EyeWorld Asia-Pacific September 2021 Issue

FEATURE 12 EWAP SEPTEMBER 2021 by Chiles Aedam R. Samaniego A n SNEC Instruction Course held at the 33rd APACRS– SNEC 30th Anniversary Virtual Meeting looked at the role of traditional surgery in the era of minimally invasive glaucoma surgery (MIGS) by looking at how and when not to perform MIGS. Manchima Makornwattana, MD, Thailand, kicked off the course by taking the question head on. Dr. Makornwattana said that glaucoma treatment is a life-long commitment and ranges from eye drops through laser treatments to traditional glaucoma surgery. When patients are given the choice, “100% will go for the eye drops”; however, in the long-term patients run into problems with compliance and complications such as prostaglandin-associated periorbitopathy (PAP), conunctiÛal fibrosis, blepharitis, and dry eye syndrome (DES). Meanwhile, laser treatments are effective but temporizing procedures at best and traditional surgery remains the This article was adapted from the ye7orld Ƃsia-*acific daily coverage of the 33rd APACRS–SNEC 30th Anniversary Virtual Meeting, held online from 30 to 31 July 2021. gold standard but is delayed for as long as possible due to side effects and serious complications. MIGS, then, Dr. Makornwattana said, help delay traditional surgery by providing add-on IOP lowering with a greater degree of safety, though they are limited by being only able to provide mild to moderate IOP lowering and requiring more skills with a not insignificant learning curÛe for surgeons. Dr. Makornwattana cited ocular conditions such as conjunctival hyperemia, previous ocular surgery, and conjunctival scars as reasons to avoid MIGS. oweÛer, she presented the case of a 50-year-old glaucoma patient who successfully underwent MIGS despite corneal injury and conjunctival hyperemia. They opted for MIGS to give the patient’s corneal surface time to recover before proceeding with glaucoma surgery. Ultimately, she said that “there is no ‘NO’ in glaucoma treatment,” meaning treatment should be tailored to each patient, with decisions made together with them and according to their particular needs to help them “keep their vision forever.” Taking the opposite tack, Graham Lee, MD, MBBS, FRANZCO, Australia, detailed when not to do trabeculectomy. e noted that the ideal patient for trabeculectomy has healthy tissue in “virgin eyes”; primary open-angle glaucoma (POAG), which doesn’t usually have a lot of inyammationÆ are receiving primary glaucoma treatment; and have compliant personalities. Trabeculectomy then is not the optimal choice for patients with scarred conjunctiva or thin sclera, secondary forms of glaucoma such as uveitic, neovascular, or aphakic glaucoma, and who have been on long-term multiple topical medications, particularly if the conjunctiva has been destroyed by eÝposure to the preserÛatiÛe benzalkonium chloride (BAK). MIGS failures MIGS promises better quality of life balanced against poor cost-effectiveness, but offering “lowered reward with the promise of much, much lower risk,” said Shamira Pereira, MD, Singapore. Dr. Pereira talked about several devices with which there has been enough eÝperience to proÛide good evidence of complication rates. Although he began by describing complications involving stent devices, he noted that MIGS designed to How and when not to do MIGS An SNEC Instruction Course at the 33rd APACRS-SNEC 30th Anniversary virtual meeting Chelvin SNG, Singapore Jayant V. IYER, Singapore Manchima MAKORNWATTANA, Thailand Graham LEE, Australia Ike K. AHMED, Canada Leonard YIP, Singapore Shamira PERERA, Singapore How (and When) Not to do MIGS.indd 1 31/08/2021 12:02 PM