March 28, 2017
2 min read
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Will MIGS replace drops as first-line treatment?

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Joseph F. Panarelli

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POINT

MIGS may be ideal in ocular hypertension, mild glaucoma

Microinvasive glaucoma surgery has the potential to replace drops as first-line therapy, not in all situations but in certain ones. When a newly diagnosed patient presents with moderate to severe glaucomatous disease, the proper course of action is to institute medical therapy and then move to incisional surgery if the patient is progressing or deemed likely to progress despite maximally tolerated medical therapy. However, for patients with ocular hypertension or mild glaucomatous disease, a MIGS procedure may be ideal as initial therapy.

Patients are often noncompliant with medical therapy for a variety of reasons. There are those who cannot tolerate the side effects of the medication, those who cannot afford the cost of the medications, those who run out of their medication before it can be refilled, those who have difficulty administering drops, those who do not see a direct benefit from taking their medication, and those who simply forget, even though they have good intentions to take their drops. There is now solid evidence in the literature to support the use of various MIGS devices as standalone procedures or in combination with cataract extraction to lower IOP in patients with early disease. With newer devices gaining FDA approval in the U.S., our surgical armamentarium will continue to expand.

It is important to remember that risks and benefits of the surgical procedure should be discussed with the patient and that although MIGS procedures have an excellent safety profile, complications can always arise. However, for many this risk is acceptable if it means that they can go years or decades without the need for topical therapy. In the end, the surgeon’s comfort with these newer procedures will play a large role in how often they are used earlier in the treatment algorithm. Remember, prescribing a patient an IOP-lowering medication is not the same as writing a patient a 10-day course of antibiotics. You are often writing them a prescription for a two or even three-decade course.

Joseph F. Panarelli, MD, is an assistant professor of ophthalmology at New York Eye and Ear Infirmary of Mount Sinai. Disclosure: Panarelli reports he is a consultant for Allergan and Aerie Pharmaceuticals and received honoraria from Glaukos.

COUNTER

MIGS procedures expand options for personalized treatment

MIGS procedures are extremely useful and are increasingly becoming an important part of our armamentarium. However, they still require entrance into the eye by some means, and once you enter the eye, you add possible complications that do not exist with medical treatment. Certainly, medications have their own complications and side effects that surgery avoids. Cost and adherence may also be issues. In many parts of the world, MIGS procedures are an effective choice as first-line therapy because high costs and distances limit access to medications, eye care facilities and regular visits, and adherence to therapy is therefore unlikely. In the industrialized world, where medical care is widely accessible, less risky interventions can be used in treating glaucoma as first-line therapy. However, MIGS procedures occupy an important place in glaucoma management.

Joel S. Schuman

I use MIGS fairly early in the course of the disease and whenever patients on medical glaucoma treatment need cataract surgery because it adds significant benefit with low risk. Even in moderate disease I tend to use MIGS rather than a more aggressive procedure. Devices such as the Xen (Allergan) and the InnFocus MicroShunt (InnFocus) have bridged the gap between blebless procedures and trabeculectomy, and I use them with more aggressive or intense disease. There is a lot of talking nowadays about personalized treatment. In glaucoma, due to the nature of the disease, we have been doing personalized treatment for a long time, and now we have a larger spectrum of possible options.

Joel S. Schuman, MD, is an OSN Glaucoma Board Member. Disclosure: Schuman reports he has consulting interests in Ocugenix, Pfizer, Alcon, Aerie and Shire Pharmaceuticals.