What does the future of minimally invasive glaucoma surgery (MIGS) look like? Ike K. Ahmed, MD, offered a succinct overview during Glaucoma Subspecialty Day.
In addition to increased standalone usage, emerging trends include employing MIGS earlier in the disease process, combining with drug delivery, and diagnosing and addressing downstream outflow disease.
Newer approaches include the following:
Laser-based systems. The Elios system, which uses excimer laser technology, is moving from the refractive to the glaucoma space, Dr. Ahmed said. It may provide some durability, and delivery of treatment via a fiberoptic probe is “fairly efficient,” Dr. Ahmed said. However, as he acknowledged, it is an expensive approach, and cost-effectiveness issues remain to be clarified.
A second approach, using the femtosecond laser, allows the surgeon to perform MIGS without actually entering the eye, Dr. Ahmed said. As the femtosecond laser beam is guided by OCT, patient-specific placement of drainage channels is possible. Moreover, additional retreatments are possible at any time, he noted.
New era of supraciliary MIGS. Given the recall of the CyPass stent because of endothelial cell loss, “What can we do to mitigate risk?” Dr. Ahmed asked.
Next-generation approaches include the MINIject, which is made of micropore antifibrotic silicone material. This is not a stent; rather, it is a soft implant that conforms to eye tissues. Results of a two-year study show promising IOP-lowering results and medication reduction with no significant cell loss.1
A second option involves Iantrek’s AlloPass. “This is not a typical shunt; it’s basically a stenting approach,” in which a cannula is used to place scleral tissue in the supraciliary space, Dr. Ahmed said. To date, investigators have observed good ocular tolerability with no emergent side effects.
Other options in the pipeline.These include a Gore-Tex implant, Avisi’s ultrathin VisiPlate, and—perhaps the most novel of all—the Beacon Aqueous Microshunt (MicroOptx), which is designed to shunt aqueous to the surface of the eye.
—Jean Shaw
1 Denis P. Br J Ophthalmol. 2022;106(1):65-70.
Financial Disclosures: Dr. Ahmed: Acucela: C; Aequus Pharmaceuticals: C; Aerie: C; Akorn: C; Alcon: C,L,S; Allergan: C,L,S; Aqua Health: C; ArcScan: C; Avisi: C; Bausch + Lomb: C; Beaver-Visitec: C; Beyeonics: C; Bionode: C; Carl Zeiss Meditec: C,L,S; Centricity Vision: C; CorNeat Vision: C; Custom Surgical: C; Elios Vision: C; Elutimed: C; Equinox: C; eyeFlow: C; Genentech: C; Glaukos: C,S; Gore: C; Iantrek: C; iCare: C; InjectSense: C; Iridex: C; iStar: C; Ivantis: C,S; Johnson & Johnson Vision: C,S; LayerBio: C; Leica: C; Long Bridge Medical: C; MicroOptx: C; MST Surgical: C,L; Myra Vision: C; New World Medical: C,S; Ocular Instruments: C; Ocular Therapeutix: C; Oculo: C; Omega Ophthalmics: C; PolyActiva: C; Ripple Therapeutics: C; Sanoculis: C; Santen: C; Sight Sciences: C; Smartlens: C; Stroma: C; Transcend Medical: C; TrueVision: C; ViaLase: C; Vizzario: C,S; VSY Biotechnology: C,L.
Disclosure key: C = Consultant/Advisor; E = Employee; EE = Employee, executive role; EO = Owner of company; I = Independent contractor; L = Lecture fees/Speakers bureau; P = Patents/Royalty; PS = Equity/Stock holder, private corporation; S = Grant support; SO = Stock options, public or private corporation; US = Equity/Stock holder, public corporation For definitions of each category, see aao.org/eyenet/disclosures.
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