EyeWorld Asia-Pacific March 2016 Issue

57 EWAP DEVICES March 2016 by Michelle Dalton EyeWorld Contributing Writer MIGS devices and cataract surgery continued on page 58 Should surgeons always combine the two, or can the newer devices stand alone? M icroinvasive glaucoma surgery (MIGS) has revolutionized how surgeons are able to control intraocular pressure (IOP)—and the devices used in these procedures often lend themselves to an adjunctive procedure if the patient has a visually significant cataract as well. With four potential areas for a MIGS procedure to work (Schlemm’s canal, suprachoroidal space, aqueous humor production, and subconjunctival space), and three types of surgical approaches (ab interno, small incision, and conjunctival- sparing), there are significant advantages to using MIGS devices. But are they “good enough” to become standalone procedures? Or will they likely be used in conjunction with cataract surgery for the time being? Or can cataract surgery be enough to adequately control IOP? EyeWorld asked some leading experts to weigh in. “Cataract surgery by itself is still a viable option but is not appropriate for every patient,” said Brian Francis, MD , associate professor of ophthalmology, Doheny Eye Institute, Geffen School of Medicine, UCLA, Los Angeles. Currently, the “only procedure that falls within Medicare guidelines to get paid as a standalone MIGS procedure is the Trabectome [NeoMedix, Tustin, Calif.],” said Douglas J. Rhee, MD , chair, Department of Ophthalmology and Visual Sciences, Case Western Reserve University Hospitals Eye Institute, Cleveland. For now, “it will always be cataract and MIGS together, as all the MIGS studies are cataract vs. cataract plus MIGS.” The “foundation” and the genesis for MIGS is that phacoemulsification has a favorable effect on IOP for most patients, and surgeons are “going to the operating room anyway for the cataract surgery. With MIGS we add a procedure that’s synergistic to the favorable effect of the cataract removal without significantly increasing the risk of the procedure and without adverse effects on the visual or refractive outcome,” said Thomas W. Samuelson, MD , attending surgeon and a co-founder, Minnesota Eye Consultants, Minneapolis. Admittedly, MIGS has more modest efficacy than traditional glaucoma surgery. However, combining the best of MIGS with the best of pharma may be a winning combination. “Among the goals of traditional glaucoma surgery has been the elimination of medications, but if someone can be managed by using a single drop a day, or (in the future) a single subconjunctival or intraocular injection every 6 months with sustained delivery systems, or a safe, gentle laser procedure, combining such realistic adjuncts with MIGS expands the indications deeper into the severity spectrum.” MIGS has established a foothold in the management of glaucoma, “but I don’t know that there will be a standalone procedure any time soon as the ‘first step’ in the management of glaucoma,” Dr. Samuelson said, unless the patient is intolerant The CyPass implanted Source: Transcend Medical The iStent Trabecular Micro-Bypass Source: Glaukos