Glaucoma surgery has advanced greatly since the advent of MIGS, or micro-invasive glaucoma surgery. A breakthrough technology, MIGS procedures allow surgeons to reduce IOP by improving aqueous outflow through the natural physiologic pathway. Its other benefits are that it’s significantly less invasive than other types of implants and patients have shorter recovery times, similar to that of cataract surgery alone. They also enjoy far better postoperative vision than that seen in traditional glaucoma surgeries, with no scars. “We work through the same cut made for cataract surgery,” says ophthalmologist Annapurna Singh, MD.
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Cataract surgery is essentially the same in patients with and without glaucoma, says Dr. Singh. “With cataract surgery, the choice of lens may differ depending on the patient’s specific needs, but the techniques are unchanged,” she says.
Glaukos Corp. of Laguna Hills, Calif., makes the iStent® device, which is FDA-approved for use in MIGS. “It’s a very, very small stent that’s placed in the trabecular meshwork of people who have very mild to moderate glaucoma,” says Dr. Singh, noting that patients with advanced glaucoma or who have already lost vision or contrast are not good candidates.
The patient was a 48-year-old woman who drove a school bus for a living. She presented thinking that she only had cataracts, but upon examination, Dr. Singh found that she also had early glaucoma. She started her on eye drops and her IOP improved. When Dr. Singh removed her cataract, she combined it with the MIGS procedure.
“The patient needed to wake up at 5 a.m. every day, and at times, it was difficult for her to remember to take her drops,” says Dr. Singh. The surgery gave her the convenience and freedom of going off drops completely.
For the bus driver, the iStent® offered quite a few advantages. According to Dr. Singh, it brought down the IOP, and if, at a later date, the patient needs more invasive glaucoma surgery, she won’t have any scars on her eye. “Her outcomes were great,” says Dr. Singh. “We’re all very glad that the approach has worked so well for her.”
If the iStent isn’t enough to keep IOP down in patients who have moderate to advanced glaucoma, Dr. Singh combines the cataract surgery with a trabeculectomy or one of two available glaucoma valve drainage implants, the Ahmed or Baerveldt.“If a patient has glaucoma that’s refractory to maximum tolerated medical therapy, we use these drainage devices to treat it,” she says. Cataract and glaucoma surgeries are combined in the same way they are with the iStent.
In operating on patients who need drainage valves, Dr. Singh tends to suture the plate onto the eye prior to cataract surgery. Others prefer to take the opposite approach. “The cataract surgery technique, per se, is the same, but there are a few nuances when we combine cataract and glaucoma valve surgery,” says Dr. Singh.