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MIGS has become a commonly used abbreviation in the glaucoma world. The study included 68 patients with refractory glaucoma who had either failed maximal medical therapy, had previous failed filtration surgery or transscleral cyclodestructive procedure. In a trabeculectomy the ophthalmic surgeon … A modified technique has also been described using 4-0 nylon suture instead of the microcatheter. Viscodilation of Schlemm’s Canal for the Reduction of IOP Via an Ab-interno Approach. TRAB 360 can be performed either in adult or pediatric patients with open angle glaucoma and a clear cornea. There were no subsequent surgical interventions related to the VISCO360. Patients were followed out to 12 months and the primary endpoint was an IOP ≤21 mmHg without ocular hypotensive medications. Minimally Invasive Glaucoma Surgery (MIGS) is a new advanced type of outpatient procedure for patients with mild to moderate glaucoma. We conducted a budget impact analysis of MIGS for adults with glaucoma from the perspective of the Ontario Ministry of Health and Long-Term Care. The Hydrus Microstent was developed by Ivantis Inc. and received FDA approval in August 2018. However, minimally invasive glaucoma surgery is not a single type of treatment, but a group of surgeries that use microscopic sized equipment which require extremely small incisions. It was designed for improved excision of the trabecular meshwork during goniotomy. Traditional glaucoma filtration surgeries, such as trabeculectomy and glaucoma drainage implants (GDI), have well-established efficacy in lowering intraocular pressure (IOP), but it comes at the cost of a very high rate of complications. The Kahook Dual Blade (New World Medical, Rancho Cucamonga, CA) is a specialized goniotomy blade that was introduced in the United States in 2015. MIGS are often not sufficient treatment for patients with more advanced disease who require a low IOP goal. A predetermined amount of viscoelastic fluid is then injected into Schlemm’s canal and the distal collector channels. Most MIGS operations are designed to allow extra fluid to leave the eye, and hence lower the IOP. Minimally invasive glaucoma surgery procedures reduce eye pressure by creating new passages through or around the trabecular meshwork with tiny shunt or stent devices to allow the aqueous humor to drain more easily from the eye. J Glaucoma. Desser AS, Arentz-Hansen H, Fagerlund BF, Harboe I, Lauvrak V. Oslo, Norway: Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH); 2017 Aug 25. Both groups underwent canal viscodilation with or without cataract extraction. 2019 Feb 19;19(3):1-223. eCollection 2019. Primary endpoints examined were number of patients with 20% or greater reduction in IOP at 24 months and the change in unmedicated IOP at 24 months. What is Minimally Invasive Glaucoma Surgery? Trabecular meshwork bypass by stent placement, Trabecular meshwork bypass by tissue excision, Gonioscopy Assisted Transluminal Trabeculotomy (GATT), Enhancing aqueous outflow through Schlemm’s canal, Enhancing aqueous outflow through the suprachoroidal space, Shunting aqueous outflow into the subconjunctival space, Reducing aqueous production by ciliary body ablation. 15. After the surgeon performs viscodilation, the microcatheter is again introduced into Schlemm’s canal and a trabeculotomy is performed to achieve both viscodilation and trabeculotomy in one procedure. Treatments are adjusted based on the progression of the disease. Laser trabeculoplasty for open-angle glaucoma: a report by the American academy of ophthalmology. Hydrus plus phacoemulsification group went from 1.7±0.9 drops to 0.3±0.8 drops at 24 months after surgery while the phacoemulsification alone group went from 1.7±0.9 drops to 0.7±0.9 drops at 24 months. One of the new and exciting prospects in the treatment of glaucoma is called MIGS, or Minimally Invasive Glaucoma Surgeries. 1 Minimally invasive (or microinvasive) glaucoma … MIGS procedures involve a minimally invasive … Presented at 11/13/12 AAO Conference, Chicago, IL. NIH It can be performed in patients who are phakic, pseudophakic or aphakic. 21. MIGS procedures involve a minimally invasive approach, often with small cuts or micro-incisions through the corneathat causes the least amount of trauma to surrounding scleral and conjunctival tissues. CyPass received FDA approval in July 2016 for use in conjunction with cataract surgery in patients with mild to moderate primary open angle glaucoma. The CyPass microstent was the only FDA-approved device that targeted this mechanism of IOP reduction. The pivotal trial for approval of the stent compared iStent inject/phacoemulsifcation to phacoemulsification alone. To meet this clinical need, a number of devices have recently been developed labeled as either micro‐incision or minimally invasive glaucoma surgery (MIGS) devices that modulate aqueous humor outflow facility via one of several routes (Figure 2). Samuelson T, Chang D, Marquis R, Flowers B, Lim K, Ahmed I, Jampel H, Aung T, Crandall A, Singh K, HORIZON Investigators. Therefore, these procedures are often delayed in mild to moderate disease and reserved for patients with more severe disease who warrant aggressive intervention. The advent of microinvasive glaucoma surgery has allowed for improved management of patients with mild to moderate glaucoma. HHS ECP can also be performed in conjunction with other angle based procedures above to provide additional IOP lowering. 22. Introducing a new MIGS billing code may reduce the overall expenditures. Furthermore, the average number of IOP lowering drops decreased from 2.8±0.9 drops to 1.1±1.1 drops, which represents a 60.0% reduction on average. Br J Ophthalmol. Additionally, the tip of the Trabectome is bent at a 90° angle to create a protective triangular footplate and allow for easier insertion into Schlemm’s canal and is coated to facilitate smooth movement within the canal. Continuous irrigation and aspiration allows for removal of debris and regulation of temperature. The device is then rotated and reinserted and the procedure is repeated for the remaining 180 degrees of the angle to accomplish a full 360 degree treatment. Structured Education and Neuromuscular Exercise Program for Hip and/or Knee Osteoarthritis: A Health Technology Assessment. Minimally invasive glaucoma surgery. In addition to the above mentioned stents, trabecular meshwork bypass can also be achieved through surgical incision/excision of the trabecular meshwork tissue. Ophthalmology, Volume 118, Issue 7, July 2011, Pages 1466-1480. Mitomycin C is typically injected subconjunctivally before or after stent placement to limit bleb fibrosis. The initial study with the Xen gel stent included 65 patients with refractory glaucoma, which was defined as poorly controlled IOP on maximally tolerated medical therapy or patients who had failed previous filtering surgery or cilioablative procedure. Despite their efficacy, these surgical interventions result in labile postoperative IOPs, require frequent follow-up, prolonged recovery time and offer a risk of serious early and late complications. 2013;39(3):431-437. Please enable it to take advantage of the complete set of features! Samuelson T, Sarkisian S, Lubeck D, Stiles M, Duh Y, Romo E, Giamporcaro J, Hornbeak D, Katz LJ, iStent inject Study Group. Efficacy: MIGS should offer meaningful IOP lowering effect. There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. evaluated the safety and efficacy of ECP in refractory glaucoma of multiple subtypes. Vold, S. D. Micro-Invasive Stent Implanted During Phaco-Cataract Surgery Achieves Sustained IOP Lower Effect in Glaucomatous Eyes at 12 Months. Several studies have demonstrated the clinical efficacy of Kahook Dual Blade goniotomy for IOP reduction in patients with glaucoma. Saheb H and Ahmed I. Micro-invasive glaucoma surgery: current perspectives and future directions. The number of hypotensive eye drops decreased from 1.6±1.3 to 0.9±1.0 eye drops.20  Another study included 52 eyes of patients with open angle glaucoma and visually significant cataracts who underwent phacoemulsification with KDB goniotomy. It was FDA approved in 2004 and is used to perform an ab interno trabeculotomy. Ablation may be applied for 60°-120° of trabecular meshwork to allow for re-establishment of the drainage pathway. 28. These are mentioned below. Furthermore, 66% of iStent eyes had achieved an IOP reduction greater or equal to 20% compared to only 48% of eyes in the control (phacoemulsification only) group. While all types of glaucoma surgery share the same goal of lowering eye pressure, MIGS has been specifically developed with the goal of reducing the risk of complications associated with traditional glaucoma surgeries. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. SLT or Selective Laser Trabeculoplasty can eliminate the need for drops in up to 75% of glaucoma patients. There is a spectrum of current treatments for glaucoma that aim to reduce intraocular pressure (IOP), including pharmacotherapy (eye drops), laser therapy, and the more invasive option of filtration surgery. ABiC is performed using the iTrack microcatheter system (Ellex iScience, Fremont, CA) which is a 250 micron microcatheter with a fiber optic light allowing for visualization of the catheter while in Schlemm’s canal. 75 eyes of 68 patients with POAG underwent ABiC: 41 eyes underwent stand-alone ABiC and 34 eyes underwent combined ABiC/phacoemulsification. 12-Month Outcomes of Goniotomy Perfored Using the Kahook Daul Blade Combined with Cataract Surgery in Eyes with Medically Treated Glaucoma. Broadly, MIGS can be categorized into surgeries … Current Opin Ophthalmol 1995; 6(2): 19-29. This approach is employed in endocyclophotocoagulation (ECP) during which a laser endoscopic probe is inserted through a clear corneal incision and used to directly visualize and ablate the ciliary body. At 2 years post-op follow-up, IOP in the study group had decreased to 16.0±3.3 mmHg compared to 17.3±3.2 mmHg in the control group with a significantly greater decrease in the study group. looked at 1 year outcomes of KDB with phacoemulsification. At 12 months post-operatively, mean IOP decreased from baseline by 9.1 mmHg and 75.4% of patient had ≥20% reduction in IOP. eCollection 2017. 7. The technique of ECP was first described by Uram in 1995.31 In 1997, Chen et al. Baseline IOP of patients in the phacoemulsification/Cypass group was 24.2±2.8 mmHg with an average of 1.4±0.9 medications. 29. 16. The device was withdrawn from the market in August 2018 based on results of the 5-year COMPASS-XT trial which demonstrated a significant decrease in corneal endothelial cell counts in patients undergoing CyPass with phacoemulsification compared to patients undergoing phacoemulsification alone.28, The COMPASS trial reported on the two year safety and efficacy outcomes for Cypass.29  The study enrolled 505 subjects randomized to phacoemulsification alone (131 patients) or phacoemulsification with Cypass (374 patients). The Xen gel stent is FDA approved for use in the treatment of patients with refractory glaucoma in whom maximal medical therapy is insufficient or in patients who have failed previous glaucoma treatments. The goal of all glaucoma surgery is to lower eye pressure to prevent or reduce damage to the optic nerve. Arriola-Villalobos P, Martínez-de-la-Casa JM, Díaz-Valle D, et al. 2012; 23(2) 96-104. Minimally invasive (also known as micro-invasive or micro-bypass) glaucoma surgery refers to a class of surgical treatment used to manage mild-to-moderate cases of primary open-angle glaucoma. The blade is a single use disposable blade with a sharp tip which is used to pierce the trabecular meshwork, a ramp which stretches the trabecular meshwork and dual parallel blades which create paired parallel incisions in the trabecular meshwork. 90% of eyes achieved an IOP of £21 mmHg by final follow-up. Performance and Safety of a New Ab Interno Gelatin Stent in Refractory Glaucoma at 12 Months. Minimally invasive glaucoma surgery (MIGS) is the newest group of surgical procedures that aim to reduce pressure in the eye and slow the progression of glaucoma. Each stent is 360 microns in height by 230 microns in diameter; consisting of a tapered head with a recessed thorax and a terminal flange. At 12 months, 72% of eyes that underwent iStent placement with phacoemulsification had reached the primary endpoint versus 50% of eyes undergoing phacoemulsification alone. Treatment failure occurred in 8/85 patients (9%) due to the need for subsequent glaucoma surgery. Clinical Ophthalmology 2019; 13: 1235-1246. Furthermore, 66% of iStent eyes had achieved an IOP reduction greater or equal to 20% compared to only 48% of eyes in the control (phacoemulsification only) group. It functions to lower intraocular pressure through two mechanisms: trabecular meshwork bypass stent and scaffold for Schlemm’s canal to maintain patency. 31. It is called MIGS, the acronym for minimally invasive glaucoma surgery, and it is the biggest development in glaucoma surgical treatment in many years. 20. MIGS are a family of procedures characterized by the use of microscopic-sized equipment and tiny incisions that provide an alternative to traditional, more invasive glaucoma … Chen J, Cohn R, Lin S, Cortes A, Alvarado J. Endoscopic Photocoagulation of the Ciliary Body for Treatment of Refractory Glaucomas. Reiss G, Clifford B, Vold S, He J, Hamilton C, Dickerson J, Lane S. Safety and Effectiveness of CyPass Supraciliary Micro-stent in Primary Open-Angle Glaucoma: 5-Yaer Results from the COMPASS XT Study. Average number of IOP lowering mediations decreased from 3.5 drops at baseline to 1.7 at 1 year post-operative. 29. 32. Helmut H, Ahmed IK, Grisanti S, et al. 6 Month Results from a Prospective, Multicenter Study of a Nickel-Titanium Schlemm's Canal Scaffold for IOP Reduction After Cataract Surgery in Open-Angle Glaucoma. 2.2. At 1 year post-operatively, eyes that underwent phacoemulsification with KDB goniotomy experienced a significant reduction in mean IOP from 16.8±0.6 mmHg at baseline to 12.4+0.3 mmHg, 57.7% of eyes experienced a 20% reduction in IOP and the number of medications decreased from 1.6±0.2 to 0.8±0.1 eye drops.21. The management of glaucoma is continuously evaluated throughout the life of a glaucoma patient. General advantages of these MIGS procedures are the ability to bypass the trabecular meshwork and form a direct pathway to Schlemm’s canal for 3-4 or more clock hours. The VISCO360 device (Sight Sciences, Menlo Park, California) allows for catheterization and viscodilation of Schlemm’s canal. Francis BA, Berke SJ, Dustin L, Noecker R. Endoscopic cyclophotocoagulation combined with phacoemulsification versus phacoemulsification alone in medically controlled glaucoma. These barriers include noncompliance with the prescribed regimen, intolerance of medication side effects, financial burden limiting access to medications, or physical inability to reliably self-administer eye drops. MIGS comprises a group of surgical procedures which share common features. 3. Francis BA, Minckler D, Dustin L, et al. In recent years, a new class of treatment called ‘minimally invasive glaucoma surgery’ or ‘MIGS’ is changing the glaucoma treatment model. ECP is performed with an endoscopic probe attached to a laser unit (BVI, Little Silver, NJ) which includes a diode laser (810nm), a Xenon light source, a helium-neon aiming beam, and fiber optic imaging. Reiss G, Clifford B, Vold S, He J, Hamilton C, Dickerson J, Lane S. Safety and Effectiveness of CyPass Supraciliary Micro-stent in Primary Open-Angle Glaucoma: 5-Yaer Results from the COMPASS XT Study. Minimally Invasive Glaucoma Surgery (MIGS) The acronym MIGS refers to a group of glaucoma surgeries that lower IOP through small incisions and improve the natural outflow pathways, as opposed to … Knowledge Centre for the Health Services at The Norwegian Institute of Public Health (NIPH).  |  Bypass can be achieved by placing a trabecular meshwork bypass stent which allows aqueous to flow directly through the stent from the anterior chamber into Schlemm’s canal. 28. See this image and copyright information in PMC. Ophthalmology 2009;116:191-9. 2006; 90(3):262-7. Alternatively, cataract surgery can be combined with a minimally invasive glaucoma procedure. Their main advantage is that they are bleb-independent procedures that avoid the uncommon major complications of traditional surgery… Enter Minimally Invasive Glaucoma Surgery, or MIGS. Further, 85% of eyes in the Cypass group were drop free at 2 years.29. This site needs JavaScript to work properly. 12. doi: 10.1371/journal.pone.0183142. Glaucoma refers to a group of eye disorders that are a leading cause of vision loss and blindness among Americans. For over 40 years the standard surgical treatment for glaucoma was a procedure called a trabeculectomy. Assuming a fast uptake scenario, the annual budget impact of publicly funding MIGS in Ontario over the next 5 years ranges from $6 million in year 1 to $70 million in year 5. Often our patients are able to stop one or more of their glaucoma medications at the time of cataract surgery. Vold S, Ahmed II, Craven R, Mattox C, Stamper R, Packer M, Brown R, Ianchulev T. Two-Year COMPASS Trial Results: Supraciliary Microstenting with Phacoemulsification in Patients with Open-Angle Glaucom and Cataracts. At 1 year post-operative follow-up, 40% of eyes were off all IOP lowering drops.24. Gallardo et al. 3. One such study by Greenwood. 19. MIGS procedures constitute a group of surgical interventions which share five characteristics. [4] As an alternative to traditional glaucoma treatments, minimally invasive glaucoma surgery (MIGS) has shown promise for the future management of glaucoma… Further, 88% of eyes in groups 2 were off all IOP lowering drops at 12 months with IOP at baseline. Ophthalmology Jun 2019; 126(6): 811-821. CyPass received FDA approval in July 2016 for use in conjunction with cataract surgery in patients with mild to moderate primary open angle glaucoma. The procedure is also available as a stand alone treatment in patients that have had cataract surgery in the past. These procedures use tiny incisions to place microscopic devices inside the eye to lower the pressure inside the eye, aiming to reduce or eliminate the need for glaucoma eye drops or invasive surgery. A total of 546 patients with primary open angle glaucoma who had visually significant cataracts, IOP between 22-34 mmHg, and who were on between 1-4 hypotensive eye drops were enrolled. 21. The tech… Understand the role of ocular hypotensives in the treatment of Glaucoma; The Mode of Action of the Hydrus Microstent ; The peer reviewed efficacy and safety of the Hydrus Microstent; Patient Management following MIGS Surgery; Max points awarded: 2.00. American Glaucoma Society Annual Meeting.  |  To contextualize the lived experience of glaucoma and treatments for glaucoma, we also interviewed people with glaucoma and family members of people with glaucoma, some of whom had experience with surgical procedures such as MIGS and some of whom did not. Furthermore, it is believed to decrease herniation of the inner wall of Schlemm’s canal into the distal collector channels to improve outflow. Am J Ophthalmolo 2017; 183: 25-36. The device spans 90 degrees of the trabecular meshwork. The study included 71 eyes from a mixed population of patients with mild to severe glaucoma of various types, including primary open angle glaucoma, pigmentary glaucoma, pseudoexfoliation, normal tension glaucoma and angle closure glaucoma. Pascolini D and Mariotti S. Global estimates of visual impairment: 2010. Average number of medications decreased from 1.3±1.0 at baseline to 0.6±0.8 at 2 years in the phacoemulsification only group, and from 1.4±0.9 drops at baseline to 0.2±0.6 at 2 years in the Cypass group. MIGS procedures constitute a group of surgical interventions which share five characteristics5: 1. Grover DS, Godfrey DG, Smith O, et al. The blade is then used to pierce the trabecular meshwork and advanced along the canal to excise the tissue. (2014) compared IOP reduction with phacoemulsification alone to ECP with phacoemulsification. Grover DS, Flynn WJ, Bashford KP, Lewis RA, Duh YJ, Nangi RS, Niksch B. The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group. 20. Because this approach results in the formation of a filtering bleb, there is debate as to whether this approach can truly be classified in the MIGS category. Micro-invasive glaucoma surgery (MIGS) is the latest advance in surgical treatment for glaucoma, which aims to reduce intraocular pressure by either increasing outflow of aqueous humor or reducing its production. The iStent Trabecular Micro-Bypass Stent (Glaukos, Laguna Hills, CA) received FDA approval in 2012 as the first MIGS implant. Glaucoma is a disease affecting an estimated 60.5 million people worldwide and 5.7 million people in the United States as of 2010. Greenwood M, Seibold L, Radcliffe N, Dorairaj S, Aref A, RomanJ, Lazcano-Gomez G, Darlington J, Abdullah S, Jasek M, Bahjri K, Berdahl J. Goniotomy with a single-use dual blade: Short term results. This design allows for complete excision of the trabecular meshwork and reduces the potential for scarring from residual tissue leaflets. It was a prospective, randomized trial that included 240 eyes with mild to moderate glaucoma and intraocular pressure less than or equal to 24 mmHg on one to three drops. Br J Ophthalmol. MIGS procedures are an especially useful treatment option in patients with poor medication tolerance, poor compliance and patients who need more IOP-lowering than drops or laser trabeculoplasty can provide. One Incision. Why were Minimally Invasive Glaucoma Surgery (MIGS) developed? It is made of nitinol which is a flexible, biocompatible titanium and nickle alloy that has been used in cardiac stents. The pivotal trial for approval of the iStent compared the effectiveness of phacoemulsification alone to phacoemulsification with iStent placement. Viscodilation of Schlemm’s Canal for the Reduction of IOP Via an Ab-interno Approach. Clinical Ophthalmology 2016; 10: 189-206. Minimal disruption of normal anatomy: MIGS allow for enhancement of physiological outflow mechanisms avoiding major alterations in normal ocular anatomy. Ab interno approach: MIGS are typically performed ab interno through a traditional clear corneal wound with direct visualization of the anatomical target. GATT can be performed in adult or pediatric patients with open angle glaucoma and a clear cornea. This article examines MIGS and its potential benefits for glaucoma patients. Minimally invasive glaucoma surgery Trabeculectomy or its modification remains the operation of choice for most surgeons. How MIGS Works. While traditional glaucoma surgery involves making a large incision or placing a large tube in the eye to lower the pressure, Dr. Song thought she was a good candidate for a newer, minimally invasive glaucoma surgery (MIGS). There was also a significantly greater reduction in hypotensive eye drops in the Hydrus group compared to the phacoemulsification alone groups. How MIGS Works. 1. Background: Glaucoma is a condition that causes progressive damage to the optic nerve, which can lead to visual impairment and irreversible blindness. Outcome measures were mean reduction in IOP, proportion of patients with ≥20% reduction in IOP and reduction in IOP-lowering eye drops. Micro- or minimally invasive glaucoma surgeries (MIGS) have been the latest addition to the glaucoma surgical treatment paradigm. In a trabeculectomy the ophthalmic surgeon … 23. ECP is most commonly used in open angle glaucoma but also has a particularly advantageous role in the treatment of angle closure or plateau iris where it can function to deepen the angle. 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