There are now several types of surgeries that fit in the MIGS category and many of them are used in conjunction with cataract surgery. Dr. Aditi Singh Minimally invasive glaucoma surgery (MIGS) 2. 19. MIGS has become a commonly used abbreviation in the glaucoma world. After implantation, the gelatin in the stent hydrates slightly causing expansion of the device to ensure improved stability. Home | MIGS. The gel stent is loaded in a single-use, single-handed disposable injector with a 27-gauge needle. 32. evaluated the safety and efficacy of ECP in refractory glaucoma of multiple subtypes. J Cataract Refract Surg 2014; 40: 1313-1321. The study included 80 patients that underwent phacoemulsification (control group) and 80 eyes that underwent phacoemulsification with ECP (study group); baseline IOP was 18.1±3.0 mmHg in both groups. 2. The injector is inserted into the anterior chamber through a clear corneal incision and the tip of the injector is used to pierce through TM and the sclera into the subconjunctival space. Viscodilation of Schlemm’s Canal for the Reduction of IOP Via an Ab-interno Approach. The level of IOP reduction is often inferior to traditional filtering surgery but should be at least 20%. One Incision. 12. 2006; 90(3):262-7. ECP can also be performed in conjunction with other angle based procedures above to provide additional IOP lowering. 5. Background: Glaucoma is a condition that causes progressive damage to the optic nerve, which can lead to visual impairment and irreversible blindness. The HORIZON study was the pivotal study for approval of the Hydrus microstent; it compared phacoemulsification alone to phacoemulsification with Hydrus microstent implantation. The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group. Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. The OMNI ® Glaucoma Treatment System is the only device that combines two well-established micro-invasive glaucoma surgery (MIGS) … Eyes in groups 2 had a mean baseline IOP of 14.9±1.8 mmHg and a post-operative mean IOP of 13.6±2.3 mmHg with no significant difference between the two time points. Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. To meet this clinical need, a number of devices have recently been developed labeled as either micro‐incision or minimally invasive glaucoma surgery (MIGS) devices that modulate aqueous humor outflow facility via one of several routes (Figure 2). 33. CADTH OPTIMAL USE Optimal Use of Minimally Invasive Glaucoma Surgery: A Health Technology Assessment 2 Clinical Review Authors: Dr. Veronica Poitras,1 Charlotte Wells,1 Dr. Cindy Hutnik.2 Economic Evaluation Authors: Dr. Scott Klarenback,3 Helen So,3 Dr. Bernice Tsoi.1 Patients’ Perspectives and Experiences Review Authors: Andrea Smith,1 Elijah Herington.1 There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. At 12 months post-operatively, there was a significant reduction in IOP from a baseline of 24.6±7.1 mmHg to 14.6±2.8 mmHg with an average reduction in IOP of 41% across all eyes. The number of IOP lowering medications decreased from 1.7±1.3 eye drops pre-operatively to 1.1±1.0 eyes drops at 12 months. The number of hypotensive eye drops decreased from 1.6±1.3 to 0.9±1.0 eye drops.20  Another study included 52 eyes of patients with open angle glaucoma and visually significant cataracts who underwent phacoemulsification with KDB goniotomy. Average number of medications decreased from 1.3±1.0 at baseline to 0.6±0.8 at 2 years in the phacoemulsification only group, and from 1.4±0.9 drops at baseline to 0.2±0.6 at 2 years in the Cypass group. Gonioscopy-assisted transluminal trabeculotomy, ab interno trabeculotomy. Minimally invasive glaucoma surgery (MIGS) is the newest group of surgical procedures that aim to reduce pressure in the eye and slow the progression of glaucoma. Bloom P, Au L. “Minimally invasive glaucoma surgery (MIGS) is a poor substitute for trabeculectomy”—The great debate. 20. There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. How MIGS Works. There was also a significant reduction in IOP lowering drops in group 1 eyes from 2.1±1 to 0.2±0.6 and 85% of eyes required no medications to maintain pre-operative IOP or lower. The iStent inject consists of a single-use injector that comes pre-loaded with two devices, which are to be placed 2-3 clock hours apart in the nasal angle at the time of cataract surgery. Thirteen eyes required subsequent surgeries due to uncontrolled IOP, with 10 patients receiving trabeculectomy and 3 patients receiving repeat Trabectome.8  In a study completed in 2008 involving 304 eyes in patients with open angle glaucoma, similar results were found with combined phacoemulsification and Trabectome.25  Mean IOP was found to have decreased from 20.0±6.3 mmHg to 15.5±2.9 mmHg at 1 year post-operative and the average number of topical medications was reduced from 2.65±1.13 to 1.44±1.29 drops. Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. A total of 546 patients with primary open angle glaucoma who had visually significant cataracts, IOP between 22-34 mmHg, and who were on between 1-4 hypotensive eye drops were enrolled. Ophthalmology January 2019;126(1): 29-37. Hydrus plus phacoemulsification group went from 1.7±0.9 drops to 0.3±0.8 drops at 24 months after surgery while the phacoemulsification alone group went from 1.7±0.9 drops to 0.7±0.9 drops at 24 months.18. At 24 months, 75.8% of patients who received iStent inject at the time of cataract surgery had experienced at least a 20% reduction in IOP compared to 61.9% in the phacoemulsification alone group. Open angle glaucoma (OAG) is a disease affecting an estimated 2.8 million people in the United States as of 20101, accounting for an approximate cost of $1.5 billion per year.2 Initial therapy for OAG typically consists of medications that can aid in decreasing aqueous humor production or increasing aqueous humor outflow. The management of glaucoma is continuously evaluated throughout the life of a glaucoma patient. Glaucoma is an eye disease that causes damage to the optic nerve, often as a result of high pressure within the eye. Vold S, Ahmed II, Craven R, Mattox C, Stamper R, Packer M, Brown R, Ianchulev T. Two-Year COMPASS Trial Results: Supraciliary Microstenting with Phacoemulsification in Patients with Open-Angle Glaucom and Cataracts. Adv Ther 2018; 35:1460-1469. The study included 68 patients with refractory glaucoma who had either failed maximal medical therapy, had previous failed filtration surgery or transscleral cyclodestructive procedure. Uram M. Endoscopic Cyclophotocoagulation in Glaucoma Management. At 1 year post-operative follow-up, 40% of eyes were off all IOP lowering drops.24. 30. 31. The iStent Inject is the second generation trabecular meshwork bypass stent which received FDA approval in June 2018 (Glaukos, Laguna Hills, CA). Art of Minimally Invasive Glaucoma Surgery. The XEN gel stent (Allergan, Dublin, Ireland) is a 6mm device composed of porcine-derived gelatin cross linked with glutaraldehyde. Grover DS, Godfrey DG, Smith O, et al. The probe comes in a 19, 20, or 23 gauge size that is either straight or curved and is inserted into the anterior chamber through a clear corneal incision. MIGS comprises a group of surgical procedures which share common features. Ophthlamology 2016; 123: 2103-2112. JAMA 2019;322:20:1996-2016. Being minimally invasive surgery, the complication rate of iStent inject is lower than that of conventional Glaucoma surgery. Patients can be phakic, pseudophakic or aphakic. This resistance can be overcome through bypassing or removing this tissue to lower IOP through increased outflow. It stands for minimally invasive glaucoma surgery. 2013;39(3):431-437. Combining minimally invasive glaucoma surgery procedures is a feasible, versatile alternative for lowering IOP and minimizing the side effects of a surgical approach to glaucoma, … Presented at 11/13/12 AAO Conference, Chicago, IL. It can be performed in patients who are phakic, pseudophakic or aphakic. It was a prospective, single-masked, multi-center study with 505 eyes randomized 3:1 to iStent plus phacoemulsification (n=387) or phacoemulsification alone (n=118). At 24 months, 77.3% of eyes in the Hydrus group experienced at least a 20% reduction in IOP compared to 57.8% of eyes in the phacoemulsification group alone. Mitomycin C is typically injected subconjunctivally before or after stent placement to limit bleb fibrosis. At 6 months, mean IOP decreased from 17.4±5.2 mmHg to 12.8±2.6 mmHg, and 58.3% of patients had an IOP reduction of ≥20% from baseline. March 1-4 2012. 24. What is Minimally Invasive Glaucoma Surgery? The connected video monitor provides for endoscopic viewing by the surgeon and a foot pedal allows for surgeon control of the laser. 1096-1103. Secondary outcome measures included reduction in hypotensive eye drops. ECP treatment was performed on 180-360 degrees of the ciliary body. MIGS trusitdave 2020-06-20T10:53:38+00:00. Dorairaj S, Seibold LK, Radcliffe N, Aref A, Jimenez-Roman J, Lazcano-Gomex G, Darlington J, Mansouri K, Berdahl J. Minimally Invasive Glaucoma Surgery (MIGS) is a new advanced type of outpatient procedure for patients with mild to moderate glaucoma. ECP is most commonly used in open angle glaucoma but also has a particularly advantageous role in the treatment of angle closure or plateau iris where it can function to deepen the angle. When these two options are no longer sufficient or are not suitable, … The Visco 360/OMNI System is indicated for the treatment of open angle glaucoma and ocular hypertension. modern glaucoma surgery where it is - essentially a standstill. Minimally invasive glaucoma surgery (MIGS) has recently been a popular topic among both comprehensive ophthalmologists and glaucoma specialists. 369 eyes underwent phacoemulsification with Hydrus microstent implantation and 187 eyes underwent phacoemulsification alone. They are utilized much earlier in the disease process and when combined with cataract surgery … Grover DS, Flynn WJ, Bashford KP, Lewis RA, Duh YJ, Nangi RS, Niksch B. Furthermore, the average number of IOP lowering drops decreased from 2.8±0.9 drops to 1.1±1.1 drops, which represents a 60.0% reduction on average. This term refers not to a single surgery, but rather to a group of distinct procedures and devices that aim to decrease intraocular pressure. At 24 months, 77.3% of eyes in the Hydrus group experienced at least a 20% reduction in IOP compared to 57.8% of eyes in the phacoemulsification group alone. Several studies have demonstrated the clinical efficacy of Kahook Dual Blade goniotomy for IOP reduction in patients with glaucoma. Bypass can be achieved by placing a trabecular meshwork bypass stent which allows aqueous to flow directly through the stent from the anterior chamber into Schlemm’s canal. J Cataract Refract Surg; 34(7). Primary outcome measures were reduction in IOP and proportion of patients achieving a reduction in IOP of more than 20% from baseline. How minimally invasive glaucoma surgery reduces risk to patients. Of the 72 eyes in group 1, 11 underwent VISCO360 alone and 61 underwent VISCO360 with cataract extraction. 84.9% of eyes experienced an IOP reduction of greater than 20% from baseline. As previously mentioned, trabecular meshwork bypass can be achieved either through the placement of stents or through surgical incision/excision of the trabecular meshwork tissue. looked at 1 year outcomes of KDB with phacoemulsification. Purpose: The last decade has witnessed an unprecedented growth in glaucoma treatment options through the introduction of minimally invasive glaucoma surgeries (MIGS).The aim of the present … Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. Chen J, Cohn R, Lin S, Cortes A, Alvarado J. Endoscopic Photocoagulation of the Ciliary Body for Treatment of Refractory Glaucomas. 7. The procedure is then repeated for the remaining 180 degree of Schlemm’s canal. Ophthalmology 2011; 118: 459-467. There was a significant reduction in medications at 12 months from 1.8±0.9 to 0.2±0.6 post-operatively. The technique of ECP was first described by Uram in 1995. To contextualize the lived experience of glaucoma and treatments for glaucoma, we also interviewed people with glaucoma and family members of people with glaucoma, some of whom had experience with surgical procedures such as MIGS and some of whom did not. Results: NLM 15. The tip of the hand piece is used to pierce the trabecular meshwork and the microcatheter is advanced from the tip of the device and threaded through 180 degrees of Schlemm’s canal. A mean preoperative IOP of 26.6±8.1 mmHg was reduced to a mean of 17.4±3.4 mmHg at 6 months post-operatively. This is an excellent alternative to invasive filtering surgery in patients with mild, moderate or severe glaucoma. It can be done at the same time as cataract surgery (a surgery to remove a cloudy eye lens), and may be safer than more invasive surgeries for glaucoma. Ophthalmol Ther 2018;7:203-210. The pivotal trial for approval of the stent compared iStent inject/phacoemulsifcation to phacoemulsification alone. Alternatively, cataract surgery can be combined with a minimally invasive glaucoma procedure. Average IOP reduction at 12 months post-op was 32.3% in both groups; 32.8% in the stand-alone ABiC group and 31.7% in the ABiC/phacoemulsification group. Furthermore, it is believed to decrease herniation of the inner wall of Schlemm’s canal into the distal collector channels to improve outflow. 28. Background: The Kahook Dual Blade (New World Medical, Rancho Cucamonga, CA) is a specialized goniotomy blade that was introduced in the United States in 2015. We analyzed the budget impact of publicly funding MIGS in adults with glaucoma in Ontario. 4. However, as mentioned below, the device has been withdrawn from the market. It was designed for improved excision of the trabecular meshwork during goniotomy. Samuelson T, Katz LJ, Wells JM, Duh Y, Giamporcaro J. Randomized Evaluation of the Trabecular Micro-Bypass Stent with Phacoemulsification in Patients with Glaucoma and Cataract. Ab interno approach: MIGS are typically performed ab interno through a traditional clear corneal wound with direct visualization of the anatomical target. Glaucoma is a disease affecting an estimated 60.5 million people worldwide and 5.7 million people in the United States as of 2010.1  Globally, it accounts for 8% of all cases of blindness and is the leading cause of irreversible blindness worldwide.2  In the United States, it accounts for an approximate annual cost of $1.5 billion.3   Initial therapy for glaucoma typically consists of topical eye drops or laser trabeculoplasty, both of which aim to lower intraocular pressure and have similar efficacy.4  Historically though, when pharmacologic and/or laser treatment fails to control IOP, incisional surgery such as trabeculectomy or glaucoma drainage device implantation is required. 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