But if I compare what we have now to 30 years ago, patients have significantly better outcomes. I used who are eligible to receive them, especially if he is already treating them for cataract. While MIGS de- vices are not a must in the treatment of glaucoma, they offer a viable, effective alternative to cumbersome drop regimens. "It's similar to not treating a patient's astigmatism in my mind. I'm not going to leave someone with two diopters of cylinder, and similarly I don't want to leave them on two drops that are drying out their corneas and their bank account," he said. "I think glaucoma is a surgical disease, and treatment should be interventional in nature. The data is overwhelm- ing in showing that patients aren't compliant with their drops. Putting glaucoma patients on drops in- stead of treating them surgically is not setting them up for long-term success. The benefits of 100% MIGS would be numerous. The surgeon would know exactly what treatment the patient was getting, instead of trying to estimate what percentage of drop therapy the patient was getting, which based largely on patient feedback, may or may not be truthful; patients would be able to save money that they would have been spending on costly eye drops each month; finally, patients would feel and see better due to the cornea and ocular surface being healthier from less glaucoma drops." According to Dr. Williamson, it would pay for comprehensive eye doctors and cataract surgeons to become more comfortable in the chamber angle and with the use of multiple MIGS devices. "I always say MIGS is inevitable. It's not going anywhere, and the market is pro- jected to be in the billions in a few years. My advice is to buy a ticket and get on the bus instead of being left at the station. Plus, it's great for patients, getting them off drops and buying more time before invasive surgeries are needed," he said. Footing the bill Economic factors play a key role in putting patients off of MIGS. Dr. Craven thinks that patients may well see the benefits of MIGS, but as long as they have to foot the bill, they will often opt out. The high, almost prohibitive price of glaucoma drops in the U.S. can act as a strong incentive for patients to adopt MIGS devices, in some cases. Clinical Crossfire: MIGS Decision Making Curriculum 365 This activity is approved for AMA PRA Category 1 Credits. TM New Orleans 2017 NEW TALK SHOW FORMAT Experts discuss key issues in the rapidly changing area of MIGS in this EyeWorld Clinical Crossfire, a unique CME program featuring a videotaping of the faculty in a talk show format.

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