EyeWorld India December 2018 Issue

MIGS in relation to traditional glaucoma surgery by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor AT A GLANCE • MIGS procedures could potentially help surgeons cut back on their use of traditional glaucoma surgeries. • MIGS procedures don’t have some of the risks of traditional glaucoma surgeries, but this should be weighed against the effectiveness of the procedure. Sometimes a trabeculectomy is still necessary when lower pressure is needed. • MIGS procedures could have potential in patients with a previous traditional glaucoma surgery that has failed. December 2018 28 EWAP SECONDARY FEATURE Experts discuss how MIGS may decrease the role of traditional glaucoma procedures W ith MIGS proce- dures expanding and the utility of new devices be- ing explored, glaucoma surgeons now have a variety of options for the entire spectrum of glau- coma. Valerie Trubnik, MD , Ophthalmic Consultants of Long Island, Lynbrook, New York, and Marlene Moster, MD , Wills Eye Hospital, Philadelphia, discussed how this has changed their prac- tice and the different procedures that they use. Reducing traditional glaucoma surgeries Dr. Trubnik said she has been able to cut back on the number of traditional glaucoma surger- ies she performs, and she has recently transitioned most of her trabeculectomies to the XEN Gel Stent (Allergan, Dublin, Ireland) procedure. She noted that her use of tubes has stayed relatively the same because she generally reserves this option for someone with a failed trabeculectomy or XEN stent. In her practice, Dr. Trubnik uses the iStent (Glaukos, San Clemente, California), endoscopic cyclophotocoagulation (ECP), the Kahook Dual Blade (KDB, New World Medical, Rancho Cucamon- ga, California), the XEN, and the CyPass (Alcon, Fort Worth, Texas). Dr. Moster agreed that she has cut back on the number of traditional glaucoma surgeries she does. “With the available MIGS, we’ve been able to cut down the triple procedures,” Dr. Moster said. “Where before we had mostly tubes and trabs, now we can oper- ate sooner with decreased risk.” Dr. Moster said she is cur- rently using the XEN, the iStent, the KDB, the CyPass, and gonios- copy-assisted transluminal tra- beculotomy (GATT), and she will be trying the Omni Combined Procedure System (Sight Sciences, Menlo Park, California). She also has experience using the InnFo- cus MicroShunt (Santen, Osaka, Japan) in clinical study. “The best part of the MIGS space is that the conjunctiva is preserved, so a tra- beculectomy is always an option,” Dr. Moster said. Balance of safety and efficacy Dr. Moster thinks that MIGS procedures are a safer option compared to traditional glaucoma surgeries. “They are being exten- sively studied, giving us a better understanding of their limitations and side effects,” she said. “We can now pick and choose which MIGS device is best to use for which patients.” Dr. Moster added that it’s im- portant that the surgery balance the degree of damage. “With tubes and trabs, there are increased risks including hypotony, bleed- ing, suprachoroidal hemorrhage, and flat chambers,” she said. If the patient needs a lower pressure and there’s no other way to get it without these risks, they are worth taking. “But in mild to moderate glaucoma, if we can avoid these standard risks, this is certainly an advantage,” she said. “We are still doing a lot of trabs and tubes but no longer in everyone.” “I think the XEN is a safer op- tion, and I think visual recovery is faster,” Dr. Trubnik said, add- ing that she’s more likely to use it with a toric IOL. “I used to do toric with combined trabeculec- tomy/cataract surgeries,” she said. However, Dr. Trubnik is now more likely to use the XEN in these cases because she finds less tram- polining of the anterior chamber and less likelihood of hypotony. “I think it’s a better option for patients with good central visual acuity,” she said. Dr. Trubnik thinks the XEN is safer than a trabeculectomy, and she said that the bleb is not as ischemic. “I think that the risk of infection from bleb leak is less likely with XEN than with tradi- tional trabeculectomy,” she said. As far as the CyPass, Dr. Trub- nik said she doesn’t have a lot of experience with it, and she has been wary about trying it because of reports of late myopic shift and hypotony. “That’s concerning to me—taking a patient with good central VA and promising a less invasive surgery,” she said. Poten- tial for myopic shift, even if a rare complication, is concerning to her, as is the fact that there could be sudden IOP spikes with it.