Eyeworld Daily News

8 | EYEWORLD DAILY NEWS | MAY 7, 2023 ASCRS ANNUAL MEETING DAILY NEWS D uring the Glaucoma Essen- tials Symposium Saturday morning, Oluwatosin Smith, MD, presented "MIGS: Ready to Take the Leap?" She began by saying the MIGS was a golden oppor- tunity to make the most of a unique moment with glaucoma patients. In defining the attributes of MIGS, Dr. Smith noted the ease of use in the ab interno approach and the fact that it's minimally traumatic because there is negligible disruption of normal anatomy and physiology and excellent biocompatibility. Both of these factors help ensure proce- dural success in the short term, she said. In terms of long term treat- ment success, Dr. Smith highlighted the rapid recovery with MIGS, the extremely high safety profile, and the fact that its efficacious (MIGS can lower IOP, reduce drop burden, and improve quality of life). When deciding if you're ready to take the leap with MIGS, Dr. Smith said there are a number of consider- ations. Dr. Smith then went on to dis- cuss the glaucoma therapy algorithm, which includes medication, laser, and incisional surgery. Medication options may include prostaglandin analogues, beta blockers, alpha ago- nists, carbonic anhydrase inhibitors, miotics, rho-kinase inhibitors, and nitric oxide releasing agents. Mean- while, laser options include SLT/ALT, MicroPulse, ECP, and CPC. Finally, in- cisional surgery could refer to MIGS, MIGS +, or traditional surgery. "The glaucoma management algorithm has become more fluid," she said. She said it's important to sharp- en your skillset. Improve surgical gonioscopy skills, attend wet labs or skills transfer courses, and learn modified surgical techniques/pearls of surgical implantation, Dr. Smith said. She recommended to "select and learn one surgical procedure in each category and then broaden your reach." Dr. Smith stressed the impor- tance of finding the right patients when performing MIGS. Look for the right patients that match indications and the specific procedure, she said, adding that it's important to set rea- sonable expectations for an outcome. She also said to individualize care based on the patient history and expected outcome. Consider well de- lineated, wide open angle with good cornea clarity for the first few cases, she suggested, and she added that, if not administering a block, patients that will be most cooperative during topical surgery should be considered for your first few cases. There are different options available, depending on the stage of disease, Dr. Smith said. There are also some expanded indications, like standalone MIGS, pediatric use, and MIGS for primary angle closure glaucoma. She stressed that it's important to review publications for informa- tion on efficacy and safety. Learn about possible complications and prevention strategies, she said, and know how to treat common compli- cations. It's also important to review long-term outcomes, when available, Dr. Smith said. Intraoperative considerations are also important in MIGS. This could include when to do the MIGS, before or after cataract surgery, when doing a combined procedure, and you also have to think about incision sizes and locations, depending on the proce- dure. Other important considerations include viscoelastic options, gonios- copy and maintaining a good view, gonio prism options, and hyphema control. Dr. Smith stressed that support is critical when learning new approach- es in MIGS. She said to be aware of surgical center and operating room offerings, and a surgical representa- tive can also help. She also suggested finding a mentor or colleague. Recording cases and discussing the difficulties and complications that occur may also be helpful, she said. MIGS procedures are here to stay, Dr. Smith said, and the use in clinical practice continues to broad- en and evolve as we learn. A special skillset is required for surgeons adopting new technology, she said. "Matching patients to the procedures is important, based on the glaucoma type, severity, and treatment goals." She added that preparedness in adopting MIGS procedures is im- portant to ensure good outcomes and increase the ability to stay the course. Editors' note: Dr. Smith has financial interests with a variety of ophthalmic companies. 'Glaucoma Essentials' symposium highlights how to get involved in MIGS "Matching patients to the procedures is important, based on the glaucoma type, severity, and treatment goals." —Oluwatosin Smith, MD

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