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    Know your minimally invasive glaucoma surgery (MIGS) options

    These procedures offer good results and low complications for mild to moderate glaucoma patients

    Minimally invasive glaucoma surgery (MIGS) is becoming a popular option for patients with mild to moderate glaucoma. Multiple devices and procedures effectively lower intraocular pressure (IOP). These procedures can significantly reduce your patients’ dependency on topical therapy or work synergistically with topical therapy. MIGS can be performed with or without cataract surgery.

    With relatively low incidence of complications and side effects, these procedures offer a great treatment option for patients needing mild to moderate IOP lowering who are not reaching target pressure with topical therapy but are not candidates for more invasive filtration surgery. With moderate efficacy, quick recovery, minimally invasive through a clear corneal incision, and low risk of complications, there is a pretty good rate of return with these procedures.

    Previously from Dr. Fluder: Offer options to your cataract patients

    Research is showing good efficacy for MIGS. A 12-month study followed 27 patients (54 eyes) treated with cataract surgery with Trabectome (Group 1) in one eye and cataract surgery with two Glaukos iStent Inject devices (Group 2) in the fellow eye. The average preoperative IOP decreased from 22.3±-3.7 mm Hg (Group 1) and 21.3 ± 4.1 mm Hg (Group 2) to 15.6 ± 3.6 mm Hg for Trabectome and 14.0 ±- 2.3 mm Hg for iStent Inject at 12 months postoperatively. No vision-threatening complications such as choroidal effusion, choroidal hemorrhage, or infection occurred.1

    The following are devices and procedures that are most commonly used and performed.

    Glaukos iStent

    Glaukos iStent is the smallest FDA device approved for the treatment of mild to moderate glaucoma. It is a small snorkel comprised of heparin-coated titanium which is usually inserted nasally into Schlemm’s canal during cataract surgery.

    The iStent Inject was approved for use in Canada, Europe and other countries in 2016. It is still in clinical trials in the U.S. It is approved for use with primary open-angle glaucoma (POAG), pseudoexfoliation glaucoma, and pigmentary glaucoma with or without cataract surgery; indication in the U.S. will likely differ. The iStent Inject is preloaded with two microstents which are injected into the trabecular meshwork, specifically near collector channels. They are about 0.3 mm in diameter and 0.4 mm long and are made of titanium coated with heparin.2

    Researchers have found that iStent Inject is at least as effective at lowering IOP as two topical medications. At 12 months postop, in a study involving 192 patients, 89 of the 94 eyes that underwent the procedure reported unmedicated IOP reduction of 20 percent or more.3

    The iStent Supra is an ab-interno device that is approved in Europe, and U.S. approval is expected in 2020. It is a 4 mm tube with a hole at each end made of polyethersulfone (PES) and titanium. It is placed into the suprachoroidal space, and like iStent Inject, can be performed in conjunction with cataract surgery.4

    Alcon CyPass Micro-Stent

    CyPass Micro-Stent is a fenestrated microstent comprised of biocompatible polyimide material.5 It is a 6.35 mm long tube that is inserted into the supraciliary space via a guide wire with a special tip that separates the iris from the scleral spur. Openings along the tube allow for aqueous flow through the supraciliary space.6 It is used to treat mild to moderate glaucoma in patients undergoing cataract surgery.

    It received FDA approval in July 2016 based on the results from the COMPASS clinical trial in which 61.2 percent of 374 patients maintained an average IOP between 6 to 18 mm Hg at two years postop.7 In the CyPass Micro-Stent study group, 73 percent of patients achieved a statistically significant decrease in IOP by 20 percent.8

    Barbara J. Fluder, OD
    Dr. Fluder has been in practice for 22 years and currently practice at Williams Eye Institute in Merrillville, IN. She is a member of ...


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