GLAUCOMA 46 EWAP JUNE 2023 medications continue to be needed. Dr. Singh said he mostly performs traditional glaucoma procedures, like trabeculectomy and tube implants. These, he said, “are the ones that can sometimes prevent patients from going blind from glaucoma.” He sees MIGS as an option for patients with mild to moderate disease or controlled glaucoma and a need for cataract surgery. “But for patients who have a substantial risk of blindness from glaucoma, MIGS are much less likely to get you to the pressure goal, and you often need to accept the risks that come with trabeculectomy to have a reasonable chance of preserving vision,” Dr. Singh said. “I think the greatest value of canal-based MIGS is that each eye undergoes cataract surgery only once, presenting an opportunity to adjunctively do something good for the glaucoma. … You can piggyback onto cataract surgery, which alone results in IOP lowering, and get an additional benefit from the MIGS procedure.” With a variety of MIGS devices and procedures available, Dr. Sheybani said the choice depends on the disease. First, he mentioned partial goniotomies, which he expects would be done at the time of cataract surgery and can get pressure to 14–15 mm Hg. Dr. Sheybani added that you should be able to get patients off one or two classes of medications with this. “If they started at two to three, they might be down to a drop at 1 year,” he said. If using partial goniotomy as a standalone procedure, Dr. Sheybani said it’s unlikely to show a large pressure drop. When he performs goniotomy as a standalone, he said it’s usually 180–360 degrees. “We have the iTrack catheter [Nova Eye Medical], OMNI Surgical System [Sight Sciences], sutured GATT, and they can get pressure down as a standalone procedure.” However, there is a risk of bleeding. Secondary open-angle glaucoma patients do much better in those cases, he explained. “We’ve had uveitics with pressures in the 40s who you can get down into the teens and off their drops, if you get to them early enough,” he said. Dr. Sheybani said if he’s already worked in the angle, he will not go back in if the patient isn’t where they need to be. He will engage a subconjunctival option if he’s already tried an angle procedure, like stenting or goniotomy. That’s where the conversation gets a little more nuanced, he said. With a stent, like Hydrus (Alcon), you have the ability to access at least a few collector channels with the way it is placed. Compared to the first-generation iStent (Glaukos), Hydrus has a better pressure reduction and less need for secondary surgical intervention, he said. Dr. Sheybani also said he will not go back in the angle if he’s already been there because he wants to do as much as he can at the time of the procedure in the angle. “If I’m doing an iStent or a Hydrus, I’m trying to pick the cases where it’s going to get the maximum efficacy with that device,” he said. “We’re not going to try to push it in someone with advanced disease or someone with high pressure looking to get a dramatic pressure reduction.” Sameh Mosaed, MD, has been performing MIGS since 2003. “The IOP levels you can expect with someone on medications in whom you do MIGS in combo with phaco or even standalone is in the mid- teens, and if you supplement it with medications, you can get it to the low teens,” she said. When performing MIGS in combination with cataract surgery, Dr. Mosaed thinks it’s a good trade-off to have moderate IOP lowering with less medications. But she noted that she won’t typically perform MIGS as a standalone procedure just to reduce the medication burden. “The place where it fits into my practice as a standalone procedure is in the setting of steroid-induced glaucoma where the patient will come in with a very high pressure in the 30s–40s, sometimes 50s; the trabecular bypass procedures work well for steroid-induced glaucoma,” she said. When Dr. Singh chooses a MIGS procedure, he looks for options where there is high quality data to support the use. He noted that many of the implantable MIGS devices went through rigorous review processes for approval, so there is a lot of data on safety and efficacy. “Some of the most robust trials done by the glaucoma community were for implantable MIGS procedures,” Dr. Singh said. He thinks that the quality of long-term efficacy and safety data available for adult goniotomy is insufficient presently, thus he has not incorporated this procedure in his practice. Dr. Singh also said that reimbursement plays no role in his decision making, and he has been disappointed by trends suggesting that the use of various MIGS devices in the U.S. has been influenced by levels of and changes in reimbursement. Determining if a MIGS procedure worked or if it’s necessary to try a different approach depends on a couple of factors, Dr. Sheybani said. First is the severity of the patient’s glaucoma. “I tell patients that we might not know where the pressure will settle until a couple months after the procedure because then I’ve been able to taper steroids,” he said, explaining that you need 4–6 weeks to know the steroid effect is washed out. The earliest Dr. Sheybani
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