It was just over 10 years ago that the iStent^® trabecular micro-bypass (Glaukos) set off a sea change in glaucoma treatment. Its approval by the FDA in 2012 signaled the beginning of microinvasive glaucoma surgery (MIGS), which forever altered the disease-management landscape. To celebrate this milestone, four renowned surgeons came together to discuss the past, present, and future of MIGS with moderator Blake K. Williamson, MD.

CHAPTER 1: THE PAST

BLAKE K. WILLIAMSON, MD: Our discussion focuses on the evolution and impact of MIGS over the past decade. To appreciate where we are today and what the future may hold, let’s first take a look at where we started.

In 1999, Glaukos Corporation produced the first trabecular micro-bypass stent prototype. By 2001, that device—the iStent—had been implanted in a human eye, and in 2004 it was CE marked. The following year, the U.S. Food and Drug Administration (FDA) granted Glaukos an investigational-device exemption for clinical trials.

In 2009, the term “microinvasive glaucoma surgery,” shortened to “MIGS,” was coined to describe these new interventions. In 2012, iStent became the first MIGS device approved in the United States.

Dr. Ahmed, I’m curious to learn how you became interested in this unique approach to treating glaucoma.

IKE AHMED, MD: I was lucky to be involved early on and witness the changes in how we treat glaucoma. I think it was just the right time and the right environment for MIGS. Our technology, visualization, and training had improved, and we had industry support, which propelled this concept forward.

Originally, the idea was to find an alternative to filtering surgery, with lowering of pressure as the primary goal. Safety quickly became a priority, and we realized that with earlier treatment, secondary changes in the trabecular meshwork and the canal outflow system are not necessarily fully irreversible, and therefore, outcomes can be better.

As I was practicing in Canada, I had access to iStent technology before many ophthalmologists did. In our early trials, we immediately saw the safety benefit. The goal at that time was to do something that was refractively and postoperatively neutral to cataract surgery, with the benefit that exists for phacoemulsification. Everything we did was trying to build around safety while delivering effective IOP control.

At the beginning stages, MIGS was novel, and there were concerns and questions. It upset the balance in terms of where glaucoma surgery was being performed, which created some discomfort and challenges. Over time, however, MIGS has become mainstream.

DR. WILLIAMSON: Dr. Samuelson, when did you first hear about MIGS and iStent? What were your thoughts?

THOMAS SAMUELSON, MD: My first exposure to less invasive glaucoma surgery was in 1997, when I took Dr. Robert Stegmann’s nonpenetrating deep sclerectomy course. Dr. Stegmann, from South Africa, had been talking about trying to enhance trabecular outflow via canal-based surgery for some time, but back then it fell on deaf ears in much of the glaucoma community.

During most of my early years in glaucoma, we were all about getting pressures of 6 mmHg and 8 mmHg with our trabeculectomies, and we accepted the fact that complications “came with the territory.” We really had to change our thinking to value safety as much as we value efficacy.

While our initial approach to canal-based surgery was via an ab externo approach, as soon as ab interno options like iStent^® became available, that changed quickly. The ab interno approach has absolutely transformed what we do.

ADDRESSING UNMET NEEDS

DR. WILLIAMSON: Prof. Hengerer, you were involved with iStent technology early on in Germany. Why do you think MIGS, and specifically the iStent, was created?

FRITZ H. HENGERER, MD: When we look at the need for glaucoma treatment, we must consider the burden that patients suffer when using eyedrops to lower IOP. In the past, trabeculectomy was the only efficient and safe operating technique to reduce IOP to the target pressure. But trabeculectomy is a major surgery, requiring intensive postoperative care and carrying risks of complications, such as hypotony and scarring. Cyclophotocoagulation is another IOP-lowering option, but we avoid using it to treat young patients because of the risk of severe vision loss.

The missing link in the glaucoma surgery process was something that we could easily apply to the natural outflow pathway to relieve the resistance in the trabecular meshwork and lower IOP. Several other surgeons and surgeries had tried this with varying success, but there was nothing on the market that we could implant that would work reliably for the long term.

HENNY J.M. BECKERS, MD, PHD: I agree with Prof. Hengerer that if we treat patients well, we can reduce the number of eyedrops they require and address that unmet need. In my opinion, overtreating patients with medication is becoming the norm. Many patients who are referred to my practice are using three or four medications for their moderate glaucoma. By implanting iStent^®, we can often 1) reduce or eliminate the need for those medications; 2) help alleviate the ocular surface disease that often accompanies those medications; and 3) save these eyes so that patients can have additional glaucoma surgery, if needed.

In the Netherlands, our research related to cost-effectiveness found that even if patients are using less expensive generic medications, the combination of cataract surgery and iStent is still a cost-effective procedure.¹ So everything is very much in favor of these new techniques.

ATTRACTING EARLY ADOPTERS

DR. WILLIAMSON: Prof. Hengerer, why did you choose to be one of the earliest adopters of iStent technology?

PROF. HENGERER: My colleagues and I at University Eye Clinic of Bochum were the first in Germany to have access to the first-generation iStent. Not only were we treating patients during the initial studies, but we also could use the iStent for our regular glaucoma surgeries. I gained a great deal of experience working with the device during that time, both in combination with cataract surgery and as a standalone procedure. We had very few failures and achieved maximum effectiveness in lowering IOP.

By definition, MIGS should be microinvasive, and it should be effective in lowering IOP. It should be a safe and consistent procedure that is done once with the effect maintained over time, reducing the patient’s medication burden while reserving the opportunity for future treatments. For these reasons, I became an early adopter, and over time, we progressively started using this device very early in treatment, even in cases when we considered adding another eye drop if initial treatment had failed.

DR. WILLIAMSON: Prof. Beckers, as a leader in ophthalmology, were you concerned about adopting a new procedure very early? Did your peers express any misgivings about iStent or MIGS in general?

PROF. BECKERS: The glaucoma community was skeptical in the beginning because of rumors that the device was expensive and it probably didn’t work. In spite of those rumors, I decided to adopt this technique, because it sounded like a safe and straightforward procedure and potentially something that would bridge the treatment gap between medications/laser and trabeculectomy. I was impressed with our results using the iStent. Also, the training by Glaukos was excellent, which I believe is paramount for success.

WORKING WITH THE FDA

DR. WILLIAMSON: What was the FDA’s response to the iStent?

DR. SAMUELSON: The FDA had some skepticism, as did much of the glaucoma community. To justify a trip to the OR for an unproven procedure, it was deemed necessary to combine it with cataract surgery, and the timing was perfect. You see, at that time, we were starting to truly appreciate that modern, small-incision cataract surgery lowers IOP. The FDA preferred that we study iStent^® with cataract surgery rather than as a standalone procedure so as not to subject patients to the risk for endophthalmitis. We were already opening the eye, and we were proposing that the iStent would augment the favorable effect of the cataract surgery on IOP. I think that’s the reason why the FDA allowed the study.

It was a grind getting through the FDA approval process because it was a completely new concept. I recall explaining to the panel that while this procedure does not have the efficacy of a trabeculectomy, the safety is exponentially greater. After a rough morning of deliberation, by afternoon we could see the panel starting to understand what we were saying, that we need a safe option for our patients with mild to moderate glaucoma. We can’t subject them to a surgery that has potentially catastrophic risks.

Any procedure that can generate pressures of 2 mmHg or 3 mmHg and subsequently put patients at risk for suprachoroidal hemorrhage has to be taken off the table for patients with mild to moderate glaucoma. The panel began to appreciate that mindset, and ultimately the iStent was approved.

CONVINCING THE COMMUNITY

DR. WILLIAMSON: Dr. Ahmed, tell us about the uptake after the FDA approved the original iStent. I suspect convincing surgeons to accept this new approach was a challenge.

DR. AHMED: Uptake always will be difficult for folks, whatever the reason—whether it’s technical, their mindset, cultural, or related to reimbursement—and these barriers persist today. MIGS moved glaucoma surgery toward the cataract surgery arena, which was not traditional. That also created some challenges in terms of understanding where the perceived boundaries were.

We realize now that well-trained surgeons, whether they’re glaucoma specialists or cataract surgeons, are best suited to treat patients at the point of contact, the point where they’re seeing patients. In many ways, I think MIGS has democratized glaucoma surgery to the comprehensive world, which has been great to see.

PROF. BECKERS: I agree. The appeal of such a minimally invasive procedure is that it can be used in conjunction with cataract surgery. The practicalities are enormous, because MIGS is quite easy to adopt. We need straightforward and safe surgery that can be performed by more ocular surgeons to treat many patients, because it is estimated that 112 million people will have glaucoma worldwide by 2040.² That’s an enormous number of people who will need treatment, and we don't want all of them using multiple medications. I believe earlier adoption of MIGS will ultimately save many glaucoma patients from going blind in the end.

2005

Landmark trial evaluating iStent^® in conjunction with cataract surgery begins

 

 

 

DR. WILLIAMSON: Prof. Hengerer, why do you think doctors in Germany were reluctant to embrace this new category?

PROF. HENGERER: There were concerns about the failure rates of those who were not familiar with the anatomical structures of the chamber angle. We saw during our training period that it’s not so easy. You must adhere to certain milestones and steps, and when you adhere to them, you will have a steep learning curve.

After initial training, my physicians were competent to operate by themselves, because they know how to interact with the chamber angle. They know what to do when the trabecular meshwork is not pigmented; they know how to lower the IOP, and they know how to maximize visualization.

CHAPTER 2: THE PRESENT

DR. WILLIAMSON: The original definition of MIGS was created at about the same time as the first iStent^® was being developed. Over time, however, that definition has evolved and so have the products in that space. Prof. Beckers, can you comment on how the original definition of MIGS has changed and discuss the subcategory of minimally invasive bleb surgery (MIBS)?

PROF. BECKERS: That’s something that we have struggled with, and perhaps the reason is when the newer bleb-forming techniques were introduced, they were also marketed as minimally invasive. New terminology like “less invasive” or “minimally invasive bleb-forming surgery” is more appropriate.

When we address the trabecular meshwork, everything that remains in that place is ab interno and is a minimally or microinvasive type of surgery. We are seeing the spectrum broaden with new types of implants and other procedures that do not use implants but still address the same spaces. Thus, they should all be under the nomenclature of minimally or microinvasive, but bleb-forming technology certainly does not belong in this group.

In my opinion, MIBS is a totally different category and should remain in the hands of glaucoma surgeons, as experience with bleb management and antimetabolites such as mitomycin C and/or 5 FU is mandatory to achieve good results. In contrast, MIGS can be learned by cataract surgeons who have large-volume practices and good training concerning the anatomy of the trabecular meshwork and entering the canal.

DR. WILLIAMSON: In view of how MIGS has evolved, Dr. Samuelson, how do you utilize it in your practice today?

DR. SAMUELSON: It’s the rare patient these days for whom I would not at least consider canal surgery as an initial option for incision surgery. We have better drugs and a variety of approaches to the canal, and patients love that we have an opportunity to potentially enhance their natural outflow system. The advantages are safety, rapid recovery, and the fact that we’re not going to worsen the patient’s refractive status. Most importantly, severe complications are rare. All of these factors resonate with patients.

I use a MIGS approach in the vast majority of my initial surgical interventions, except for patients who have advanced glaucoma or extremely high IOPs. For the overwhelming majority of patients, however, I initially try to enhance physiological outflow. Whether I perform MIGS as a standalone procedure or with cataract surgery, patients are receptive to the idea of improving physiological outflow. With iStent initially, and now many other options, we have a portfolio of tools that we can use to do that.

DR. WILLIAMSON: Dr. Ahmed, do you consider MIGS the standard of care today?

DR. AHMED: When we talk about standard of care—I think “best practice” is the better term—we’re looking at the evidence and at what the community feels is the standard.

It’s becoming more difficult for many of us to justify not at least considering combining some form of pressure-lowering procedure with cataract surgery, as long as we can do it safely and without impacting the results of the cataract surgery. Some of the best available data confirms not only reduction of pressure-lowering medication, but also improvement of quality of life, cost-effectiveness, visual field preservation, and reduced need for secondary surgery.

We’ve seen a natural evolution in innovation in the MIGS category. As a glaucoma academic, I believe we are looking for high-quality data, control data, data that’s longer term to justify doing some of these things—fortunately, after more than 10 years of iStent technologies, we now have more than 270 studies to draw from.

DR. WILLIAMSON: Prof. Hengerer, do you feel that MIGS, particularly at the time of cataract surgery, has become a standard of care in Europe?

PROF. HENGERER: Five years ago, I became medical director of the department of ophthalmology at Bürgerhospital Eye Clinic. The colleague who led this department before me was a famous glaucoma surgeon in Germany. He and his team performed more than 400 trabeculectomies and about 50 cyclophotocoagulation procedures per year. When I came onboard, I introduced my team to the iStent^® technology, which I considered the gold standard of MIGS at that time. My team were all hungry to see how the new boss would perform this surgery, and they adopted it early. Now, 5 years later, we perform about 250 trabeculectomies and 50 cyclophotocoagulations annually, and we perform more than 1,200 MIGS a year, and more than two thirds of them are with the iStent technology.

We present this option in a positive way to all patients who have glaucoma and cataracts. Patients are sometimes skeptical about having a solid device implanted in their eye, but then I show them how small the iStent is, and I explain that it’s made of titanium and that we have data showing that it’s safe and effective. I estimate that if these patients had to do it all over again, 95% of them would agree to have cataract surgery in combination with an iStent.

2012

iStent^® Trabecular Micro-Bypass Stent (Glaukos) is the first MIGS implant to be approved by the FDA (for use in conjunction with cataract surgery)

 

 

DR. WILLIAMSON: That's a great insight into your hospital and your practice, Prof. Hengerer, and it certainly sounds like MIGS is a standard of care there, particularly with an iStent device.

Prof. Beckers, what are your thoughts on MIGS as a standard of care today at a national level in the Netherlands and perhaps even western Europe? Do you think we’re there yet?

PROF. BECKERS: That’s a difficult question to answer. Of course, with all new technologies, reimbursement plays an important role. If we can get that right, then we will see many opportunities for newer surgeries.

In our clinic, we still perform many trabeculectomies and large tube implants, but we also implant many iStents and perform newer bleb-forming surgeries. Many patients may benefit from earlier surgery, particularly those who have been using multiple medications for many years. Even patients who are using only one eye drop but are experiencing side effects or other issues with their medications may be able to reduce their medication burden after receiving an iStent during cataract surgery.

Furthermore, early surgical intervention may save or delay patients from needing future glaucoma surgery. If a patient would need bleb-forming surgery in the future, it may be more successful because the ocular tissues were less exposed to the adverse effects of glaucoma medications. So, yes, I believe MIGS is bridging the treatment gap and is becoming standard of care.

ENTERING AN INTERVENTIONAL ERA

DR. WILLIAMSON: How has MIGS changed the treatment algorithm for glaucoma? Have 10-plus years of MIGS driven the development of the interventional glaucoma mindset?

DR. AHMED: I remember going through residency and not being interested in glaucoma initially because I felt the algorithm was so passive. It was depressing in terms of just watching and waiting, having medications that were not working well, patients who were struggling with adherence, and surgery that was a last resort. By contrast, we are proactive in treating cataracts nowadays. I felt that glaucoma treatment, although different, could develop the way cataract treatment had developed, where we could be proactive with our interventions.

That proactive mindset opens opportunities for earlier intervention, and MIGS has driven that mindset. I call it “interventional glaucoma,” because it’s a different way of looking at glaucoma. We can now ask, “What intervention can I use to alter the course of this patient’s journey?”

DR. SAMUELSON: That’s a great point, but in fairness to the glaucoma community, I think the mindset was there much earlier. Think CIGTS (Collaborative Initial Glaucoma Treatment Study), which compared trabeculectomy to medication as the initial treatment of glaucoma.³ The mindset was there, but the tools to execute that mindset were not. Our surgeries were simply not safe enough to be used early. Now, with iStent^® and the other technologies we’re discussing, we do have the opportunity to execute that plan and intervene earlier before permanent changes occur in the meshwork. It’s exciting to be able to offer that to patients.

DR. WILLIAMSON: While interventional glaucoma has been discussed for a few years, it has gained momentum over the last 12 months. The goal is to be much more proactive in disease management and to intervene earlier on a procedural basis. Prof. Hengerer, do you feel that such a movement is happening in Germany right now?

PROF. HENGERER: To some extent, we must adhere to the European Glaucoma Society (EGS) guidelines, although reading between the lines, we can consider laser treatment as a first-line therapy in some cases. I believe that the earlier we can intervene in the chronic disease process the better, because we can reduce the burden for medication uptake, avoid damaging the ocular surface, and allay patients’ fear that they can become blind if they forget to use their medications over the long-term. We know that many patients who are prescribed eyedrops are no longer using them after one year.⁴ We often can avoid medication nonadherence altogether when we use MIGS devices early.

DR. WILLIAMSON: Prof. Beckers, while the EGS guidelines may not yet address interventional glaucoma, do you see movement toward this approach?

PROF. BECKERS: It’s important to note that one of the reasons guidelines are good is that they are conservative. Before something becomes a European or an American guideline, a lot of experience and evidence has to be collected. It takes time. Ophthalmologists in the vanguard of Europe need to try new technologies and prove their effectiveness and safety, after which they can be used on a larger scale, and more surgeons will adopt them. The evidence will get there, and MIGS will become part of our guidelines, but it will take time. In the meantime, we continue treating our patients well and recognizing that this really works.

DR. WILLIAMSON: What type of patient would you select for an iStent technology or any other MIGS procedure?

PROF. BECKERS: I usually implant iStents in combination with cataract surgery, and always after completing phacoemulsification. I prefer my method because I have a good view of the angle and can always judge if the angle is sufficiently open to successfully place the iStent. A closed angle or multiple synechiae are contraindications for the iStent.

Patients with early glaucoma have excellent results with iStent MIGS, but even patients in the later stages of stable glaucoma may benefit from it, sometimes even after previous surgery. However, evidence on this is still limited.

ADVANCING STANDALONE MIGS

DR. WILLIAMSON: The potential market for pseudophakic standalone MIGS is massive. What has been your experience with MIGS in patients who are not having cataract surgery?

DR. SAMUELSON: It’s become an easy continuum for me. I think most of the glaucoma community and much of the ophthalmology community has accepted that selective laser trabeculoplasty (SLT) is a terrific initial intervention. Now it’s easy to advance therapy from SLT to drug delivery with a bimatoprost implant (Durysta^®, Allergan) and hopefully iDose^® (Glaukos), if approved, and then to iStent infinite, goniotomy, GATT, and so on. We have one tool after another that we can use sequentially to effectively minimize complex drug regimens, risk of ocular surface toxicity, and the burden of compliance.

For those just starting to perform standalone iStent MIGS, I recommend starting with your aged population, people who have difficulty administering drops. Maybe they’ve developed a tremor, or they live in a nursing facility where they’re charged extra for every dose of medicine delivered. As soon as I tell a family member that we can administer a medication in the office that might last 6 months or a year, they jump on that immediately.

DR. WILLIAMSON: How do you coach people to accept that mindset shift of performing pseudophakic MIGS?

DR. AHMED: I think many people see the value of pseudophakic MIGS. The challenge is where to put it into practice and how to operationalize it. The practice management side of standalone MIGS or interventional glaucoma needs to be developed, just like, for example, the premium IOL side of cataract surgery.

You will find candidates for SLT, drug delivery, and standalone MIGS in any busy clinic where glaucoma patients are seen. They may have early-stage glaucoma and are not doing well with eye drops. They may have had cataract surgery already, and they’re using a number of glaucoma medications, and they’re not doing well with them. We know that adherence and persistence are challenging, so we could argue that everybody is not doing well with their eye drops. The patients who have ocular surface issues, lid issues, and compliance issues are the first patients to address. They’re usually motivated and willing to go into the OR to do something that will alleviate these issues.

The challenge is when surgeons choose standalone MIGS for patients who have advanced glaucoma and are using 4 or 5 medications. The outcomes are just not going to be very good for these patients. Knowing this causes some hesitation.

The balance is still developing, and I think surgeons will continue to become more comfortable with pseudophakic MIGS. That starts with some of the tools we already have. Cutting procedures have been available, but there has been some concern about the risk/benefit in terms of recovery. Now that the iStent infinite^® is approved for standalone surgery, that will create more opportunities.

CHAPTER 3: THE FUTURE

DR. WILLIAMSON: Prof. Beckers hit on an interesting topic earlier, when she discussed using iStent technologies in patients with more advanced disease. Glaukos just launched the iStent infinite device that contains three stents and has a new injector system. Unlike the typical MIGS pivotal study that enrolled patients with mild to moderate glaucoma, patients in the iStent infinite study had advanced refractory disease and had failed prior medical and surgical therapy—having undergone two or more unsuccessful invasive surgeries, many of them trabeculectomies. In talking to a number of the investigators, I learned that they were surprised at the level of efficacy achieved.

We currently have more than 250 peer-reviewed publications on the iStent technology showing safety and efficacy. Now we’re starting to develop evidence that the iStent infinite can be successful in patients with more advanced disease when invasive surgeries have failed. Prof. Hengerer, where do you see these new technologies in the future?

PROF. HENGERER: Currently, most of our European colleagues are conservative with respect to treating glaucoma. My perspective on the future is that we must educate our conservative colleagues and show them that they can lower IOP with a single, straightforward procedure. This is important for the long term. In 10 years, I hope we won’t see so many patients with advanced-stage glaucoma because MIGS has become much more accepted. We also need to educate our patients that MIGS is a worthwhile treatment and that each millimeter of mercury counts. As long as we can lower IOP and possibly minimize pressure spikes over time, then we have the potential to improve the survival of the optic disc.

2018

iStent inject^® (Glaukos) is approved by the FDA for use with cataract surgery

 

 

Here’s how I envision future patient encounters: We must evaluate patients carefully, noting their age and life expectancy. Then we must determine which treatment is best to lower IOP, not necessarily to 12 mmHg but maybe to 15 mmHg. Past ocular history will be important: Maybe a patient had glaucoma surgery at age 50 and now, at age 70, their IOP still needs to be lower. Why shouldn’t we have the potential to use an iStent infinite^®, even in earlier stages of glaucoma, when we discover a new patient’s IOP is 35 mmHg and he has untreated open-angle glaucoma? Why should we start his course of therapy with eye drops, watching as the retinal nerve fiber layer becomes thinner and the IOP remains too high? So my future perspective is to educate all of our colleagues, to show them that we can effectively treat all stages of glaucoma with minimal reliance on eye drops.

DR. WILLIAMSON: The MIGS category is evolving, as many research and development projects are underway. Prof. Beckers, what excites you most about glaucoma treatment in the coming years?

PROF. BECKERS: While we will see newer routes of medication administration, perhaps with fewer side effects, I think the future lies in combinations. “Mix-and-match” will be the new watchword going forward. That may lead to even fewer conventional surgeries and their associated complications.

2020

iStent inject^® W (Glaukos) is launched

 

 

2021

Glaukos completes patient enrollment in Phase 3 clinical program for iDose^® TR

Glaukos surpasses 200 peer-reviewed publications on iStent^® technologies

 

 

DR. WILLIAMSON: Where is MIGS headed? If you could fast-forward 10 years, what do you think your future treatment algorithm would look like?

DR. AHMED: I’m excited about all of the technologies that are enabling us to move the paradigm. Coupled with that, we will need better diagnostics to help us utilize these procedures. We need to understand the outflow, where the pathology is, and where to treat it. Most of all, I think the next decade will be about building the evidence, understanding which patients are appropriate for each intervention, and then helping our practices to develop and move toward that.

I envision a future where we are in an interventional space, where we start with laser and drug delivery and then move to our secondary interventional approach, whichever one we don’t use first. Then we move to MIGS and another MIGS, and so on and so forth. We also will have less-invasive bleb surgeries available to us.

Medications will likely have a secondary role as bridge therapy, serving as additional therapy rather than primary therapy. I think that’s where we could be, should be, can be, but of course, many questions will remain and much development will be required. Nevertheless, I think that’s exciting.

To arrive at this new level of glaucoma management, all of us need to be thinking the right way and working together collaboratively to obtain data and evidence and to adapt our practices to break through some of the barriers. And let’s not forget regulatory reimbursement. That’s a significant driver and/or barrier. We need to come together to help everybody, including our fellow citizens, to understand and to stand up and speak up for what this innovation means for patients who have glaucoma.

DR. SAMUELSON: I agree with Dr. Ahmed. I think we need to maintain adequate reimbursement so people continue investing. When I say people, I mean industry and venture groups, the people who help capitalize this innovative research. They need some return on investment or they will invest in other disciplines, so we have to maintain reimbursement at adequate levels.

As for the future, I’m anxious for the day when I don’t have to do transscleral surgery. We’ve seen some terrific advances in that space. The Xen^® Gel Stent (Allergan) and the ab-externo PRESERFLO™ MicroShunt (Santen, Inc.) give us a more standardized, controlled transscleral option. But if we can keep the fluid in the eye where it belongs and control pressure with either supraciliary or canalicular outflow, I think that’s an element of safety that our patients will enjoy.

DR. WILLIAMSON: If you look at the compound annual growth rate of all the different subspecialties, glaucoma has been way up there for a while now, likely because of MIGS. My ask would be for ophthalmologists who aren’t interested in performing MIGS to at the very least let patients know it exists, and make sure you have a relationship with a MIGS surgeon whom you can trust.

Dr. Ahmed: It’s a good time to be a surgeon treating glaucoma. I believe MIGS has made all of us better glaucoma specialists. It’s made us better gonioscopy assessors. It’s made us better at understanding how to look at OCT and visual fields. It’s made us better in terms of how to monitor patients and stage their disease. It's actually uplifted our field by just being better at glaucoma because we’re doing it in our surgical arena. ■

2022

Glaukos launches iAccess^® trabecular trephine in the U.S.

 

 

Glaukos announces FDA 510(k) clearance of iPRIME™

 

 

Glaukos announces FDA 510(k) clearance of iStent infinite^®

 

 

Glaukos exceeds 1 million iStent^® devices implanted

REFERENCES

1. Beckers H, Theriou C, Kleintjens J. Cost-utility analysis of iStent Inject for the treatment of mild to moderate open-angle glaucoma. Poster presented at Annual Meeting of the Netherlands Ophthalmological Society; June 21-23, 2023; Maastricht, Netherlands.
2. Tham YC, Li X, Wong TY, Quigley HA, Aung T, Cheng CY. Global prevalence of glaucoma and projections of glaucoma burden through 2040: A systematic review and meta-analysis. Ophthalmol. 2014;121(11):2081-2090.
3. Lichter PR, Musch DC, Gillespie BW, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmol. 2001;108(11):1943-1953.
4. Schwartz GF, Quigley HA. Adherence and persistence with glaucoma therapy. Surv Ophthalmol. 2008;53 Suppl1:S57-S68.