Pushpinder Kanda, Garfield Miller

Considerations for Adding Minimally/Microinvasive Glaucoma Surgery (MIGS) to a Planned Cataract Surgery

Introduction

Considerations for adding minimally/microinvasive glaucoma surgery (migs) to a planned cataract surgery. Explore considerations for adding Minimally Invasive Glaucoma Surgery (MIGS) to planned cataract surgery. Learn about patient-centered decisions, reducing IOP, and less invasive options for glaucoma management.

Abstract

Glaucoma is a progressive optic neuropathy defined by retinal ganglion cells loss and characteristic visual field loss. It is a leading cause of irreversible blindness and affects over 60 million people worldwide. Its prevalence is estimated to increase to 111.8 million by 2040. Intraocular pressure (IOP) is a major clinically modifiable risk factor for glaucoma. Thus, glaucoma therapy aims to reduce the IOP using medications, lasers (e.g., selective laser trabeculoplasty) or surgery. Historically, surgery has been reserved for advanced glaucoma and in cases with poorly controlled pressure despite medical and laser treatment. For decades, trabeculectomy and tube shunt devices have been the predominant surgical methods for lowering ocular pressure. However, these traditional surgeries are invasive requiring significant manipulation of ocular tissue and have significant post-operative complication rates. Many patients have fallen in the gap of needing more pressure lowering but not enough to justify a higher risk surgery. Fortunately, the landscape of glaucoma surgery has rapidly evolved over the past 20 years with the emergence of minimally/micro- invasive glaucoma surgery (MIGS). MIGS is often performed as an adjunct to cataract surgery. As such, there is minimal added long-term risk if the procedure is done in the same space as the already planned cataract surgery. This represents a large group of patients, some of whom would not have been considered as glaucoma surgical candidates in the past. The clinician is now faced with the question, “Should I add MIGS to the cataract surgery?” In this paper, we suggest a series of questions to ask about each case in order to help make a patient-centred decision.

Review

This paper addresses a highly pertinent and increasingly common clinical dilemma: the decision to incorporate minimally/micro-invasive glaucoma surgery (MIGS) into a planned cataract surgery. The authors effectively frame the significant global burden of glaucoma, a leading cause of irreversible blindness, and underscore the critical role of intraocular pressure (IOP) reduction in its management. They rightly point out the historical limitations of traditional glaucoma surgeries (trabeculectomy, tube shunts), which, despite their efficacy, are associated with considerable invasiveness and post-operative complications, thus often being reserved for advanced cases. This context sets the stage for the emergence of MIGS as a less invasive alternative, filling a crucial gap for patients who require additional IOP lowering but may not be candidates for higher-risk conventional procedures. The central problem tackled by this work is the burgeoning question faced by clinicians regarding the optimal integration of MIGS, particularly when performed concurrently with cataract surgery. The abstract highlights the significant advantage of MIGS as an adjunct to cataract surgery, noting its minimal added long-term risk due to leveraging the existing surgical space. This synergistic approach broadens the pool of potential glaucoma surgical candidates, including many who were previously deemed unsuitable. Consequently, the paper clearly identifies the need for a systematic approach to guide clinicians in making informed, patient-specific decisions on whether to add MIGS to a planned cataract extraction. To address this complex clinical choice, the paper proposes a pragmatic solution: a series of guiding questions designed to facilitate a patient-centred decision-making process. This structured approach is invaluable given the rapid evolution of MIGS technologies and the varying clinical presentations of glaucoma patients undergoing cataract surgery. By suggesting a framework for evaluation, the authors aim to empower clinicians to thoughtfully assess each individual case, considering factors that lead to the most appropriate and beneficial intervention. This contribution holds substantial promise for standardizing and improving surgical planning in the contemporary management of combined cataract and glaucoma conditions.

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