Minimally Invasive

Glaucoma Surgery
(MIGS)
Cynthia V. Verzosa, MD, DPBO, MSc
 Outline
• Introduction
• Definition
• Types
• Indications
• Contraindications
• Future
Introduction Trabeculectomy
Definition
• Performed on patients whose
Types eyes have not achieved target
IOP despite maximum medical
Indications and laser therapy
• Cairns, 1968
Contra- • Modifications
Indications

Future
Introduction Trabeculectomy
Definition
• Complications
Types – Overfiltration/Hypotony
– Cystic, avascular blebs
Indications – Choroidal effusion/detachment
– Blebitis/Endophthalmitis
Contra- – Cataract development
Indications

Future
Introduction Aqueous Shunts
Definition
• Valved vs non-valved
Types • Biocompatible material
• ± Anti-metabolites
Indications

Contra-
Indications

Future
Introduction Aqueous Shunts
Definition
• Complications
Types – Overfiltration/Hypotony
– Conjunctival/Scleral erosion
Indications – Choroidal effusion/detachment
– Endophthalmitis
Contra- – Cataract development
Indications – Corneal decompensation

Future
Introduction MIGS
Definition
• Minimally Invasive Glaucoma
Types Surgery
• MicroIncisional / MicroInvasive
Indications Glaucoma Surgery
• 2006
Contra-
Indications

Future
Introduction Basic Tenets
Definition • Ab interno surgical approach
• Small incision
Types
• Spares the conjunctiva and sclera
• Minimally traumatic
Indications
• Minimal tissue disruption
Contra- • Excellent safety profile
Indications • Rapid recovery
• Preservation of vision
Future • IOP lowered to “physiological levels”
Introduction Manipulation of aqueous
movement
Definition
• Trabecular/Schlemm’s canal
Types • Suprachoroidal space
• Aqueous humor production
Indications
• Subconjunctival space
Contra-
Indications

Future
Introduction
Trabecular Outflow Surgery
Definition
• Trabectome (NeoMedix)
Types – Ab-interno trabeculotomy
– Removal of 90°-180° of TM via a
Indications plasma thermocautery handpiece

Contra-
Indications

Future
Introduction
Trabecular Outflow Surgery
Definition
• Trabectome (NeoMedix)
Types – Avar M et al (2019)
– 81 eyes, 74 patients (46 POAG, 28
Indications PEXG)
– 3.5 years
Contra- – IOP reduction: 28% POAG, 26%
Indications PEXG
– Meds reduction: 32% POAG, 29%
Future PEXG
Long-term follow-up of intraocular pressure and pressure-lowering medication in patients after ab-interno trabeculectomy with the Trabectome. Avar M,
Jordan JF, Neuburger M, Engesser D, Lubke J, Anton A, Wecker T. Graefes Arch Clin Exp Ophthalmol. 2019 Feb 9.
Introduction
Trabecular Outflow Surgery
Definition
• Trabectome (NeoMedix)
Types – Esfandiari H et al (2019)
– 93 patients
Indications – 5 years
– Success: ≤ 21 mmHg, >20% IOP
Contra- drop, no need for glau sx
Indications – Cumulative prob of success: 82.6%
(1), 76.7% (2), 73.9% (3), 72.3%
Future (4), 67.5% (5)
Five-year clinical outcomes of combined phacoemulsification and trabectome surgery at a single glaucoma center. Esfandiari H, Shah P, Torkian P, Conner
IP, Schuman JS, Hassanpour K, Loewen NA. Graefes Arch Clin Exp Ophthalmol. 2019 Feb 9.
Introduction
Trabecular Outflow Surgery
Definition
• Trabectome (NeoMedix)
Types – Esfandiari H et al (2019)
– Risk factors for failure
• Lower baseline IOP
Indications
• Younger age
• Higher central corneal thickness
Contra-
– Higher success: PEXG
Indications

Future
Five-year clinical outcomes of combined phacoemulsification and trabectome surgery at a single glaucoma center. Esfandiari H, Shah P, Torkian P, Conner
IP, Schuman JS, Hassanpour K, Loewen NA. Graefes Arch Clin Exp Ophthalmol. 2019 Feb 9.
Introduction
Trabecular Outflow Surgery
Definition
• Trabectome (NeoMedix)
Types – Esfandiari H et al (2019)
– IOP drop: 20.0±5.6 mmHg to
Indications 15.6±4.6 mmHg (p= 0.001)
– Meds drop: 1.8±1.2 to 1.0±1.2
Contra-
Indications

Future
Five-year clinical outcomes of combined phacoemulsification and trabectome surgery at a single glaucoma center. Esfandiari H, Shah P, Torkian P, Conner
IP, Schuman JS, Hassanpour K, Loewen NA. Graefes Arch Clin Exp Ophthalmol. 2019 Feb 9.
Introduction
Trabecular Outflow Surgery
Definition • iStent (Glaukos)
– TM bypass
Types – Titanium stent
– iStent: 1mm x 0.3mm
Indications – Inject: 230 μm (D), 360 μm (H)

Contra-
Indications

Future
Introduction
Trabecular Outflow Surgery
Definition • iStent (Glaukos)
– Hernstadt DJ et al (2019)
Types – 2-center prospective
– Success: IOP drop 20% without
Indications meds
– 37 patients, PAC or PACG, 1 med
Contra- – 1 year
Indications

Future
Case Series of Combined iStent Implantation and Phacoemulsification in Eyes with Primary Angle Closure Disease: One –Year Outcomes.
Hernstadt DJ, Cheng J, Htoon HM, Sangtam T, Thomas A, Sng CCA. Advances in Therapy. 2019 Feb 28
Introduction
Trabecular Outflow Surgery
Definition • iStent (Glaukos)
– Hernstadt DJ et al (2019)
Types – Mean IOP: 17.5±3.82 mmHg to
14.8±3.94 mmHg (p=0.008)
Indications – Complete success in 89.2%
– Meds drop: 1.49±0.77 to
Contra- 0.14±0.48 (p<0.001)
Indications

Future
Case Series of Combined iStent Implantation and Phacoemulsification in Eyes with Primary Angle Closure Disease: One –Year Outcomes.
Hernstadt DJ, Cheng J, Htoon HM, Sangtam T, Thomas A, Sng CCA. Advances in Therapy. 2019 Feb 28
Introduction
Trabecular Outflow Surgery
Definition • iStent (2nd gen) (Glaukos)
– Hengerer FH et al (2018)
Types – 81 pxs, 60 POAG, 15 PEXG, 4 PACS,
1 Pigmentary, 1 NVG
Indications – 32.1% with previous glaucoma sx
– 56% on 3-4 meds, 1 eye no meds
Contra- – 36 months
Indications

Future
Prospective, Non-randomized, 36-month Study of Second-Generation Trabecular Micro-Bypass Stents with Phacoemulsification in Eyes with
Various Types of Glaucoma. Hengerer FH, Auffarth GU, Riffel C, Conrad-Hengerer I. Ophthalmology and Therapy 2018 Dec; 7(2):405-415.
Introduction
Trabecular Outflow Surgery
Definition • iStent (2nd gen) (Glaukos)
– Hengerer FH et al (2018)
Types – Mean IOP: 37% reduction
• ≥20% in 78%
Indications • ≤ 18 mmHg 100%
• ≤ 15 mmHg 71%
Contra- – Meds: 68% reduction
Indications • 54% meds free
• 2% needed ≥ 3 meds
• 92.7% reduced meds
Future
Prospective, Non-randomized, 36-month Study of Second-Generation Trabecular Micro-Bypass Stents with Phacoemulsification in Eyes with
Various Types of Glaucoma. Hengerer FH, Auffarth GU, Riffel C, Conrad-Hengerer I. Ophthalmology and Therapy 2018 Dec; 7(2):405-415.
Introduction
Trabecular Outflow Surgery
Definition
• Hydrus implant (Ivantis)
Types – TM bypass
– Nitinol
Indications – 8mm length

Contra-
Indications

Future
Introduction
Trabecular Outflow Surgery
Definition
• Hydrus implant (Ivantis)
Types – Pfeiffer N, et al (2015)
– Multicenter, RCT
Indications – 100 eyes, 100 patients
– 21-80 years
Contra- – OAG with cataract
Indications – IOP 24 mmHg or less, ≤ 4 meds

Future
A Randomized Trial of a Schlemm’s Canal Microstent with Phacoemulsification for Reducing Intraocular Pressure in Open-Angle Glaucoma. Pfeiffer N,
Garcia-Feijoo J, Martinez-de-la-Casa JM, Larrosa JM, Fea A, Lemij H, Gandolfi S, Schwenn O, Lorenz K, Samuelson TW. Ophthalmology 2015
July;122(7):1283-93,
Introduction
Trabecular Outflow Surgery
Definition
• Hydrus implant (Ivantis)
Types – Pfeiffer N, et al (2015)
– IOP drop 20%: 80%
Indications – No meds post op: 73%

Contra-
Indications

Future
A Randomized Trial of a Schlemm’s Canal Microstent with Phacoemulsification for Reducing Intraocular Pressure in Open-Angle Glaucoma. Pfeiffer N,
Garcia-Feijoo J, Martinez-de-la-Casa JM, Larrosa JM, Fea A, Lemij H, Gandolfi S, Schwenn O, Lorenz K, Samuelson TW. Ophthalmology 2015
July;122(7):1283-93,
Introduction
Trabecular Outflow Surgery
Definition
• iStent and Hydrus implant
Types – Usually combined with cataract
surgery
Indications – May be a stand-alone procedure
(off-label for iStent)
Contra-
Indications

Future
Introduction
Suprachoroidal Outflow Surgery
Definition
• Establish connection between
Types the AC and suprachoroidal space
• Pressure gradient: aqueous will
Indications flow to potential space
• Stent in the potential plane
Contra-
Indications
between the SS and CBB

Future
Introduction
Suprachoroidal Outflow Surgery
Definition
• iStent Supra (Glaukos)
Types • PES (polyethersulfone) and
titanium
Indications • Stand alone or with cataract sx
Contra-
• 4mm (L)
Indications

Future
Introduction
Suprachoroidal Outflow Surgery
Definition
• iStent Supra (Glaukos)
Types – Junemann (2013)
– 42 eyes with advanced POAG
Indications – 12 months
– Post-op Travoprost
Contra-
Indications

Future
Juneman A. Twelve-month Outcomes Following Ab Interno Implantation of Suprachoroidal Stent and Postoperative Administration of Travoprost to Treat
Open Angle Glaucoma. 31st Congress of the European Society of Cataract and Refractive Surgeons. Oct 2013. Amsterdam, Netherlands.
Introduction
Suprachoroidal Outflow Surgery
Definition
• iStent Supra (Glaukos)
Types – Junemann (2013)
– Mean preop IOP: 20.4±2.4 mmHg
Indications on 2 meds
– 1° endpont (≥20% IOP drop with
Contra- reduction of 1 med): 98%
Indications – 2° endpoint (IOP < 15 mmHg and
reduction of 1 med): 90%
Future
Juneman A. Twelve-month Outcomes Following Ab Interno Implantation of Suprachoroidal Stent and Postoperative Administration of Travoprost to Treat
Open Angle Glaucoma. 31st Congress of the European Society of Cataract and Refractive Surgeons. Oct 2013. Amsterdam, Netherlands.
Introduction
Suprachoroidal Outflow Surgery
Definition
• CyPass (Transcend Medical)
Types • Non-degradable polyimide
material
Indications • 0.51mm (ED), 6.35mm (L)
Contra-
Indications

Future
Introduction
Suprachoroidal Outflow Surgery
Definition
• CyPass (Transcend Medical)
Types – Garcia-Feijoo (2015)
– Multicenter, 1 year
Indications – OAG, IOP≥21 mmHg
– 65 eyes, 55 completed ffup
Contra-
Indications

Future
Garcia-Feijoo J, Rau M, Grisanti S, et al. Supraciliary micro-stent implantation for open-angle glaucoma failing topical therapy: 1 year results of a
multicenter study. American Journal of Ophthalmology 2015; 159:1075-1081.
Introduction
Suprachoroidal Outflow Surgery
Definition
• CyPass (Transcend Medical)
Types – Garcia-Feijoo (2015)
– Mean IOP drop: 34.7%
Indications • 24.5±2.8 mmHg to 16.4±5.5 mmHg
(p<0.0001)
Contra- – Meds: 2.2±1.1 to 1.4±1.3
Indications (p=0.002)

Future
Garcia-Feijoo J, Rau M, Grisanti S, et al. Supraciliary micro-stent implantation for open-angle glaucoma failing topical therapy: 1 year results of a
multicenter study. American Journal of Ophthalmology 2015; 159:1075-1081.
Introduction Endoscopic
Cyclophotocoagulation
Definition
• ECP (Beaver Visitec Intl)
Types • Destruction of ciliary body
through direct visualization
Indications • Diode laser, 810nm
Contra-
Indications

Future
Introduction Endoscopic
Cyclophotocoagulation
Definition
• ECP (Beaver Visitec Intl)
Types – Berke (2006)
– RCT
Indications – 626 medically controlled glaucoma
• Phaco/ECP vs Phaco only
Contra-
Indications

Future
Endoscopic cyclophoocoagulation and phacoemulsification in glaucoma management. Berke SJ. Techniques in Ophthalmology 4(2):74-81, 2006.
Introduction Endoscopic
Cyclophotocoagulation
Definition
• ECP (Beaver Visitec Intl)
Types – Berke (2006)
– Phaco/ECP IOP: 19.08±4.14 mmHg to
Indications 15.73±3.00 mmHg
– Phaco only IOP: 18.16±3.38 to
18.93±4.12
Contra-
– Meds Phaco/ECP: 1.53±0.89 to
Indications
0.65±0.95
– Meds Phaco only: 1.20±0.83 to
Future 1.20±0.87
Endoscopic cyclophoocoagulation and phacoemulsification in glaucoma management. Berke SJ. Techniques in Ophthalmology 4(2):74-81, 2006.
Introduction Transconjunctival Filtration
Procedure (ab interno)
Definition
• XEN (Aquesys, Allergan)
Types
• Cross-linked porcine collagen
Indications • 45-55μm (ID), 6mm (L)
• MMC augmentation (10-30μg)
Contra-
Indications

Future
Introduction Transconjunctival Filtration
Procedure (ab interno)
Definition
• XEN (Aquesys, Allergan)
Types
– Karimi A et al (2019)
– 259 eyes of 226 patients
Indications
– IOP change: 19.2±mmHg to
14.2±4.4 mmHg (12 mos) to
Contra-
13.5±3.3 mmHg (18 mos)
Indications
(p<0.0001)

Future
A multi-centre interventional case of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery. Karimi A,
Lindfield D, Turnbull A, Dimitriou C, Bhatia B, Radwan M, Gouws P, Hanifudin A, Amerasinghe N, Jacob A. Eye (Lond) 2019 Mar;33(3):469-477.
Introduction Transconjunctival Filtration
Procedure (ab interno)
Definition
• XEN (Aquesys, Allergan)
Types
– Karimi A et al (2019)
– Meds: 2.6±1.1 to 0.8±1.0 (12 mos)
Indications
to 1.1±1.3 (18 mos) (p<0.0001)
– Outcomes in combined xen/phaco
Contra-
with comparable results
Indications
– 40.9% needed bleb needling or
antimetabolite injection
Future
A multi-centre interventional case of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery. Karimi A,
Lindfield D, Turnbull A, Dimitriou C, Bhatia B, Radwan M, Gouws P, Hanifudin A, Amerasinghe N, Jacob A. Eye (Lond) 2019 Mar;33(3):469-477.
Introduction Transconjunctival Filtration
Procedure (ab interno)
Definition
• XEN (Aquesys, Allergan)
Types
– Karimi A et al (2019)
– Complications
Indications
• IOP spikes > 30mmHg (12.7%)
• Needing 2nd sx (9.3%)
Contra- • Implant exposure (2.3%)
Indications • Hypotonous maculopathy (1.9%)

Future
A multi-centre interventional case of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery. Karimi A,
Lindfield D, Turnbull A, Dimitriou C, Bhatia B, Radwan M, Gouws P, Hanifudin A, Amerasinghe N, Jacob A. Eye (Lond) 2019 Mar;33(3):469-477.
Introduction Transconjunctival Filtration
Procedure (ab interno)
Definition
• XEN (Aquesys, Allergan)
Types
– Karimi A et al (2019)
– Complications
Indications
• Choroidal effusions (1.5%)
• Cyclodialysis cleft (0.5%)
Contra- • Endophthalmitis (0.5%)
Indications

Future
A multi-centre interventional case of 259 ab-interno Xen gel implants for glaucoma, with and without combined cataract surgery. Karimi A,
Lindfield D, Turnbull A, Dimitriou C, Bhatia B, Radwan M, Gouws P, Hanifudin A, Amerasinghe N, Jacob A. Eye (Lond) 2019 Mar;33(3):469-477.
Introduction Transconjunctival Filtration
Procedure (ab externo)
Definition
• InnFocus Microshunt (Innfocus,
Types Santen)
• 62-70μm (ID), 8.5 mm (L)
Indications • SIBS (polystyrene plastic)
• MMC augmentation (0.2mg/mL)
Contra-
Indications

Future
Introduction Transconjunctival Filtration
Procedure (ab externo)
Definition
• InnFocus Microshunt (Innfocus,
Types Santen)
– Dominican Republic II
Indications – 21 phakic, 2 pseudophakes
– Microshunt only 14,
Contra- microshunt/phaco 9
Indications – % IOP change: 55% (1 yr), 50% (2
yrs)
Future
Introduction Transconjunctival Filtration
Procedure (ab externo)
Definition
• InnFocus Microshunt (Innfocus,
Types Santen)
– Mean IOP: 23.8±5.3 mmHg to 10.7
Indications ±2.8 mmHg (1 yr) to 11.9±3.7
mmHg (2yrs)
Contra- – Meds: 2.4±0.9 to 0.3±0.8 (1 yr) to
Indications 0.4±1.0 (2 yrs)

Future
Introduction Transconjunctival Filtration
Procedure (ab externo)
Definition
• InnFocus Microshunt (Innfocus,
Types Santen)
– Complications
Indications • IOP < 5 mmHg (13%)
• Shallow AC (13%)
• Choroidal detachment (8,7%)
Contra-
Indications

Future
Introduction
Trabecular & Suprachoroidal Outflow
Definition Surgery, Endoscopic Cyclophotocoagulation

Types
• Patients with mild to moderate
Indications
glaucoma, target IOP in mid-
teens
Contra-
Indications

Future
Introduction
Transconjunctival Filtration
Definition
Procedure

Types
• Patients with moderate to
Indications
severe glaucoma

Contra-
Indications

Future
Introduction
MIGS
Definition • Patients with IOP targets below
the episcleral venous pressure
Types • Active neovascular glaucoma
• Active uveitis
Indications
• Conditions with elevated
Contra- episcleral venous pressure
Indications (Grave’s disease, Sturge-Weber)

Future
Introduction
MIGS
Definition • Angle dysgenesis
• Corneal edema or opacities
Types
• Patients with tight scleral
Indications
buckles
• Closed angles
Contra- • Significant conjunctival scarring
Indications

Future
Introduction
Trabecular Outflow Surgery
Definition
• Trabecular bypass – new
Types designs, multiple stent
placements, larger stents
Indications • Mapping of trabecular outflow
system for more targeted
Contra- placement of stents
Indications
• Modulation of fibrosis and
maintenance of stent patency
Future
Introduction
Suprachoroidal Outflow,
Definition Transconjunctival Filtration Surgery

Types
• Stent design modifications
Indications • Modulation of fibrosis and
maintenance of stent patency
Contra-
Indications

Future
 Point to Remember
• MIGS is an emerging treatment option for
patients with glaucoma
• Careful device and patient selection
• Training is needed