December 2019


YES Connect
The lowdown on MIGS for the young eye surgeon

By Liz Hillman EyeWorld Editorial Co-Director

Claudia Perez-Straziota, MD
YES Connect Co-Editor

It has been almost a decade since MIGS joined our surgical tool box, with several different devices now available. However, as MIGS slowly incorporates into residency surgical training with varying degrees of exposure to different devices among programs, there are still many young eye surgeons learning this technique after completing residency.
In this month’s column, Constance Okeke, MD, and Michael Patterson, DO, discuss how young eye surgeons can become proficient in implantation of MIGS, having had little exposure and experience during their training.

–Claudia Perez-Straziota, MD
YES Connect Co-Editor

“For us, the most important thing is to not try to do
everything at once.”
—Michael Patterson, DO

The extent to which young eye surgeons are receiving training with MIGS in residency varies and, as such, many will need continued training with these devices and techniques as they start incorporating them into their practice.
“Every program is a little different, and every program has a different opinion on what should be taught first, second, third, fourth, and fifth,” Michael Patterson, DO, said. “Some surgeons are exposed to [MIGS] not at all, and other surgeons are exposed to it aggressively.”
Dr. Patterson said he thinks most ophthalmologists are, at least in training, getting exposure to “something simple” like iStent (Glaukos) or iStent inject (Glaukos).
Constance Okeke, MD, said she thinks a “good portion of residents or fellows will need to have some additional learning that will be done after their training” when it comes to MIGS.
And that’s what she and Dr. Patterson are discussing in this month’s column: How young eye surgeons can get involved with MIGS if they have little exposure and experience. Both Dr. Patterson and Dr. Okeke have had to do most of their MIGS learning while in practice. Dr. Patterson said he had some experience with the first-generation iStent in training, as it was just being approved at that time. Since then, as more MIGS procedures became approved, he and his practice considered the ones they felt would be most efficacious for their patients.
“In our playbook, we felt very clear that we were going to offer as many as we could,” Dr. Patterson said, noting that he has experience with OMNI (Sight Sciences), XEN Gel Stent (Allergan), iStent, iStent inject, Hydrus (Ivantis), and endocyclophotocoagulation (Beaver-Visitec).
Dr. Okeke said she started with Trabectome (MST) after fellowship in 2009 and has since added iStent, iStent inject, OMNI, ab interno canaloplasty (ABiC, Ellex), Kahook Dual Blade (New World Medical), XEN Gel Stent, and GATT (gonioscopy-assisted transluminal trabeculotomy) to her practice.

Making sure you can offer MIGS

After learning about what a MIGS option has to offer, based on studies and experience of other surgeons, and deciding that it’s something that would benefit your patients, both Dr. Okeke and Dr. Patterson said you have to find out if you can actually perform the procedure where you practice.
Dr. Okeke said she finds out if a MIGS procedure is actually viable option at her surgery center, if the codes are something the center can accept, and if it makes sense for the practice to make it financially viable for her to do.
Dr. Patterson emphasized the importance of ensuring that you’ll get reimbursed for a new MIGS procedure before taking it on.

Getting started

Dr. Patterson advised that new surgeons pick one or two MIGS procedures to start out with.
“Get really good at those—ones that you can hit home runs with—because if you’re trying to manage all of them all at once when you come out, it’s going to be very difficult,” he said.
To get familiar with these procedures, Drs. Patterson and Okeke said to start watching surgical videos and attend wet lab training. Dr. Patterson suggested wet labs at ophthalmic meetings. While Dr. Okeke agrees this early exposure is essential, there will ultimately be a need to schedule a wet lab for the weekend or morning before her first cases. This wet lab, she said, includes herself, being instructed, and the surgical rep talking to her surgical staff so they can be oriented on what they’ll need to do to assist the surgeon.
Dr. Okeke said she’ll schedule 3–5 cases in a row with a new MIGS procedure to help get a good handle on the nuances of the technique, while Dr. Patterson advised “slowly [getting] your feet wet.”
“I think that these devices are easy enough for the average, competent cataract surgeon to take them slowly, one at a time, and then figure out what works,” he said.
Dr. Patterson and Dr. Okeke both recommended starting to practice with intraoperative gonioscopy, learning the correct positioning, ahead of your first MIGS cases.

Patient selection

To Dr. Patterson, patient selection for MIGS comes down to “really what do your patients want.” He said he tries to select patients who are highly motivated to get off drops and, at least to start, who aren’t needing a premium IOL, because the vision can be blurry for a few days longer with MIGS-phaco cases.
“I think the people who are on two drops or even three seem to have the highest satisfaction, because we know from one drop to two or three your compliance is horrible. So if you can get them down to one drop from three, that’s a big change in their life,” he said.
Dr. Patterson also said patients who have severe dry eye love MIGS, if it allows them to come off glaucoma drops that are toxic to the eye. Similarly, Dr. Okeke said she finds patients with a tube or trab with viable angles can benefit from cataract-MIGS procedures for this reason. MIGS can be “quite beneficial to this class of patient who might have some ocular surface disease due to the change in anatomy after traditional glaucoma surgeries, as well as the additional drops,” she said, adding that she’s used canaloplasty, goniotomy, and stents, as well as a combination of these, for such patients.
Ideal candidates, Dr. Okeke said, are those who have an open angle with normal anatomy, great structures, and mild to moderate disease. “You want them to have enough disease to warrant the procedure,” she said.

Final thoughts

Dr. Okeke shared three, final take-home points for the young eye surgeon taking on a new MIGS procedure. 1) Make a decision that you are ready to embark on adding a new procedure to your armamentarium. 2) Find a mentor who has done the procedure, someone you can follow or discuss their experiences. Surgical reps also have helpful resources and can act as a liaison to find mentors. 3) Consult other resources. Dr. Okeke referenced her iGlaucoma YouTube channel’s MIGS University Video series, which she launched specifically to help those new to MIGS.
Dr. Patterson advised against trying to do everything at once—master one or two MIGS procedures at a time—and prepare for complications in advance.
“I would say most important is take a deep breath and know that sometimes things can go wrong in these surgeries. … Your mental preparation is key to make sure you are ready to go and you understand what are your risks, understand what can happen during surgery,” he said.

About the doctors

Constance Okeke, MD, MSCE
Assistant professor of ophthalmology
Eastern Virginia Medical School
Virginia Eye Consultants
Norfolk, Virginia

Michael Patterson, DO
CPT United States Army Reserves
Eye Centers of Tennessee
Crossville, Tennessee

Relevant financial interests

Okeke: MST, Glaukos, Ellex, Sight Sciences, Allergan, Santen, Bausch + Lomb, Aerie, Alcon, Novartis, Reichert
Patterson: New World Medical, Ivantis, Glaukos, Sight Sciences, Beaver-Visitec, Bausch + Lomb, Johnson & Johnson Vision, Carl Zeiss Meditec

Contact information


The lowdown on MIGS for the young eye surgeon The lowdown on MIGS for the young eye surgeon
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