GLAUCOMA EWAP MARCH 2023 37 C ombining MIGS procedures is something James Murphy, MD, considers if he wants to get the most IOP-lowering effect balanced with a minimal surgical risk profile. “I routinely combine MIGS procedures that target different contributors to the conventional inflow/outflow system of the eye,” he said. As an example, he described combining a canaloplasty with a MicroPulse CPC (Iridex) laser treatment or canaloplasty with goniotomy and a trabecular microbypass stent. “I sometimes combine subconjunctival MIGS with MicroPulse CPC as well,” he said. “Typically, I am targeting patients with mild to moderate open-angle glaucoma, patients with additional risk factors for complications from shunts or blebs, and patients for whom having one of the traditional glaucoma procedures may not fit well with their lifestyle. Sometimes patients present with an already well-informed impression of what types of glaucoma surgeries fit with their lifestyle and risk tolerance.” Dr. Murphy added that there are patients who have already had a tube shunt or trabeculectomy in the fellow eye, had a bad experience, and are therefore resistant to having the same or a similar procedure in the second eye, even if that by Ellen Stodola Editorial Co-Director Contact information Murphy: jamestmurphyiiimd@gmail.com Razeghinejad: reza@willseye.org procedure may be the most likely to achieve target IOP. “As a glaucoma surgeon, I use the preoperative counseling session as my opportunity to gauge what the patient’s acceptance of partial success or tolerance for failure would be. I want to avoid a patient who fails a MIGS procedure and is unwilling to follow through with an escalation in surgical care if the need arises.” Reza Razeghinejad, MD, said that he would be more inclined to combine MIGS procedures in those patients with higher IOPs when it is preferable to avoid filtering procedures or in those needing lower target IOPs. Generally, MIGS is used in mild and moderate glaucoma patients, he said, but it may be used in severe glaucoma patients requiring a decrease of a few points of IOP, especially those patients with unfavorable outcomes with filtering surgery in the contralateral eye. “When we plan to combine MIGS, we are looking for more IOP reduction due to higher baseline IOP, more optic nerve damage requiring lower target IOP, or discontinuing of some of the medications,” Dr. Razeghinejad said. “We do not have any evidence-based data on combined MIGS efficacy and safety; currently physicians are combining MIGS based on their personal experience and the current literature on standalone MIGS.” Dr. Murphy said there are cases in which it would be acceptable to perform MIGS if the patient is properly counseled that while MIGS offers an attractive risk profile, they are less likely to achieve target IOP, and the chances are higher that additional, more invasive glaucoma surgery will Using the RPT forceps (MicroSurgical Technology) to maneuver the iTrack (Nova Eye Medical) LED lighted tip microcatheter into Schlemm’s canal for 360-degree canaloplasty. Source: James Murphy, MD Combining MIGS procedures This article originally appeared in the December 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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