FEATURE 22 EWAP DECEMBER 2023 T he reason for MIGS, according to Manjool Shah, MD, is to address the gap that existed with the conventional paradigm in glaucoma management — the paradigm that had patients either on “safe” options, like drops or SLT, or facing higher-risk surgeries, like trabeculectomy and tube shunts, with little in between. “The promise of MIGS is to fill that gap, specifically when it comes to safety,” he said. While MIGS do, for the most part, fulfill that promise, there can be complications during and after MIGS procedures that the surgeon needs to be prepared to identify and address. Arsham Sheybani, MD, said that if you’re performing MIGS procedures, you should be able to address the common complications that occur without needing to refer the patient to another surgeon for management, at least not immediately. Dr. Shah agreed that management of many common MIGS complications are within the wheelhouse of those performing MIGS. “If you can place the stent, if you can do the canaloplasty or the goniotomy, you’ve already performed the most nuanced surgical technique that day,” Dr. Shah said. “The hardest part of dealing with complications is recognition and choosing the appropriate intervention to manage it, and the management is completely in the skillset of those who perform the initial procedures.” Complications with stenting MIGS Dr. Shah said the most common complication with stenting MIGS, which in the U.S. include iStent (Glaukos) and Hydrus (Alcon), is malpositioning. “The key to success and safety Contact information Shah: manjool@gmail.com Sheybani: sheybaniar@wustl.edu Common complications associated with MIGS by Liz Hillman Editorial Co - Director This article originally appeared in the September 2023 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. with any angle surgery is visualization,” he said. “A good en face gonioscopic view will allow you to catch a misplaced stent easily.” If you notice that the stent is in the wrong place, generally you can reposition it, Dr. Shah said, but he noted that the current iStent Inject only has a few clicks available with the current generation injector. This issue has been addressed with the newest generation iStent Infinite, which is rolling out across the U.S. Dr. Shah said reloading an iStent into the injector is a skill. “You might need to rethread it in the anterior chamber, then redeploy it, assuming you have more clicks at your disposal. If you run out of your four clicks, you can reposition an iStent manually using some microforceps, directly placing it where you need to or move it from point A to point B.” Dr. Shah shared that over deployed iStents (usually caused by over dimpling of the cannula) can be repositioned with microforceps. To avoid under deployed stents, Dr. Shah advised applying a bit more force than you think you need, especially with the second stent. With the Hydrus, the injector system allows you to remove and replace the stent as needed. Dr. Shah also noted the importance of a 15-degree upward angle of the cannula for proper Hydrus entry, as well iTrack Advance (Nova Eye Medical); the blinking light verifies that the catheter is still in the canal to reduce the risk of a blind pass that could create complications. Source: Arsham Sheybani, MD
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