GLAUCOMA EWAP JUNE 2023 47 said he would go back in would be around 2 months after a procedure, though it’s uncommon. These would be cases where the patient’s collectors weren’t going to work no matter what, or perhaps the stent isn’t in the right spot. “If you’re taking a patient in [and doing a MIGS procedure] for drop irritability or compliance issues, you should make sure your procedure can reduce medication load,” Dr. Sheybani said. “I always tell patients that it’s a marriage between the medicines and the surgery.” Sometimes the surgeries can’t lower the pressure to what it needs to be, and medicines will get these patients the rest of the way, he said. Dr. Mosaed said that she finds that patients are often still enjoying a pressure reduction years later. “I think patients fall into two broad categories: those in whom it’s very minimally effective and doesn’t do much for them, and those in whom they get a nice robust pressure response, and in those, it does tend to be sustained for many years,” she said. Even though you’re bypassing the trabecular meshwork where you would expect any steroid effect to be playing a role, Dr. Mosaed said there’s still a lot of fluctuation in pressure during the early postop period when patients are using steroids and physicians are titrating their glaucoma medications and trying to figure out where they land. “I will give them at least a couple of months to figure out if we need something more,” she said, adding that in the rare case that the patient has a sustained IOP spike, she will take them to surgery quickly. When discussing combination MIGS, Dr. Sheybani said two MIGS you often hear being used in combination are the Hydrus and OMNI Surgical System. He said he doesn’t usually combine devices though. One reason for this is that he trains fellows, and he needs them to understand what each device does individually. Dr. Mosaed said that she has seen many people use MIGS devices in combination, but she does not. “If you’re attempting to do moderately effective procedures in combination to try to get the pressure down dramatically, these all add cost and additional unknowns on top of one another,” she said. “Most of the MIGS do function through similar methods, like bypassing the trabecular meshwork. If you’re doing MIGS that function through different mechanisms of action, combining those might be a better approach.” In general, though, Dr. Mosaed said, doing combination MIGS might not make sense “when you do have trabeculectomy that is cheap and effective and when done by the right hands can give excellent results. “Having had so much experience with a wide range of MIGS and long-term results, I’m a believer and it has a place in my armamentarium. However, I still have a deep respect for trabeculectomy and tube shunts,” she said. “I think knowing how to do a good trabeculectomy is very much a value, and I don’t want MIGS to appear so technically less demanding as to make people lose interest in maintaining trabeculectomy skills.” This is key in the training of residents and fellows, Dr. Mosaed said. It’s critical to provide solid trabeculectomy training because it’s the single most effective IOP-lowering procedure to date. “Many of these training programs are teaching more MIGS, less valveless tubes and even less trabs,” she said. “Coming from a place where I’ve done all of them for 20 years, I can say that they all have their place, but nothing beats a trab.” Discussing trabeculectomy, Dr. Sheybani described it as a “powerful surgery,” but he said the consequences can be powerful, too. With MIGS, the risk for vision loss related to surgery is lower, but these devices don’t lower the pressure as much. Much depends on the timeframe and how early you’re able to treat the patient. “If we operate earlier and can predict who’s going to get into trouble sooner, I think these MIGS procedures have even more value,” he said. Dr. Singh noted the importance of continuing to train surgeons on traditional glaucoma procedures even as the MIGS field advances. “I foresee a public health problem in the future if there aren’t enough people trained in trabeculectomy to prevent those who need it from going blind from glaucoma,” he said. The field is moving in parallel, he said, with some trying to make traditional surgery better and others trying to refine MIGS to better care for those with mild disease. “To me, those aren’t mutually exclusive. You can do both,” he said. He also thinks that practitioners who did not receive the necessary training to make trabeculectomy as safe and effective as possible in their practices may gravitate to other bleb-forming options. But he agreed with Dr. Mosaed that nothing beats a trabeculectomy when done by the right hands. EWAP Editors’ note: Dr. Mosaed is Director of the Glaucoma Service, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, and has interests with Alcon and Sight Sciences. Dr. Sheybani is Associate Professor, Ophthalmology and Visual Sciences, Washington University School of Medicine in St. Louis, Missouri, and has interests with AbbVie, Alcon, New World Medical, Nova Eye Medical, Santen, and Sight Sciences. Dr. Singh is Professor and Chief of the Glaucoma Division, Stanford University School of Medicine, Palo Alto, California, and has interests with Alcon, Allergan, Glaukos, Santen, and Sight Sciences.
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