Steven R. Sarkisian, Jr. MD: I want to thank these MIGS pioneers for being part of this discussion about interventional glaucoma. All of you been part of the MIGS revolution from either the very beginning or at least very early on.

At the beginning of MIGS, even before the iStent (Glaukos) came out, the road to less invasive glaucoma was very difficult. We advocates of MIGS really had to stick together. It was really fighting for the right of our patients to get MIGS. We had to fight insurance companies, Medicare and other glaucoma doctors. There was a lot of resistance, and we had to advocate for better treatments relentlessly.

We must never forget, there was a great deal of hostility from the glaucoma community concerning these new procedures. I remember many surgeons being strongly against the EX-PRESS shunt (Alcon), then viscocanalostomy, then ab externo canaloplasty. I want to hear some perspectives from the group about the difficult road to MIGS.

Paul Harasymowycz, MD: I remember when everyone, instead of calling it MIGS, called it “MEGS” — minimally effective glaucoma surgery. When you’re trying to shift the paradigm, it does take many years, and it took several years. We used to have separate meetings from the main meetings. It took years for it to become part of glaucoma subspecialty days. But I agree with you. Those weren’t easy days.

SS: Nate, between EX-PRESS and ab externo canaloplasty, what are your remembrances of the difficulties we had?

Nathan Radcliffe, MD: I think for those two, they aren’t really what we consider MIGS today, but they had one thing in common: you had to admit that trabeculectomy wasn’t perfect to think about doing either ab externo canaloplasty or the EX-PRESS.

A lot of people will never change their mind. But I think that was the first thing you had to say that trab needs to be better, and maybe we need to look at alternatives and that’s where it began for me.

PH: Also, you mentioned, Nate, canaloplasty. Because of it, we started talking about the canal. In the past, we were always making holes, filtering fluid where it’s not supposed to go and we still do that. But sometimes, as we were expanding the canal in canaloplasty, we would have no blebs whatsoever. You would do anterior segment OCT and would see a nicely dilated Schlemm’s canal with viscoelastic and Prolene sutures. And you’d say, “Wow, the pressure is really good. So, maybe there’s another way to treat glaucoma.”

SS: I start with this because I refuse to let people who are coming up and who are out there now and industry forget how far we’ve come. I think we need to stop and remember because it’s still happening. It’s just more subversive. And I think it’s good to call it out and shed light on it. I think what happened with MIGS is analogous to what happened with Dr. Charles Kelman and phaco.

Arsham Sheybani, MD: Rich Parish put out that American Glaucoma Society survey, and you had 55% of AGS members pick a MIGS device for their own eye compared to 14% who wanted a trab.

SS: This might seem controversial, but do you see a shift in the practice of glaucoma where, really, if you don’t do cataract surgery, if you are not a phaco surgeon, can you really be a surgical glaucoma specialist?

Jacob Brubaker, MD: I don’t think you can at this point. I’ve been advocating for a long time that the world has passed you by if you’re just doing cataract surgery and you’re not taking the opportunity to do a MIGS procedure.

I think that the standard of practice now is MIGS with cataract surgery. This applies not only to the glaucoma surgeon but also to comprehensive doctors. Since they don’t want to learn MIGS, a lot of doctors are simply doing cataract surgery and giving them Diamox afterwards. Unfortunately, many of these patients end up seeing a glaucoma specialist a few months later. I feel so bad that they missed their chance to get a glaucoma microstent.

My platform at this point is really making sure that not only the glaucoma specialist, but also the comprehensive doctors are taking the advantage of using MIGS. In the United States, we don’t have the option in a lot of cases to decouple MIGS from cataract surgery, so it’s really their one shot to get either an iStent or Hydrus (Ivantis). If you lose that chance, it’s never coming back.

SS: That’s a good way to use that word, “opportunity.” We need to not lose the opportunity to do MIGS at the time of cataract surgery.

Paul, tell us a little about your Canadian experience.

PH: As you know, the labeling differs in different countries. For instance, when iStents first came out and our colleagues in the United States were officially able to put one in, in Canada we were immediately starting to target two collector channels. We found that multiple stents decreased the pressure further.

To Jacob’s point, in our Canadian program, in order to graduate as an ophthalmologist, every resident used to have to do five trabeculectomies, but that just doesn’t happen anymore. Our residents learn how to do phaco. And most of them want to feel comfortable, if they want to treat glaucoma, to do some angle-based surgery and maybe some subconjunctival-based MIGS.

SS: That brings up a good point. Most of us have had fellows in the past. We certainly all were a fellow, at one point. What is our responsibility training the next generation, to have them know how to do a trabeculectomy? Or do you think it’s just good enough that they know how to fix them?

Manjool Shah, MD: I think of trab as the extracap of glaucoma surgery. So, we’re in a phaco era, but a good, thorough cataract surgeon should probably have an extra cap in their back pocket.

NR: I haven’t done a trab since 2010. I just stopped with EX-PRESS a few years earlier. I still repair a bleb every week from some other surgeon in my community and I still also revise someone else’s trab to get some short-term pressure reduction when I put in a ClearPath (New World Medical) or Baerveldt tube (Johnson & Johnson Vision).

SS: This is a good segue to the next question. If we’re not doing trabeculectomies and if you have a 39-year-old patient on max meds with a clear lens and a pressure of 45 mm Hg, what’s the surgery for that patient? Arsham, what do you think?

AS: If you have someone who’s under 40, you have to start thinking that there might be angle dysgenesis. Pressures don’t get that high in someone that young, and I’m going to treat mechanism.

JB: Yeah, I agree 100%. Obviously, you have to talk to them about what to expect — the bleeding, amongst other potential complications. You have to be prepared for it to maybe not work. For surgeons today: We really have to have multiple tools in our kit, right?

NR: Jacob, twice now in the past year from another surgeon, I’ve had someone with an Ahmed valve and diplopia. I had to take the Ahmed out, so I went ahead and often it was the OMNI (Sight Sciences) with canaloplasty followed by trabeculotomy. I got rid of their Ahmed, got rid of their diplopia and finally got their pressure down with my ab interno surgery.

SS: So same patient but with severe glaucoma and significant visual field loss. What then?

MS: I think mechanism is still the issue here. I think the big concern, looking at the longer term outcome data from the GATT group in Dallas, there’s a little bit of a drop in efficacy once we get a higher mean deviation on Humphrey visual field, so we do have to worry a little bit about perhaps distal outflow disease. But that being said, I think you’ve got to give the canal a chance.

AS: Manjool, do you know how people always ask, “Well, why are you doing a surgery and planning your next?” I say, “Have you found the one glaucoma surgery device that doesn’t potentially need something else?” There is something to be said for staging surgeries.

MS: I tell my patients glaucoma docs are like pool players — we’re always calling the next shot. And again, the more tricks we have in our toolkit, the more refined, the more nuanced, the more patient-centric we can be, right? That’s what the MIGS revolution has allowed us to do.

SS: So, what if they were 70 and pseudophakic? With the pressure 45 mm Hg on max meds; how does that change your plan?

JB: For me that’s a XEN (Allergan) — 100%.

MS: At 70, you’ve probably knocked out the whole system at this point. If it didn’t cost anything, I think opening the canal is still worth a chance. We’ve been surprised, but this sounds like an eye that really doesn’t have a lot of wiggle room, and they need a XEN.

SS: Everybody is nodding their heads. Did we all just agree on something? Did we all just agree that a XEN is the way to go in an older, pseudo-phakic patient with a pressure of 45 mm Hg? That’s amazing!

AS: But if you’re on the front lines and you’re dealing with it all the time, it’s not a surprise. You don’t want patients coming back for repeat surgery. So, we come to the same conclusions because we do it. We’re going to come to the most logical conclusion based on what we’ve seen.

NR: I’m an early SLT guy, and at AGS I was asked if I do SLT on a severe glaucoma patient with a high pressure. And my comment was, “Well, I wish they would have had the SLT by then.”

And I feel like in some ways, again with the resistance even for just SLT, I have a lot of doctors who say, “Well, you don’t want to do it when they’re too young and early because it doesn’t last long enough.” And then they’ll say, “But now it’s too severe.” And I just want to ask them, when was the day? And I think the same thing happens with MIGS.

SS: I’m still amazed people are talking about whether primary SLT is a good idea, because I’ve been doing primary SLT my entire career. I’ve been saying from the podium for years, glaucoma is a surgical disease.

So, let’s target this exact thing right now. Because the MIGS dream is to get a patient to target pressure safely on no meds. What’s the path to get there? Nate, what are the two most common MIGS that you combine?

NR: I would say there’s been an evolution in my career that started with ECP. I am right now sort of focusing on trabecular outflow, so I would say canaloplasty with a stent has been popular. I think not just for me, but it’s the one I’m hearing the most about.

SS: So, combined with the phaco you’re doing an ab interno canaloplasty combined with a trabecular micro-bypass of some kind?

NR: Yes. I’ve done it with iStent and Hydrus. You can do whatever your “fastball” is, but I do like combining when people are on two or three drops, when they’re far from target or when their disease is pushing the severity limits of standard MIGS.

AS: I don’t actually mix and match, to be honest with you. I would say if I was talking about mixing surgeries, it’s with cataract surgery.

MS: Most of the time I’m sticking with a single intervention, again based on disease severity, lens status, mechanism of disease. I’ll occasionally throw a little ECP in there.

JB: I really like the idea of being able to do a goniotomy at the same time as an iStent. With one iStent, I was always worried that I wasn’t going to the right collector channels. Now with the iStent inject, I’ll put in the two stents and then I’ll rotate my microscope to create a goniotomy with a straight Sinskey.

SS: Speaking of Dr. Sinskey, he chose to have canaloplasty with his phaco when he had to decide what glaucoma procedure to have and was very public about it. So, what would you do in your own eye? Paul, I know your palette of paints is going to be a little broader perhaps, but what do you do with combining MIGS?

PH: So, it would be nice to be able to predict who will have distal outflow problems. I usually won’t do too many combinations, except for when inserting a stent or two, then do maybe some GSL if PAS are present or a small goniotomy.

Arsham, I’ve done maybe 20 or so bent-needle procedures that you have described in certain hospitals where there’s a financial limit for MIGS, and we use a 27-gauge bent needle to remove trabecular meshwork. We’ve had great results.

AS: We came up with the name “BANG” — bent ab interno needle goniotomy. I thought of it sitting on a plane, coming back to staff surgery the next day for an indigent uninsured patient population that every little piece of device that you use matters for their copay and their cost.

NR: I used to do a lot of combos with Cypass (Alcon).

SS: That was my number one trab killer when we had the Cypass. I’d combine OMNI and Cypass. That was just such a great combination. It was just phenomenal in the older pseudophakes where pressure was high and I didn’t want to do a filter and I didn’t have XEN as an option.

In the white paper that I wrote with the ASCRS glaucoma committee about visual outcomes with MIGS, in the summary we made a fairly bold statement: just because someone has the diagnosis of glaucoma doesn’t mean that we shouldn’t offer them cataract surgery as refractive surgery, period. It’s always refractive surgery. Even if they have angle closure glaucoma, you’re doing refractive surgery on them, and if you can’t accept that then you shouldn’t be doing cataract surgery.

So, if we have someone with mild to moderate glaucoma, say they had moderate glaucoma and have good central vision. Maybe they have a nasal step on visual field, controlled on one or two meds; two diopters of astigmatism. What are you doing with that patient? Assuming cost wasn’t a factor, the patient has a laid-back personality. They want to be as spectacle independent as possible. Are you just correcting their astigmatism? Are any of them getting any kind of expanded depth of focus or multi-focality?

PH: For sure they will be offered combined angle surgery with their cataract surgery. Then in terms of the IOLs, I definitely offer, from mild up to sometimes moderate glaucoma, some newer lenses, such as the Eyhance (Johnson & Johnson Vision) and Vivity (Alcon). In terms of contrast — monofocal and Eyhance are the best contrast and second best are probably Vivity and Symfony (Johnson & Johnson Vision).

As long as their glaucoma is well controlled and the patients understand the limits of these IOLs. They’ll have to have reading glasses, but at least they’ll keep some intermediate vision and good quality distance VA. It’s all about contrast, right? And glaucoma destroys contrast, so we want to keep that.

JB: It’s been actually really nice for me with the Vivity and the Eyhance now. A lot of our patients are just really not candidates for multifocals, at least even the more traditional ones. Now their options are so vast.

So as glaucoma surgeons, I think we now have to kind of put on a different cap again. Rather than just saying, “This is your lens. We’re not going to talk about the lens — we’re going to talk about the MIGS.” It’s now, “We’re going to talk about the MIGS, and we’re going to talk about your options for lenses.”

SS: I think that’s really going to be a game changer for glaucoma surgeons. I usually have to say, “We’re going to do two talks: a glaucoma discussion and a cataract discussion. Let’s have the glaucoma discussion first, because that’s going take about 3 minutes.” And then you then spend 30 minutes talking about lens choice.

Manjool — toric lenses in glaucoma patients, assuming cost isn’t an issue for the patient?

MS: As much as possible. And we know that the surgically induced astigmatism from pretty much any of our MIGS procedures is essentially nil. So, yeah, why not?

I will never offer a toric to a tube or trabeculectomy patient, whereas any other MIGS that’s out there, I think, is amenable to it. You’re trying to focus light as best as you possibly can. So, yes, absolutely to a toric with MIGS, especially in a patient who already has compromised vision.

NR: I will just say that I think what makes glaucoma patients unhappy is when their glaucoma affects their fovea and their central vision. No matter what lens they have. There are far more patients where the surgeon misses the fact that they have fovea-involving glaucoma and puts a multifocal in. And then they are the “unhappy glaucoma multifocal patient.” Well, they would have been unhappy with a monofocal lens, and they need to be counseled about that prior to surgery.

With a great informed consent discussion, I would put any of these lenses just mentioned in patients with field defects — if they are stable — with a conversation about the possibility for IOL exchange immediately or years later for glaucoma patients receiving a presbyopia-correcting IOL.

SS: Final question: What interventional glaucoma treatment are you most looking forward to?

MS: I’m looking out in the distance. I think we need new mechanisms of action. I’m kind of excited about things like the Beacon (MicroOptx), which are trans corneal outflow, for example.

AS: Of what’s potentially coming down the pike, probably the MINIject (iStar), just to give us a suprachoroidal back in refractory glaucoma.

JB: I agree with Manjool. I think MicroOptx with the transcorneal placement. I think that’s going to be game changer, especially for advanced disease. But then I’m excited by iDose (Glaukos). Just the fact that it lasts up to 3 years, I think that will be a pretty big game changer, too.

NR: I’m looking forward to next-generation drug delivery and that does include iDose, but just the way iDose is going to bridge some Durysta (Allergan) patients, and there will be some playback between those two. I can’t wait to see what bridges the iDose patient.

PH: In short-term for sure the Santen Microshunt. I really want to deliver aqueous humour as far back as possible. In Canada, we’ve been using some XEN 63, with a larger lumen XEN. I use them exclusively in patients with previously failed subconjunctival surgery with really good results, so I think having that bigger lumen will probably avoid it from getting clogged as often with pigment, etc. OM

About the participants

Steven R. Sarkisian, Jr., MD, moderator, is founder and CEO of Oklahoma Eye Surgeons in Oklahoma City and former professor of ophthalmology and director of the glaucoma fellowship at University of Oklahoma College of Medicine.

Disclosures: Alcon, Allergan, BVI, Katena, Glaukos, New World Medical, Santen, Sight Sciences.

Jacob Brubaker, MD, is partner and president of Sacramento Eye Consultants in Sacramento, Calif.

Disclosures: Aerie Pharmaceuticals, Allergan/Abbvie, Equinox, Glaukos, Ivantis, New World Medical, Nicox and Santen.

Paul Harasymowycz, MD, is a founder-director of the Montreal Glaucoma Institute and former chief of glaucoma at the University of Montreal.

Disclosures: Aequus, Aerie, Alcon, Allergan, Bausch Health, Glaukos, Ivantis, Iridex, Johnson & Johnson Vision, New World Medical, Novartis, Santen, Thea, Zeiss.

Nathan Radcliffe, MD, is lead surgeon at the New York Eye and Ear Micro Incisional Glaucoma Surgery Center and recently served as the glaucoma director at New York Universtiy.

Disclosures: Aerie, Alcon, Alimera, Allergan, Bausch + Lomb, Endo Optiks, For Sight Vision 5, Glaukos, Iridex, Lumenis, New World Medical, Reichert, Shire and TearScience.

Manjool Shah, MD, is assistant professor of ophthalmology and medical director of the glaucoma clinic at the University of Michigan Kellogg Eye Center in Ann Arbor.

Disclosures: Allergan, Glaukos, Katena, Ivantis, ONL Therapeutics.

Arsham Sheybani, MD, is an associate professor at Washington University in Saint Louis and residency and glaucoma fellowship director.

Disclosures: Alcon, Allergan, Ivantis and Santen.