We have finally arrived at a place in glaucoma therapy where we have all 3 safe surgical pathways available to us: trabecular, uveoscleral, and subconjunctival. Indeed, the trabecular options are literally exploding, with a new instrument, approach, or technology becoming available it seems every few months. Each new technique comes with it its own nuances, surgical safety and efficacy profile, and indication. One of the key differentiators among novel surgical options are whether or not they can be used on label as standalone procedures. To be clear, as surgeons we may use any stent or technique in a standalone manner, provided we give informed consent and of course help our patients understand any financial implications of doing so. Procedures that are indicated to be performed in conjunction with cataract extraction may not be reimbursed as standalone procedures. If minimally invasive glaucoma surgery (MIGS) procedures are defined as having an excellent safety profile, rapid visual recovery, minimal damage to target tissue, and at least modest efficacy, then standalone MIGS may be considered to have all of the above with the added demand that the patient must receive a clearly tangible benefit to having gone to the operating room. Cataract surgery has always been the glucose that has sweetened the bitter pill of glaucoma surgery, and without it, our standalone procedures must deliver on patient expectations. One potential solution to this problem is combination MIGS procedures, which may offer slightly enhanced efficacy with a similar safety profile as individual procedures. Ultimately, this boils down to the concept of “Interventional Glaucoma,” an idea introduced by Ike Ahmed, MD, at the Glaucoma 360 conference in San Francisco this winter. To seize the opportunity to be proactive in our patients’ care, we will indeed need to have our safe glaucoma procedures stand alone. 

Authors in this issue of Glaucoma Physician address a range of important topics, but a common theme is MIGS: how MIGS fits in to treatment of glaucoma with dry eye, how to bring MIGS to your practice, and new MIGS devices. You’ll also find discussion of diagnostic testing, laser treatment, and the medication pipeline. We hope you find some helpful tips in these pages to use in practice. GP

Nate Radcliffe, MD, is a clinical assistant professor in the department of ophthalmology at the New York Eye and Ear Infirmary and a surgeon at the New York Eye Surgery Center.

On the cover: Corneal epitheliopathy induced by topical medications, from "The Role of MIGS to Manage Glaucoma in the Dry Eye Patient," page 11.