July 2019


MIGS continues to surprise

by Nathan Radcliffe, MD EyeWorld Glaucoma Editor

More than a year has passed since we celebrated the arrival of a nearly complete set of trabecular, supraciliary, and transscleral MIGS. The future has arrived, but it isn’t quite what we thought it would be. 
In this issue of EyeWorld, we look at four fantastic topics, each of which takes us in a somewhat surprising direction. We discuss MIGS complications, a topic that we thought might not be necessary to discuss. But of course, with growing patient expectations, even the smallest of complications need to be managed adeptly. We look at a data set that certainly should be celebrated: The COMPARE trial, which randomized patients to either two generation one iStents or to the Hydrus—all standalone—provided the first large scale comparative MIGS stent data.1 As you will read, how we use things in the real world is hard to address with a single clinical study. It looks like we will need quite a few large scale prospective clinical studies in order to develop a true MIGS algorithm.
I am one of many surgeons who has changed his or her XEN 45 gel stent technique in order to get a little more control over postoperative healing and bleb failure. While my new ab externo technique still delivers an efficient and straightforward operation, it isn’t quite as streamlined as the original ab interno approach. This new approach gives us a nice example of taking a small step backward from the ideal intraoperative MIGS experience in order to deliver an overall better experience in both the operating room and the clinic for the surgeon and patient.
Last year’s CyPass withdrawal was, of course, the greatest surprise. Not only did we not see the endothelial problem coming, I think it is safe to say that the field of glaucoma as a whole has much to learn about the corneal endothelium. We don’t even truly know the baseline rate of endothelial cell loss in pseudophakic glaucoma patients. The CyPass withdrawal left us in need of a better understanding of the balance between corneal endothelial cells and retinal ganglion cells in patients with glaucoma. My suspicion is that once we know the full impact of traditional glaucoma surgery on the endothelium, the CyPass risks will seem more acceptable. 
In summary, glaucoma continues to be a fascinating and challenging disease, even when we try to “keep things simple” with MIGS.


1. Ahmed IIK, et al. A prospective randomized trial comparing Hydrus and iStent micro-invasive glaucoma glaucoma surgery implants for standalone treatment of open-angle glaucoma: The COMPARE Study. Ophthalmology. 2019. Epub ahead of print.

MIGS continues to surprise MIGS continues to surprise
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