EyeWorld Asia-Pacific June 2018 issue

Skills needed to implant vs. skills needed to manage According to Dr. Huang, the skills to manage postoperatively are dif- ferent than the skills needed for implantation. “The benefit of MIGS procedures is they often have lower rates of complications compared to traditional filtering surgery, such as hypotony, which can be difficult and time consuming to manage,” she said. “However, MIGS proce- dures are not free of these compli- cations.” Less invasive MIGS proce- dures, such as trabecular meshwork bypass stents (iStent) may be easier to manage than procedures that more resemble traditional surgery, Dr. Huang said, such as gel stents (XEN), which may even require postoperative bleb needling and injections of anti-fibrotics. Sig- nificant postoperative care can be a barrier to adoption of MIGS procedures, she said. “There is a spectrum of MIGS, and refractive surgeons should take into account postoperative care when deciding what devices they are comfortable implanting,” Dr. Huang said. Dr. Patterson said that in these cases it’s important for the surgeon to be comfortable manag- ing hyphema, shallow chamber, choroidal folds, and other issues that may arise. He added that he has no problems with the majority of his MIGS patients, but you do need more chair time with certain patients. Dr. Brubaker said that most sur- geons initially focus on performing the procedure itself, but once these techniques are learned, postopera- tive management becomes more crucial. With the iStent, success resolves around appropriate glauco- ma medication management in the postoperative period to avoid IOP spikes, he said. With the CyPass it is crucial to prepare the patient for the likely delayed visual recovery due to early hypotony and myopic shifts. With trabecular meshwork ablating procedures, Dr. Brubaker said, the surgeon needs to be pre- pared to deal with postoperative hyphema. “While this usually self clears, it is important to prepare the patients for this possibility and have a clear understanding when these need to be surgically washed out.” Finally, with the XEN, the postoperative management is crucial for success, he said. “Having a firm comprehension of bleb man- agement is critical for success.” “I think the bigger barrier to adoption varies by procedure,” Dr. Brubaker said. “With internal MIGS, I think the challenge pen- dulum swings toward the technical procedure itself, while the more aggressive MIGS such as GATT and XEN have a potentially more dif- ficult postoperative course.” “It is important for surgeons to understand that the follow-up care is as important, and possibly more important, than the actual proce- dure,” Dr. Samuelson said. “Glau- coma cannot be cured, it can only be managed.” He said that adequate surveillance postoperatively is mandatory for this reason. “I would discourage surgeons from adopting MIGS if they are un- willing to be accountable for appro- priate postoperative surveillance,” he said. “While it is true that many patients are co-managed in today’s medical environment, proper co- management still requires careful correspondence with the referring doctor and coordination of care, to Adopting MIGS – from page 35 June 2018 36 EWAP SECONDARY FEATURE Kahook Dual Blade goniotomy CyPass insertion iStent insertion Source (all): Michael Patterson, DO