Change is coming to glaucoma surgery

San Francisco-A dramatic shift is starting to transform the practice of surgery in glaucoma. While trabeculectomy and trab-like procedures show steady, evolutionary improvements, three new types of surgery are moving interventional care from a last resort to front-line therapy.
    
“In the very near future we will be looking at one of the mechanisms of micro-invasive glaucoma surgery (MIGS), then moving on to external blebless procedures, then pulling out all the stops for a trabeculectomy if needed,” said Ike K. Ahmed, MD, FRCSC, assistant professor at the University of Toronto, Ontario.
    
Dr. Ahmed explored the changing landscape of glaucoma surgery during a CME Symposium at Glaucoma 360 on Saturday. Clinicians can expect to learn three new acronyms.
    
Most glaucoma specialists are familiar with MIGS, which has become a reality in the United States with the approval of two devices by the FDA. Additional devices have been approved for use in other parts of the world. MIGS can be a viable option for patients with mild-to-moderate IOP elevation.
    
The next step will be blebless ab-externo glaucoma surgery (BAGS), which usually includes canaloplasty and shunts. These devices are designed for moderate-to-advanced glaucoma and have not yet been approved by the FDA but are in use in other countries.
    
Add ab-externo bleb surgery (ABS). These devices are designed for moderate-to-advanced glaucoma and are not yet available in the United States.
    
These new procedures are less invasive than traditional trabeculectomy, show at least modest efficacy, and have extremely high safety profiles. MIGS, for example, is often compared with cataract surgery in terms of safety.
    
While there are multiple devices in each of the three categories, all are designed to drain into Schlemm’s canal, the suprachoroidal space, or the sclera/subconjunctival space. Some devices are rigid, some are soft and noodle-like, some are closed tubes, and some are more open scaffold-like designs. There are few head-to-head comparisons and multiple trials still under way.
    
“More data, more evidence, and more randomized controlled trials will help elucidate different advantages of these different devices,” Dr. Ahmed said. “It is very early in the field, but I see a lot of promise.”

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