ABiC Blog

08 January 2019

MIGS Post-Operative Management

MIGS Post-Operative Management

“Not all tamales are made the same”

Living in the desert southwest, it is customary to see people eagerly waiting in line for hours to enter Mexican restaurants to buy dozens upon dozens of cornhusks filled maza (also known as tamales).  It’s a tradition in our community to have tamales on Christmas and New Year’s Eve, among other cholesterol elevating meals.  Though all tamales are made of maza or ground corn meal, ingredients vary considerably, kind of like doughnuts.  There are the red chili pork tamales, green chili chicken, chili con queso, and even dessert type tamales made with anise and raisins.  The culinary wizards that make these little packages of heavenly goodness typically have their own recipe that has been passed down from generation to generation.  Despite these variations, tamales are just good, plain and simple regardless of the intricate nuances.  There isn’t one right way to make a tamale.  Why am I talking about tamales when I’m supposed to be talking about microinvasive glaucoma surgery (MIGS)?

Well, surgeons are like chefs.  We all have different methods and techniques for taking out a cataract. We also have our own method for managing patients post-operatively.  And our techniques, which differ from academic institution to academic institution, are also passed down from generation to generation.  And as our graduates leave our kitchen and start to cook on their own, they develop their own dishes and recipes, and many times write cookbooks more elaborate than the ones from which they learned.  As cataract surgery and traditional filtration procedures have been utilized over the last 30 years, we have been able to add dashes (of ingenuity) or pinches (of innovation) from our own palate to enhance the flavor of the procedure.  Because MIGS procedures are still relatively new, we are continuing to evolve by tweaking the medical management of patients following surgery to maximize our outcomes. 

Over the last year, several surgeons have reached out to me inquiring as to how I manage my patients post-operatively.  Although I always share my recipe for success, mine is not the only method and many MIGS surgeons have their own formula for managing patients.  We all have our own favorite flavors and ultimately end up with similar outcomes—good tamales, I mean low eye pressures…  sorry, I am eating some left-over tamales and my mind is digressing.  So with that said, what is my cocktail of medications used in the post-operative period?  How do I manage my patients following ABiC, or other MIGS procedures?  How do I manage post-operative pressures spikes?  Put simply, with lots of love.  Wait, I’m thinking about tamales again.

In general, I have found that patients that have undergone a MIGS procedure tend to have a higher risk for developing a steroid response in the early post-operative period, more so than when undergoing stand-alone cataract.  It’s like feeding gluten to someone with Celiac disease.  We have to know our patients and what risk we present when feeding them a MIGS procedure (not a great analogy but work with me here).  Because of this hypersensivity to steroids, I typically avoid corticosteroids altogether in the early post-operative period, even in combined cases.  I limit post-operative medications to a non-steroidal anti-inflammatory and fourth generation quinolone for an antibiotic.  If the MIGS procedure is performed as a stand-alone treatment, steroids are rarely needed.  For the combined cataract extraction/MIGS cases, unless the eye is severely inflamed (2+ cell or more as a guide), I still refrain from using a steroid.  If there is more than 1+ cell after one week I’ll typically add a short course of a mild topical steroid like loteprednol etabonate.  If I feel a stronger steroid is needed I typically use prednisolone acetate 3-4 times daily and try to taper over nine days.  When I add a steroid, I routinely check the patient’s pressure 7-10 days later to ensure their eye tolerated the steroid well without sequelae.  I’ve found that by adding the steroid later in the post-operative period, I’ve all but eliminated the incidence of steroid induced pressure spikes.  Of course this is a broad generalization and when asked about a specific patient I may have a varying opinion.  Asking how I manage inflammation is like asking me how I make a taco—I use a tortilla, meat and cheese.  But when asked how I make a taco for my wife I use a soft tortilla, chicken, avocado and tomatoes.  My son, on the other hand, prefers brisket with sour cream.  Same general concept, but the flavors are tailored to each of my loved ones.  I use anti-inflammatory agents, but tailor the steroid to each individual patient. There are times we will get burned regardless of how we manage patients post-operatively and experience instances of uncommon complications, like pressure spikes.

Unless a patient has a higher than desired pressure on post-operative day one I usually discontinue all glaucoma medications in the operative eye.  However, when a patients presents with pressures above target IOP (highly variable), I tend to be quite aggressive in managing them and therefore try to reach the desired range as quickly as possible.  My response does depend on the patient’s stage of glaucoma, pre-operative pressure, angle appearance, and presence or absence of circulating red blood cells or hyphema. I typically start with a topical aqueous suppressant for pressures in the low 20s and begin to add trabecular altering medications like netasurdil or pilocarpine for pressures in the mid to upper 20s.  In terms of ABiC, my thought process for using the latter is to facilitate passage of aqueous into the newly dilated distal collector system and I like to use them for an extended period of time after the patients pressure reaches the target range (sometimes a month).  With more moderate to severe patients, if pressures are in the upper 20s, I tend to also use an oral carbonic hydrase inhibitor.  I am so aggressive because I want to avoid the development of new collector channel-obstructing herniations of the trabecular meshwork/inner wall of Schlemm’s canal.  We know from studies, the higher the pressure, the more herniations we see.   I want to keep the distal system open!

Like cooking a meal, we all have our own recipes and techniques and we all have to find what works best in our own hands – and with our own patients.  And not every patient I see is treated exactly the same way.  The practice of medicine is an art.   Cooking is an art.  We all tend to be somewhat malleable in how we manage our patients, even if our spice rack consists of only tubes or trabs.  As we continue to use more MIGS devices and procedure we will all continue to evolve.

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