MIGS and other procedures are changing the landscape of glaucoma management & treatment

In this issue of Glaucoma Physician, we expand into new areas, looking to build upon the information presented in the inaugural issue in March. We are entering a unique time in the world of glaucoma. Never before have there been so many new advances happening simultaneously in the medical, surgical, and diagnostic areas.

At the American Society of Cataract and Refractive Surgery meeting in Los Angeles last month, it was striking to see how much interest there was in glaucoma. Glaucoma subspecialty day seemed to offer more new information than ever before. Advances in office-based testing allow us to see and evaluate structures of the eye as they relate to glaucoma better than ever. Efforts are under way to validate technologies, such as electrophysiology and imaging of the angle. Laser treatments continue to evolve into gentler, less side effect-prone procedures. Surgical therapies are tapping into new pathways for increasing outflow safely.

Glaucoma surgery, especially performed in conjunction with cataract surgery, is no longer considered a last-ditch option after the patient has failed every other therapeutic pathway. New MIGS devices have changed both the risk profile of glaucoma surgery and surgeons’ perceptions of whether it is wise to do in conjunction with cataract surgery.

It is widely accepted that performing cataract surgery alone in a patient with early glaucoma tends to have a favorable effect on IOP control, at least for a while. Performing a MIGS procedure with iStent (Glaukos) or CyPass (Alcon), for example, or using goniotomy with the Trab360 device (Sight Sciences), Kahook Dual Blade (New World Medical), or endoscopic cyclophotocoagulation increases the probability of success in achieving a certain lower target IOP. Xen (Allergan) offers a way to achieve filtration-level IOPs without the trauma of traditional techniques. With these less traumatic procedures, there is less visual downtime and recovery required compared with traditional glaucoma surgery.

Just as we have done with glaucoma medical and office-based laser therapy, we now can customize the treatment plan to fit each patient’s profile. Those who have some trabecular function may benefit from a canal-based procedure that continues to use the enhanced dominant natural pathway. On the other hand, if that pathway is too compromised, we can go a whole new direction and shunt aqueous into the suprachoroidal space with a CyPass or into the subconjunctival space with Xen.

The other trend we are seeing in cataract surgery is the movement toward premium options for patients. More patients, especially those with glaucoma, are interested in having their astigmatism corrected or their near vision enhanced through toric, accommodating, or multifocal IOLs. In the past, we would be much more hesitant to combine surgery in patients pursuing one of these options. However, with the introduction of MIGS, combined surgery with premium options can have excellent outcomes.

In this issue, we explore the role of laser cataract surgery in the glaucoma patient. This technology presents both opportunities and challenges in this population.

It is, indeed, an exciting time in glaucoma.