GLAUCOMA EWAP JUNE 2023 45 MIGS procedures have become a mainstay in the surgical treatment of mild to moderate glaucoma, but what pressures can physicians realistically expect with these? Several physicians discussed this, as well as how MIGS can fit into the overall glaucoma management process and what to do if MIGS procedures don’t achieve the desired IOP. Before getting into the discussion about IOP levels attainable with MIGS, Arsham Sheybani, MD, stressed the importance of case selection from the beginning. “You’re trying to avoid having the MIGS fail, and in general, patients who have been on medications for years or who have more advanced disease aren’t going to do well with angle procedures,” he said. “[With] MIGS in general, if you need pressures that are consistently going to be in the low-teens without medications, angle surgery is not going to be a great option,” Dr. Sheybani said. “On average, the way to avoid failure is to do [MIGS] in patients where your goal pressures are in the mid-teens, and they have some tolerability to at least one class of medications.” If you are operating on a patient’s cataract and that’s the main reason for surgery, Dr. Sheybani said it may be reasonable to try an angle surgery, but for advanced disease, if the pressure is high, there’s unlikely to be a significant reduction with angle surgery. Kuldev Singh, MD, said the IOP levels that can be expected after angle-based MIGS surgery are usually similar to preoperative IOP but with reduced dependence on medications. “I think that’s the most achievable goal of MIGS— to reduce the number of medications,” Dr. Singh said, adding that there will be some patients who can get lower pressures if they were not on medications previously, but the main goal is to get patients off as many medications as possible. Dr. Singh thinks there will be data forthcoming that will show that if you achieve the same IOPs with or without IOP-lowering medications in similarly diseased patients, eyes that are off medications will do better in terms of visual field preservation than those where MIGS and IOP control by Ellen Stodola EyeWorld (US) Editorial Co-Director Contact information Mosaed: smosaed@hs.uci.edu Sheybani: arsham.sheybani@gmail.com Singh: kuldev@yahoo.com This article originally appeared in the April 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Creation of the needle bend for a goniotomy. Source: Arsham Sheybani, MD
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