Sponsored by Glaukos
The idea that glaucoma is best treated surgically has existed for decades, but safety concerns limited the enthusiasm for deploying traditional incisional surgery across the spectrum of disease. Today, there is little question that MIGS has significantly impacted how glaucoma is managed. Patients are consistently treated earlier in the paradigm, and evidence is emerging that MIGS confers long-term benefits compared to topical therapy.
So where will the next breakthrough in MIGS come from and what will it look like? If history is any indicator, evolutions follow from an expanded user base; more hands-on experience tends to breed advancements in techniques and technology. Yet, a wider user base means ensuring that surgeons, either at the start of their ophthalmology journey or mid-career, have access to the tools and resources necessary to alter their practice patterns.
One area in which providing access to MIGS (and educational resources about MIGS) seems a natural fit is in residency and fellowship programs. Providing training in MIGS at the start of the career introduces an important treatment option for glaucoma, ultimately preparing the trainee for what he or she will see in everyday clinical practice.
Sarah Van Tassel, MD, director of the glaucoma fellowship program at Weill Cornell Medicine, knows that firsthand. “MIGS is not the standard of care in glaucoma management, but it is a standard of care, and an important one at that. Those of us in training institutions have a responsibility to impart current clinical standards to surgeons in training.”
J. David Stephens, MD, appreciates the need for introducing MIGS early in one’s career from a more firsthand perspective. Following residency, he pursued a combined cornea/refractive/glaucoma fellowship at Vance Thompson Institute, where he gained exposure to MIGS, which later shaped his clinical practice. That early exposure has been particularly beneficial to his practice in Fort Myers, Florida, where a large number of patients seeking cataract consultations have co-existing glaucoma.
“Coming out of training very well-versed in MIGS, especially out of fellowship, has been very helpful for me, and a very good practice-builder that I'm able to utilize with a lot of patients,” Dr. Stephens said.
Drs. Van Tassel and Stephens recently sat down to discuss why it is important for training surgeons to gain exposure to and experience with MIGS. This conversation has been edited for length.
Why is it beneficial for training surgeons to gain exposure to MIGS?
Dr. Stephens: I trained under John Berdahl, MD, one of the pioneers in MIGS surgery, so I feel like I got an amazing education in angle-based surgery during my time in fellowship. The program was structured to give us a high volume of surgical cases with Dr. Berdahl, so we would learn his habits and methods. That inspired trust, and gave me the confidence to do solo cases with my attending serving as back-up. This training has served me well in my own practice. Looking forward, given the sheer volume of cataract and glaucoma patients that we're going to see in the clinic over the next 10 to 20 years, the need will surely exceed what our glaucoma colleagues are able to provide. Residency programs that train excellent comprehensive ophthalmologists can be part of the solution. I think that being able to perform MIGS is part of being a comprehensive ophthalmologist now.
Dr. Van Tassel: MIGS is not the standard of care in glaucoma management, but it is a standard of care, and an important one at that. Those of us in training institutions have a responsibility to impart current clinical standards to training surgeons. One of those entities is the emerging interventional mindset, especially with respect to expanding the use of MIGS and selective laser trabeculoplasty (SLT) among comprehensive ophthalmologists. We also live in a data-driven environment, and the evidence suggests long-term benefits with these interventional approaches over drop therapy. For example, SLT is probably preferable to drops in early glaucoma management, even for treatment-naïve patients.1 As well, there are visual field data to suggest greater preservation with MIGS versus drop therapy.2
The interventional mindset is driving HCPs to reexamine how and when drops are used. Frankly, any treated glaucoma is better than untreated glaucoma, so we want to equip surgeons with the knowledge and skills to know when and how to perform MIGS. Residency programs are the place where we can democratize glaucoma care. There is a net benefit to glaucoma management being handled by a greater number of clinicians.
What are your perceptions of the learning curve associated with MIGS procedures (in general)? Is it any different for training surgeons versus those already in practice?
Dr. Stephens: There are some key steps to becoming a proficient MIGS surgeon, and a lot of them have nothing to do with angle-based surgery. It's purely about getting your hands comfortable, getting your body comfortable, and knowing how to use the microscope to see what you need to see. I struggled with this as a new surgeon, which was something I didn’t expect to struggle with because I studied piano in college. I learned that it was because I was sitting improperly, basically operating with my hands floating in the air without them resting. It wasn't until I changed the microscope position and got comfortable that I had an a-ha moment. Then my hands were doing what I wanted them to do. I suspect a lot of young surgeons struggle with learning how to operate under a microscope, but like anything, you can improve with practice and by adjusting your technique.
Dr. Van Tassel: One of the challenges we face in training is that residents often complete their glaucoma rotation prior to the high-volume cataract rotations. As Dr. Stephens alluded to, a lot of the skills and techniques in MIGS grow from what is learned while getting comfortable operating with both hands inside the eye. You also have to be good at moving in the X-, Y-, and Z-planes while operating, and that takes a bit of experience. MIGS skills build upon what was learned before, and so residents have to be interested enough to double back to glaucoma before graduating, if that’s not built into the curriculum. That is sort of a shame, because we want all ophthalmologists to know about MIGS, even if they are not performing procedures routinely. For example, we want a young retina surgeon who sees a glaucoma implant to know what that implant is so that he or she can plan trocar placement during vitrectomy.
Dr. Stephens: It's almost easier to train surgeons mid-career who have acquired certain surgical skills. Unfortunately, it can be harder to want to change practice patterns after the first 5 to 10 years or so. Whereas, in residency, you’re hungry for that knowledge, but experience and exposure may be lacking.
Dr. Van Tassel: It’s never too late to learn MIGS if you’re willing. People can learn it in practice, and we all need to be prepared to learn new things in the future. But I do think it's nice that we get to train our residents with MIGS now.
Dr. Stephens: And it’s never too early, especially if you can get hands-on experience. My mentor in fellowship used to tell me that he wasn’t teaching me how to play ball; he was turning a college athlete into a professional. The better prepared residents are in MIGS, even if that may not include hands-on experience, the faster they will adjust in practice or in fellowship.
Any particular resources that surgeons, even those in practice, may not be aware of?
Dr. Van Tassel: We do not talk enough about the role that industry plays in training new surgeons and in helping us gain access to technology that we can use. I’ve experienced both of those things with Glaukos. A lot of attendings I know don’t feel as comfortable teaching MIGS as their reps do, and they’ve been great about hosting dry and wet labs for residents and fellows. Through the years, they have been an incredible resource for our training surgeons, and that deserves an acknowledgement.
Dr. Stephens: When I was in residency, Glaukos was very active in ensuring we had access to technology as well as the proper education, and they continue to support educational opportunities for surgeons interested in learning new techniques. We’ve been talking about residents and fellows here, but the resources are out there for anyone to take advantage of. I believe that the learning curve with MIGS is only long and hard if you make it so, and the barriers to adoption exist only if you believe they do. Meanwhile, there is ample evidence, empirical and anecdotal, that MIGS has spurred an evolution in the management of glaucoma. There is, indeed, a strong rationale for investing the time necessary to learn MIGS techniques for personal reasons, but in the end, adding MIGS to one’s practice is just another way we can help patients with their eye health.
1. Gazzard G, Konstantakopoulou E, Gary-Heath G, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151.
2. Montesano G, Ometto G, Ahmed IIK, et al. Five-year visual field outcomes of the HORIZON Trial. Am J Ophthalmol. 2023;251:143-155.
