October 2020


Should non-glaucoma specialists take on subconjunctival MIGS?

by Liz Hillman Editorial Co-Director

Dr. Tai performs a glaucoma procedure at New York Eye and Ear Infirmary of Mount Sinai.
Source: New York Eye and Ear Infirmary of Mount Sinai


Glaucoma procedures in the form of MIGS are increasingly being performed by non-glaucoma specialists. The 2019 ASCRS Clinical Survey found that 45% of respondents were currently performing MIGS. In terms of the overall survey demographics, 44.4% were cataract/anterior segment specialists, 25.3% comprehensive ophthalmologists, 14.4% cornea/external disease specialists, and 5.3% glaucoma specialists.
The ASCRS survey also found the majority (48%) of respondents (N=737 for this question) did not perform any incisional glaucoma procedures, but 36.6% said they performed trabeculectomy, followed by 21.8% who said they did Schlemm’s canal-based surgery, 16% tube shunts, and 6% transscleral gel stents.
Options for microinvasive glaucoma procedures are expanding, with some being performed standalone (instead of combined with cataract surgery as many are labeled) and some, like the PRESERFLO MicroShunt (Santen, not yet FDA approved) and XEN Gel Stent (Allergan, FDA approved in 2016), toeing the line of more traditional glaucoma procedures. The latter procedures, which are subconjunctival and bleb-forming, raise the question: Should non-glaucoma specialists be performing them?
EyeWorld spoke with a glaucoma specialist and a cornea specialist to get their take on this question and use of these devices that are often lumped in with MIGS, despite being more invasive and requiring more management than others in the category.

Tak Yee Tania Tai, MD

Glaucoma specialist

Dr. Tai said she does most, if not all, MIGS procedures, including XEN, and performed PRESERFLO when it was in U.S. clinical trials.
“I don’t think XEN and PRESERFLO should be regularly performed by comprehensive ophthalmologists, especially if they’re not well-versed in bleb management. These surgeries do invade the subconjunctival space, and bleb management takes a lot of experience to do well. Even a lot of beginning glaucoma surgeons need to take time to know how to manage a bleb well to be safe and to enhance the efficacy of the surgery,” Dr. Tai said.
However, she added a caveat for if a comprehensive ophthalmologist practices in an area with limited glaucoma specialists and a strong need for more advanced glaucoma management.
“I can see how it would be reasonable in those areas where there aren’t a lot of glaucoma specialists. … This is an easier procedure for them to do than a full trabeculectomy or a full glaucoma drainage device,” she said.
To learn this procedure and its management, Dr. Tai advocated for following a glaucoma surgeon who does a lot of subconjunctival MIGS procedures and their management. She also said that these cases could be comanaged with experienced optometrists if they are familiar with evaluating blebs and identifying patients who need more intervention. Surgical intervention should be done by the surgeon, Dr. Tai said.

David Goldman, MD

Cornea specialist

Dr. Goldman was such a doctor who saw a need in his area and, thus, learned how to perform XEN. Prior to offering XEN, Dr. Goldman said he was referring out at least one patient per week to a glaucoma specialist for filtration surgery. In his area, there were not a lot of glaucoma specialists.
“They were all super overwhelmed. [Learning XEN] was helping them in that they weren’t drowning in those cases,” he said, adding that it also helped patients get the care they needed more efficiently.
Dr. Goldman thinks it’s important to have a good relationship with a glaucoma specialist so that they can take over cases you might be uncomfortable with or patients who need a more intense filtration surgery.
Dr. Goldman said he’s comfortable with conjunctival surgery, which is required of XEN and PRESERFLO, due to his experience with pterygium, but he said he’d never done glaucoma surgery outside of residency. When he first sought out XEN, he had a glaucoma specialist with him through the procedure.
Bleb management intimidated him at first, but once he gained experience in needling, when to needle, and bleb revision, it “wasn’t that scary,” he said
“Once you do it, [it’s] not as challenging as you thought it was,” he said, adding that dexterous surgeons will do bleb revisions in the office, but he thinks it’s “absolutely OK” to take patients back into the OR for this.
It is important to remember to manage patient expectations at the outset, Dr. Goldman continued, so that if you do have to do a revision, the patient doesn’t see it as a complication.
Dr. Goldman is not sure if he’s going to bring PRESERFLO into his practice when it becomes available in the U.S. He said he’s going to have to wait to evaluate the clinical data and how it performs in the “real world” before jumping into this procedure.

About the doctors

David Goldman, MD
Goldman Eye
Palm Beach Gardens, Florida

Tak Yee Tania Tai, MD
New York Eye and Ear Infirmary of Mount Sinai
New York, New York

Relevant disclosures

Goldman: Allergan, Glaukos, Sight Sciences
Tai: None


: drdavidgoldman@gmail.com
Tai: ilana.nikravesh@mountsinai.org

Should non-glaucoma specialists take on subconjunctival MIGS? Should non-glaucoma specialists take on subconjunctival MIGS?
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