EyePod: Transforming the MIGS pipeline into clinical reality

In this EyePod® episode, Peter J. McDonnell, MD, and Neda Shamie, MD, discuss the transformative impact of minimally invasive glaucoma surgery (MIGS) on glaucoma care and its integration with cataract surgery, sharing insights and practical tips for ophthalmologists.

The views and perspectives expressed are those of Dr. McDonnell and Dr. Shamie.

Audio transcript

Editor’s note: This transcript has been edited for clarity.

Sheryl Stevenson: Hi, everyone! Welcome to this episode of the Ophthalmology Times EyePod podcast series.

This is Sheryl Stevenson, group editorial director with Ophthalmology Times, and we are joined today by our co-chief medical editors.

Dr. Peter J. McDonnell is the director of the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland, and Dr. Neda Shamie is a cataract, LASIK, and corneal surgeon and partner of the Maloney-Shamie Vision Institute in Los Angeles, California, as well as an adjunct clinical professor of ophthalmology at the USC Keck School of Medicine.

In today’s episode, they discuss how embracing MIGS procedures can significantly enhance glaucoma management during cataract surgeries, offering patients the opportunity to reduce their reliance on eye drops and improve overall treatment outcomes. They share how integrating MIGS into clinical practice can be a rewarding endeavor that empowers ophthalmologists to provide more effective care for patients with glaucoma.

Let’s take a listen…

Neda Shamie, MD: Welcome, everyone! This is Neda Shamie and you are listening to EyePod, which is sponsored by Ophthalmology Times, where we talk about topics at hand in ophthalmology and really kind of bring it to the forefront of your thoughts so that you can explore further.

It's going to be a short conversation that I will be having with Dr. Peter McDonnell, who is my mentor, a dear friend, and someone who is truly an expert in the field of ophthalmology and I turn to for advice all the time. Hi, Peter!

Peter J. McDonnell, MD: Hi, Neda! It's great to be here with my co-chief medical editor of Ophthalmology Times and talk about a really exciting thing that, I think, taking the world of glaucoma by storm, which are these great new MIGS devices. It's really caused in evolution in glaucoma care in the United States. And you've had very positive experience yourself with these devices, right?

Shamie: Yes, most definitely. I agree with you. I think in glaucoma, there's been a real significant paradigm shift since the advent of different MIGS devices that have allowed for a minimally invasive approach to treating glaucoma. When I was in my training, it was either [eye] drops or maybe some laser treatments, but ultimately, trabeculectomies and trabeculotomies and tubes and shunts and such, which have a lot of comorbidity associated with them.

These minimally invasive glaucoma shunts and procedures that are done often at the same time as cataract surgery can really have very little added risks to the surgery, but have significant impact on glaucoma management of patients, lessen the load of the eye drops and the toxicity that go along with them. And really a wonderful addition to the armamentarium of not just glaucoma surgeons, but also cataract surgeons. And I think that's where we should really emphasize our discussion on.

There's no question that glaucoma surgeons, at least the ones I speak to, are huge advocates of the advanced technology in the MIGS procedures. I think the challenge is that the gatekeepers are often the general eye doctors and cataract surgeons. And a lot of the time when these patients who have glaucoma and comorbidities associated with glaucoma, when they're ready to have cataract surgery and they have the opportunity to be a candidate for the MIGS, the MIGS procedures are not necessarily offered to them.

I think the hurdle is to get past that because there's not enough glaucoma surgeons out there to really take care of all of the glaucoma patients out there. And often the feedback I'm getting from glaucoma surgeons is they really want us cataract surgeons to consider MIGS procedures at the time of our cataract surgery to lessen the burden of glaucoma for these patients and, hopefully, prevent progressive disease for them.

What are your thoughts on that?

McDonnell: You know, I think you hit on a lot of really key points there. When I look at the data from the Academy's IRIS Registry [Intelligent Research in Sight] and also the Medicare database, 75% or more of glaucoma surgical procedures now are MIGS. And in this recent report only 13% were trabs. In my day, that was pretty much the glaucoma operation.

And from my perspective, it was sort of for a refractive surgeon to do this 'loosey-goosey' tighten the sutures enough but not too much, etc. It was sort of imprecise. To me, there's lots of appeal of these MIGS and to see it go from very little to such a high percentage, almost 80% now of glaucoma surgical procedures are MIGS. That's really impressive. I'm wondering, in terms of getting people who are not glaucoma specialists and don't have much experience yet, and maybe there's a little trepidation about how to get started.

What pearls would you offer? How did you make that transition to get going?

Shamie: Often, what happens with new additions to our surgical armamentarium, it's a patient that encourages us to forge ahead.

I had a patient who had glaucoma who came to me [and] really wanted to have her cataract surgery done by me and was on 3 [eye] drops for glaucoma management. She's the one who said — this is a while ago, this is probably nearly 8 years ago — why aren't you offering me MIGS. Truthfully, she put me to shame because there was enough evidence for the benefits that iStent at the time was offering that I should have offered it together with a cataract surgery. And so I was very honest and transparent with her. And I said, I have not done one. And she says, why don't you have my case be your first. It really just takes that motivation.

It takes that incentive to really want to do the best for your patients to bring on new technology. There is no question that the technology has now been proven to be effective. And the truth of the matter is, what do you have to lose and that's my attitude to my colleagues who push back on MIGS. You have really nothing to lose and everything to gain for your patients.

To bring on the MIGS procedures it's a very simple addition to your surgery. The learning curve is very, very quick. For those of us who do a lot of anterior segment surgeries, having the ability to do that gonio visualization of the angle, and being able to maneuver in the anterior chamber is not very different than what we do in our preop exams. And we all know how to use a gonio lens. And it doesn't take much to learn how to do it in intraoperatively. And we all know how to maneuver in the eye without collateral damage to structures inside the eye.

So I would say if there's trepidation, look at the data. Like anything, I do my research. I look at the data. I ask colleagues who have experience. And now with YouTube, Ophthalmology Times, all the different resources available to really get as much information ahead of time as possible it again shouldn't take much to forge ahead.

I would suggest starting with one device first, getting familiar with probably the simplest device, which for me, at least, it was the iStent, but for others, it may be different approaches. And then from there moving forward. I think probably the biggest challenge is how to use the gonio intraoperatively. And then kind of understanding what the postoperative management of these patients are.

It just simply took me communicating with colleagues and friends who've done a lot of these and getting their protocols in place. I feel great about offering it to my patients. I think as a cataract surgeon you're doing your patient disservice if they come in with glaucoma and they’re on at least 1 if not 2 drops and not offer them MIGS you have taken away an opportunity for them to be able to lessen their dependency on glaucoma drops.

McDonnell: I think those are all great pearls. The risk:benefit, I agree, is very much in favor of the benefit. We don't see the really feared complications of hypotony with the MIGS devices, so that's really nice. Now, it is true that a few years ago, Alcon did voluntarily recall the CyPass MIGS device because of concerns regarding endothelial cell loss...progressive endothelial cell loss. As two cornea specialists, you and I both love endothelial cells and we know they're important. But beyond that, I think the track record over the years has really been pretty darn positive in terms of relatively few adverse events and I think that's really helped support the increasing use over time.

And I think all the points you made are excellent. I guess if I was still concerned about getting started, I might ask a colleague who is available that day...maybe is also operating at the ASC...to sit there next to me while I do my first one or two cases or any tricks. Someone who has experience with using the MIGS. I can't agree with you more that starting with one and then getting comfortable and then moving on makes sense.

Shamie: In my practice, I don't have necessarily a go-to but I offer the iStent infinite, the Hydrus, and Omni canaloplasty and I kind of mix and match based on the degree of the patient's glaucoma, their dependence on drops, and I would say probably the biggest challenge and the steepest or the hardest learning curve really is how to fit the different options in your practice, how to present it to the patients, where does it land in your discussion and counseling of patients, and most importantly, how do you manage the postop.

Again, there's very different kind of varied ways of doing all of that. In our practice, we have trained our technicians to be familiar with all the different technologies available and to present the options to our patients as they come in right at the same time as they discuss cataract surgery with our patients and educate them and then flag the chart so that I know to talk about the different MIGS procedures when I go in.

And then postop, we have the patients continue to go through glaucoma eye drops until they're off of their steroid eye drops after which then we remove, we have 1 drop removed at a time of the glaucoma drops with a 1-month time to really kind of gauge what the pressure response would be. If a patient is comanaged, which many of my patients are, our comanaging doctors are well trained on how to do that.

I feel great about really being at the forefront of this technology and I have had great results being able to lessen the burden of glaucoma drops for my patients. And that's key I think to create just like anything else have the expectations be realistic that this is not going to cure them of glaucoma, it's only going to help with management and potentially lessen their burden of the drops, maybe 1 possibly more than 1 drops.

So with that, I think, hopefully, for those listeners out there, you're convinced to at least explore the option of MIGS and adding that to your practice. Because after all, we're here to offer our patients the best treatment options out there and this treatment has been shown to be proven effective and safe. A patient who has glaucoma together with their cataract deserve to be offered this. By the way, I should also state that their Omni can also be offered without cataract surgery. So that's one treatment option...one of the MIGS procedures that can be done standalone, which, in itself, is an excellent opportunity to lessen the burden of glaucoma on our patients.

Thank you so much, Peter, for a wonderful discussion. I look forward to our next one.

McDonnell: Always a pleasure, Neda. I love these stories of innovation in ophthalmology. It's a great field.

You'll remember, you and I in our younger days, we were colleagues with George Baerveldt. He was, of course, the author of the Baerveldt Implant and he was a great innovator and he was careful and scientific in his approach, but it's great to see what I think is this dramatic, exciting development in terms of improving our management for glaucoma patients. I'm very positive about it. Very happy to see it.

Shamie: Same here. Thank you so much.