Adopting MIGS devices

With new minimally invasive glaucoma surgery (MIGS) devices emerging every year, prospects for better serving patients have never been better. But successfully adding a new procedure to your practice requires homework, Juan F Batlle MD told Glaucoma Day at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, USA. “The first thing to do is to read about it,” said Dr Batlle, of the Dominican Republic, who was the international guest speaker at the meeting. One of the best information sources is the US FDA. “The FDA is being very cooperative in development of the new MIGS technologies. So we have data that is very accurate in terms of complications, adverse events and things that can go wrong,” Dr Battle said. Secondly, Dr Batlle recommends watching videos. “YouTube and Eyetube are great. You can see videos from Ike Ahmed or Doug Rhee or Davinder (Grover) or (Steven) Sarkisian, who are actually using these techniques now.” Implanting MIGS devices such as microshunts or even Schlemm’s canal stents is generally not as complex as cataract surgery, but proper technique is critical, Dr Batlle noted. “Usually it’s creating a channel through which you introduce the device. If you have the right optics and illumination you will be able to succeed every time, but you have to be knowledgeable,” he said. Finally, Dr Batlle recommends getting a mentor and practising. “There are tricks to everything, and unless you have someone there with you to observe what you are doing and say, ‘No, don’t do it there’, you can run into trouble.”

We have never lost an eye, we have always succeeded in Schlemmʼs canal

For example, in cannulating Schlemm’s canal, Dr Batlle has seen even glaucoma experts have problems. “Things all look the same - the pigment in front of Schwalbe’s looks like Schlemm’s, or it’s behind Schwalbe’s so you end up going higher, higher, higher because people want to put it way back in the trabecular meshwork. So have someone coach you,” he said. Fortunately, mistakes with MIGS devices usually are not serious, Dr Batlle added. “We have never lost an eye, we have always succeeded in Schlemmʼs canal. The worst that can happen is you don’t lower the intraocular pressure and you have to do it again.” Still, even a world-class surgeon like Dr Batlle needs practice. He recalls an Ivantis wetlab in Amsterdam introducing the Hydrus Microstent. “I was the only one there… I did 95 insertions of the Hydrus into cadaver eyes before I got it down.” Juan F Batlle: 
jbatlle55@gmail.com