EyeWorld Asia-Pacific June 2018 issue

continued on page 46 What the future holds for refractive surgery and MIGS M icroinvasive glaucoma sur- gery (MIGS) is “coming of age” as a lifestyle treatment—similar to refractive lens surgery’s earlier evolution. That was the recent assess- ment of George Waring IV, MD, founder and medical director, War- ing Vision Institute, Mt. Pleasant, South Carolina, who noted that they are complimentary proce- dures and both have a lifestyle component. “People seek out refractive lens procedures to reduce their need for bifocals and reading glasses,” Dr. Waring said. “With MIGS it is not only the opportunity to lower pressure to prevent the worsening of glaucoma, but there is also a lifestyle opportunity, so in many cases they may need less drops or no drops at all. That conversation resonates with patients.” Benefits of MIGS include eliminating or reducing the need for topical IOP-controlling drops, which can cause chronic issues with long-term use. Chronic condi- tions include ocular surface disease and cosmetically significant peri- orbital atrophy of fat and sunken orbits. “There’s a convenience factor as well as potential cosmetic con- siderations like the eyes not being as red, and long term avoidance of some of the other issues associated with drops, such as the periorbital fat atrophy,” Dr. Waring said. Gary Wortz, MD, Lexington, Kentucky, said pairing multifocal IOLs—not refractive surgery gener- ally—and MIGS is like putting an upgraded engine on an old trans- mission in a car. “In order to truly enjoy the benefits of refractive surgery, we need a healthy eye,” Dr. Wortz said. “While MIGS may mitigate disease, we are still talking about an eye at risk for significant loss of vision over time. I think the cor- rection of astigmatism is extremely helpful in these patients. However, I would still consider glaucoma a relative contraindication to multi- focality.” Moving into the future, ophthalmology needs to address refractive challenges of the glau- coma patient who has significant demands in terms of contrast sensi- tive and IOL optimization, said Sean Ianchulev, MD, professor of ophthalmology, New York Eye and Ear Infirmary, Icahn School of Medicine at Mount Sinai, New York. “We need a cohesive refractive glaucoma surgery solution where we provide both IOP control and a maximized refractive outcome,” Dr. Ianchulev said. New technology Among the new MIGS technology that most interests Dr. Wortz is the Hydrus Microstent (Ivantis, Irvine, California). With the iStent (Glau- kos, San Clemente, California) he has had mixed results—likely be- cause of his inability to target col- lector channels—but the Hydrus is a much larger stent that gives him a better chance of putting it in the right spot. Additionally, suprachoroidal and bleb-based devices are still finding their place and have a big potential upside, he said. “I'm taking a wait-and-see-ap- proach to them at the moment, but I am excited about their potential,” Dr. Wortz said. As the developer of the Cy- Pass Micro-Stent (Alcon, Fort Worth, Texas), Dr. Ianchulev is excited about use of the device in a supraciliary approach, which June 2018 44 EWAP SECONDARY FEATURE What’s coming in refractive surgery and MIGS? by Rich Daly EyeWorld Contributing Writer AT A GLANCE • The benefits of MIGS include eliminating or reducing the need for topical IOP-controlling drops. • Femtosecond technology has not proven highly applicable to the glaucoma space. • Future IOL developments may include their use as IOP telemetry or drug delivery devices. The iStent, if properly positioned, is stable and easy to evaluate with a gonio lens postop. Source: Gary Wortz, MD