ABiC Blog

06 August 2018

MIGS: a time for less is now

As a glaucoma specialist and member of the American Glaucoma Society I am privy to very intellectual discussions regarding challenging cases and various treatment options that are currently on the market. It seems that throughout the history of medicine, scientists, clinicians and surgeons have striven to develop treatment options that are more effective than their predecessors, offering enhanced efficacy and safety profiles. I was reminded of this fact while reading an absolutely wonderful book, The Emperor of all Maladies, which chronicles the evolution of cancer therapy and the resistance innovative minds encountered when sharing their novel treatment ideas.

There was one particular chapter that really resonated with me and reminded me of the resistance 'established ophthalmology' propelled onto those that first introduced the concept of micro invasive glaucoma surgery (MIGS). The chapter described how one courageous surgeon questioned the need to perform a disfiguring, aggressive radical mastectomy in women suffering from breast cancer. An almost centuries’ old theory proposed that cancer cells spread in a centripetal fashion and rapid and aggressive removal of the cancer and adjacent tissues was the only means to reduce mortality. Unfortunately, this radical surgery did not prevent women from perishing from the disease. The surgeon proposed a less aggressive approach, limited mastectomies, but was chastised and found little support in his attempts to establish a multi-center randomized clinical trial comparing mortality rates among those women that were treated with the older, more aggressive form of mastectomy to those treated with the more compassionate and conservative partial mastectomy. It is worth noting that it wasn’t the medical community that propelled his mission, but rather the women themselves who were suffering from breast cancer. These women assisted him in recruiting patients into a large-scale trial, the results of which showed that radical mastectomies were no more effective at preventing mortality than his partial mastectomy.  Because of this, radical mastectomies have almost disappeared from the operating room schedule of today’s surgeons.

In cardiology, not all patients suffering from coronary artery disease undergo coronary artery bypass surgery (CABG). Instead, attempts are first made to utilize the natural conduit for nourishing cardiac tissue by restoring the patency of the coronary arteries, either by dilation with balloon angioplasty or implantation of cardiac stents. Of course, some patients still require bypass surgery and cardiac catheterization cannot, nor should it, replace CABG. But the with addition of cardiac catheterization, surgeons can limit the need to perform long, arduous surgery, which carries a significant risk, in some patients.

In glaucoma, we have reached a crossroad that other fields of medicine have already encountered. In lectures I’ve given around the country as well as abroad, I’ve made the statement: “a time for less is more”.

With MIGS procedures, can we reduce the need for larger filtration procedures that are fraught with vision threatening sight complications? In my humble opinion and based on my personal experience the answer is a resounding YES!  My current opinions have not always been accepted. And despite a plethora of papers in the peer-reviewed literature, as well as the multitude of free papers and posters presented at national ophthalmic meetings, many surgeons still do not feel that MIGS procedures are effective, often referring to MIGS procedures as minimally effective glaucoma surgeries.

But, it appears as though we have reached a critical mass of 'believers' in MIGS procedures. In the USA, the pioneers of MIGS are being invited to discuss the various devices and procedures that are available or will soon become available and it appears that with each passing year, more and more time and effort is spent discussing MIGS. There was a point in time when MIGS was not even discussed at the annual meeting of the American Glaucoma Society – yet now we have entire sections at the meeting devoted to MIGS. I think we are at a point where MIGS can no longer be ignored. And given the efficacy and safety profile of these procedures, there may come a time in the near future when performing a MIGS procedure, prior to a undertaking a more aggressive procedure such as a trabeculectomy, will become our new standard of care.

If you were a patient or if your spouse, sibling or even child had glaucoma that needed more than what medications or an-office based procedure could provide, what kind of procedure would you want them to have? I know many of you would answer, “whatever would prevent them from losing vison”. Well, CABG can certainly supply blood to myocardium but so can balloon angioplasty or stent implantation.

I would say I routinely perform some form of MIGS in almost all my patients prior to performing filtration surgery. Indeed, I have seen a drastic reduction in the need to perform filters, reducing my frequency of filters from 20-30 per month to 2-3 per month. MIGS work and offer much benefit beyond their improved safety profile.

Given the growing abundance of data as well as anecdotal experience from so many surgeons throughout the world, is it time to consider MIGS more favorably? Is it our time to do less in order to achieve more?

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