MIGS and the Future of Glaucoma Treatment: New Insights

Microinvasive glaucoma surgery (MIGS) pioneer Reay H. Brown, MD, has long advocated that surgery will be the best treatment option for glaucoma once safety and efficacy are equal with current treatments utilizing eye drops or laser therapy. He discussed this further when delivering the 2017 Charles D. Kelman, MD, Innovator’s Lecture at the 2017 American Society of Cataract and Refractive Surgery (ASCRS) Symposium and Congress in Los Angeles. Dr. Brown was chosen for the lecture because of his innovations in glaucoma surgery, which are credited with leading to current MIGS.

Dr. Brown’s talk was entitled, “Overcoming Resistance: Making Glaucoma a Surgical Disease.” For now, Dr. Brown, of Atlanta Ophthalmology Associates, believes that eye drops or laser should still be considered before surgery in most cases of glaucoma. Although MIGS is safe enough, the efficacy of lowering intraocular pressure (IOP) is not as good as with those other methods, and he says MIGS is not yet ready to be considered for first-line use.

In hopes of changing this, Dr. Brown is working with a team of scientists at Georgia Tech to create a pump that will cause active flow of eye fluid – rather than the current method of passive flow – which may increase the efficacy of the procedure.

In two recent articles, Yvonne Ou, MD, of the University of California San Francisco Medical Center, supports the idea that surgery may yet become a first-line intervention for glaucoma.

One article looks at the benefits and risks of glaucoma surgery, including trabeculectomy, tube shunt implantation, and MIGS.1 She explains her belief that “the benefits outweigh risks for most advanced cases,” where therapy with medication and laser fails or is not well tolerated by the patient.

The article discusses possible complications of these surgeries, including bleeding, infection, hypotony, and vision loss, but says it is “important to recognize that the vast majority of glaucoma surgeries are successful at slowing the progression of glaucoma and achieving the intended eye pressure.”

Dr. Ou also writes that with MIGS the “enhanced safety profile is counterbalanced by a more modest eye pressure reduction” compared with other treatments. She points out MIGS is usually done in combination with cataract surgery for patients with early- to moderate-stage glaucoma, but that in patients with advanced glaucoma MIGS will be less likely to achieve the low eye pressures needed.

In a separate article in the same series, Dr. Ou discusses MIGS in more detail. She points out there are fewer associated complications with MIGS than with trabeculectomy or tube shunt surgeries, and that surgery time is generally shorter with MIGS, except for the time the usual practice of combining MIGS with cataract surgery adds to the procedure. She again points out, however, that MIGS procedures “are not as effective in lowering eye pressure” as other procedures.

But further innovations from Dr. Brown and his colleagues may lead to additional improvements in MIGS, and within a few years MIGS may be considered as a safe and effective first-line therapy for glaucoma treatment.

References

1. Ou Y: Glaucoma Surgery Series: The Risks and Benefits of Glaucoma Surgery. March 14, 2017. The BrightFocus Foundation. http://www.brightfocus.org/glaucoma/article/glaucoma-surgery-series-risks-and-benefits-glaucoma-surgery
2. Ou Y: Glaucoma Surgery Series: Minimally Invasive Glaucoma Surgeries (MIGS). March 20, 2017. The BrightFocus Foundation. http://www.brightfocus.org/glaucoma/article/glaucoma-surgery-series-minimally-invasive-glaucoma-surgeries-migs

Steve Lenier has worked with medical content for almost 30 years, with an emphasis on ophthalmology since 2005.