Eyeworld

EW FEATURE 42 Intersection of refractive surgery and MIGS • April 2018 by Ellen Stodola EyeWorld Senior Staff Writer W ith the approval of many new MIGS devices in the past several years, sur- geons choosing to incorporate them into practice must consider the learning curve that comes with each device and the skillsets needed to develop exper- tise with these procedures. Linda Huang, MD, Glaucoma Institute of Northern New Jersey, Rochelle Park, New Jersey, Thomas Samuelson, MD, Minnesota Eye Consultants, Minneapolis, Jacob Brubaker, MD, Sacramento Eye Consultants, Sac- ramento, California, and Michael Patterson, DO, Eye Centers of Ten- nessee, Crossville, Tennessee, shared their views on the MIGS learning curve and highlighted consider- ations for comprehensive and refrac- tive surgeons wanting to use these devices. Some MIGS procedures include the iStent (Glaukos, San Clemente, California), the XEN Gel Stent (Allergan, Dublin, Ireland), and the CyPass Micro-Stent (Alcon, Fort Worth, Texas). Surgeons offer information on the MIGS learning curve, barriers to adoption, and how comprehensive and refractive surgeons can use MIGS induced astigmatism based on the individual eye." Overall, Dr. Sarkisian said some ophthalmologists involved in tertia- ry care of glaucoma patients might not be used to having conversations about premium lenses, but they should start. "Don't make assumptions about what your patients are willing to do just because they have a diagnosis of glaucoma. Don't assume that your glaucoma patients don't want spectacle independence for at least distance vision," Dr. Sarkisian said. The physicians said it's import- ant to talk with patients about both toric and presbyopia-correcting lens- es, even if they're not a candidate. Dr. Sarkisian will say, "'You may have heard from some of your friends about getting an upgrade with your intraocular lens or paying cash above what your insurance pays for lenses that help you see both far and near. I'm not recom- mending that for you because of your visual field loss. I think that you would not benefit from those, and they may actually make your vision not the highest quality that I can offer you.' I've never had a patient argue with me after I've told them that." Dr. Trubnik provides a similar explanation and tells the patient that she is trying to do what is in their best interest. "With the advent of technol- ogy, in order to allow patients to have better quality of life with their vision and less dependence on glasses, I think my glaucoma colleagues should arm themselves with the education to provide these options to our patients," Dr. Okeke said. "They can have glaucoma and still have good quality of vision and good quality of life by being able to have the advantages that premium lenses and astigmatic correction can give them. It's important for us to be able to educate them about that aspect. If you're not doing these procedures, allow collaborations with your anterior segment col- leagues to help in their care." EW References 1. Ichhpujani P, et al. Premium IOLs in glauco- ma. J Curr Glaucoma Pract. 2013;7:54–7. 2. Wang JC, et al. Effect of endocyclophotoco- agulation on refractive outcomes in angle-clo- sure eyes after phacoemulsification and pos- terior chamber intraocular lens implantation. J Cataract Refract Surg. 2016;42:132–7. Editors' note: Dr. Okeke has financial interests with Alcon, Glaukos, and NeoMedix (Tustin, California). Dr. Sarkisian has financial interests with Alcon and Glaukos. Dr. Trubnik has no financial interests related to her comments. Contact information Okeke: COkeke@vec2020.com Sarkisian: Steven-Sarkisian@dmei.org Trubnik: vtrubnik@ocli.net about a patient whose level of ex- pectation is on the higher side, one might consider opting for a different procedure," Dr. Okeke said. Dr. Sarkisian said though a rare event, he tends to shy away from using the CyPass in patients getting bilateral Symfony lenses. From a refractive standpoint, Dr. Okeke said it's important for surgeons performing MIGS to know their surgically induced astigmatism. "The way I operate, I sit superiorly. When I do my MIGS procedures, I move and sit temporarily, but I'll shift back to do the cataract surgery. Depending on which eye I'm doing, I might have another incision in the eye and my surgically induced astig- matism is different," Dr. Okeke said. "I have to take this into account when I am making my measure- ments to correct astigmatism in a patient or if I'm putting in a pre- mium lens, I have to make sure the calculations to correct astigmatism are on point, using my surgically AT A GLANCE • Most surgeons agree that there is a learning curve associated with MIGS, and this often involves making sure you're familiar with intraoperative gonioscopy and angle anatomy. • Several surgeons noted that they use a Swan-Jacob gonio lens when doing intraoperative gonioscopy. • MIGS may be a particularly good option for cataract and refractive surgery patients because of its microinvasive nature. Adopting MIGS into practice Considering continued from page 41 MIGS learning curve There is a learning curve for adopt- ing MIGS, Dr. Huang said. "Many procedures involve the angle, and intraoperative gonioscopy is a skill that is not commonly used in the operating room," she said. "Rec- ognizing and identifying angle anatomy intraoperatively is also a skill to develop." Dr. Huang added that once these two are mastered, they can be applied to many MIGS devices. "Then there are specific skills unique to individual devices, but mastery of one device usually translates to other devices." Dr. Patterson agreed that there is a learning curve, particularly in making sure that physicians are capable of understanding the angle and are proficient at doing intraop- erative gonioscopy. "That is a totally different animal for MIGS surgery than it is in the clinic," he said, adding that if you can understand placement and anatomy of the an- gle, you're pretty much set. Dr. Patterson is a big proponent for doing preoperative gonioscopy. A lot of ophthalmologists rely on optometrists or outside providers to do the preoperative exam, he said, but then you don't know what you're looking at when you get into the OR. The biggest learning curve with MIGS is using the gonioprism for good visualization of the angle structures, Dr. Brubaker said. "The other challenge that can be diffi- cult initially is that the surgeon is restricted to using only one hand in the eye while the other hand is oc- cupied holding the gonioprism," he said. Most surgeons learning MIGS begin with trabecular meshwork-tar- geted procedures like the iStent, Dr. Brubaker said. "Although the iStent has a slightly longer learning curve than some of the other MIGS, I think this is a good place to start," he said. "This procedure has a lower risk profile than other MIGS." He noted that the "trick" with iStent placement is ensuring that the stent is well seated in the canal and not placed too superficially. "I think this takes 10–15 cases to get a complete feel for proper placement," he said.

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