MIGS: Alcon Laboratories S Maybe Its Glaucoma Surgery! Allergan - - PowerPoint PPT Presentation

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MIGS: Maybe Its Glaucoma Surgery!

Joseph Caprioli

I have the following financial interests and relationships to disclose:

Alcon Laboratories S Allergan C,S New World Medical S NIH-NEI S RPB S Simms-Mann Foundation S Transcend C Other Philanthropic Support S

Ophthalmology 2015

Why MIGS?

• Compliance with meds huge problem
• Complications of surgery are

considerable

• Search for bleb-less approaches

– Blebitis – Endophthalmitis

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Opinionated Facts

• Trabeculectomy is effective, with

acceptable risk-benefit ratio in patients at risk for visual loss

– But you have to do it correctly! – Real surgery for real glaucoma – Better than tubes for first surgery, especially for low target IOPs

See Editorial on TVT Study, AJO May 2011

• Evolving approaches and devices
• Current definition is fuzzy
• A group of alternative glaucoma surgeries intended

to cause less tissue disruption and fewer complications than traditional procedures

• It should be a bona fide glaucoma operation, not a

cataract surgery add-on (to bill for)

MIGS

• Intended to lower IOP via outflow
• Ab-interno or ab-externo approach
• Limited scleral dissection

– needle or device penetration of sclera OK – procedures with significant scleral dissection excluded

• Minimal conjunctival manipulation

– limited peritomy or small incision OK

Minimally Invasive Glaucoma Surgery - Implantable Devices

Definition Met: Definition Not Met:

Sustained release Anterior chamber injection Dissolvable polymer

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Locations To Which Aqueous is Directed by MIGS Device

• Influence efficacy and safety of

new devices

–Schlemm’s canal –Suprachoroidal Space –Sub-conjunctival Space

MIGS Effectiveness: What Can We Expect?

• IOP reduction based on anatomy and

physiology of aqueous outflow pathway

• Schlemm’s canal is not continuous; flow

into the collector channels and veins is segmental

MIGS Effectiveness: What Can We Expect?

• Flow in aqueous veins is pulsatile
• There is almost no circumferential flow

within Schlemm’s canal

• If entire TM is opened, outflow

resistance is reduced by 75% (Grant)

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Safety and Efficacy Considerations

• Safety and efficacy are linked, LION
• While all procedures should have

measurable efficacy…

– Safer procedures may have modest efficacy – Procedures with greater risk should have greater efficacy

• Ultimately the “MIGS” classification

should be earned, based on:

• at least some efficacy
• an enhanced safety profile as determined

by appropriately controlled clinical trials

Minimally Invasive Glaucoma Surgery My Opinion

• Goal of safe, minimally invasive surgery with

measurable efficacy to treat real glaucoma has not been attained

• Efforts to reinvent the wheel have failed
• Some promising areas

– Ab-interno suprachoroidal shunts – Injection of sustained release drugs

• We are not not there yet, but need to keep trying