MIGS and SLT Slug It Out in Bruising Arena Contest

When a jackal is confronted with a jackhammer, the only possible outcome is a violent struggle for dominance.

And while there was thankfully no blood left on the canvas, the audience at the 2023 ESCRS Congress Arena debate in Vienna on minimally invasive glaucoma surgery (MIGS) versus selective laser trabeculoplasty (SLT) were still treated to a fiery contest as Karl “The Jackal” Mercieca from Germany slugged it out against Carlo “Jackhammer” Traverso from Italy.

Making the case for MIGS, Karl Mercieca came hurtling out of the blue corner with a volley of persuasive arguments.

“MIGS is way better than SLT. It can be combined with phacoemulsification, and the IOP lowering potential is way better than SLT,” he said. “If you look at the long-term results, with one procedure, you can get consistent pressures over a much longer period. With SLT, you need to repeat and repeat and repeat, and not all patients respond.”

Barely pausing for breath, Dr Mercieca followed up with another devastating combination.

“People say that SLT is cost effective and non-invasive, and so forth. But actually, it’s not that cost effective at all. If you look at MIGS combined with phaco, for example, the quality of life is better for your patient, and it’s actually more cost effective.”

The real appeal of MIGS is its versatility, argued Dr Mercieca.

“MIGS doesn’t mean one procedure—you have got so many options to choose from. The other thing is it doesn’t depend on having a nice open angle, whereas SLT can only be used in eyes with large, wide angles. MIGS can be used in other situations, especially combined with phaco, whereas SLT is not indicated in uveitis, narrower angles, and so forth. But the true beauty of MIGS is you can really tailor it. It’s truly personalised medicine for your glaucoma patients,” he concluded.

The Jackhammer fights back

In the red corner, Carlo the “Jackhammer” Traverso took the blows without complaint and decided to come out all guns blazing.

“First of all, what is the spelling for MIGS? If you are using MIGS, this means ‘my income grows steadily,’” he said to laughter from the assembled audience.

After this opening uppercut, Professor Traverso continued his verbal assault.

“Let us face it—MIGS are minimally effective. There is no comparable risk when we look at SLT,” he said. “With MIGS, we have seen endophthalmitis, choroidal issues, [etc.]. SLT is also doable without using the gonioscope. SLT is really not expensive, it is somewhat repeatable, and as a primary treatment, it is not only effective, it’s ethical. It is evident that there is no evidence whatsoever that trabecular MIGS are really working.”

Dr Mercieca responded that Prof Traverso’s arguments were strictly in the featherweight category.

“You are in the wrong boxing category because SLT is comparable to drops,” he said. “We are here at ESCRS with cataract surgeons who want to combine something with a cataract removal to get effective results, not something which they have to wait six weeks to see something positive.”

Prof Traverso was having none of it, delivering another stinging financial argument to his opponent: “Yes, of course, combine MIGS with phaco, so you get two surgical fees in 30 seconds. Who is going to pay for this?” he asked.

Dr Mercieca was quick to respond, adding long-term data showed that MIGS is a cost-effective procedure. “I would like to quote one Carlos Traverso back in 2014 who said, ‘MIGS is definitely the way forward and an alternative to current treatment with really expanding horizons’,” he said.

However, Prof Traverso wasn’t taking this potential hammer blow lying down.

“Yes, but those were the early data. We were part of the very first trial on this trabecular stent, and we participated enthusiastically. But what are the long-term results published in the literature? If it’s not confirmed by data, what is that for? My income grows steadily if I use MIGS, but I’m not there for income. I’m there for the patient’s well-being. So, I think that as a first step, SLT is really the only way out,” he said.

Dr Mercieca said the scientific literature shows that MIGS prevents people from needing further surgery and saves vision.

“MIGS is effective, and of course it’s invasive. But if you are doing phacoemulsification and have a patient on drops, why not do something extra to give them a better quality of life?” he asked.

After some more lively trading of verbal blows in a hugely entertaining contest, both contestants retreated bloodied but unbowed to their corners and awaited the verdict of the audience present.

Summing up, the referee, Leon “The Lion” Au thanked both opponents for a lively debate and announced Dr Mercieca as the winner on points in a tight contest.

Carlo E Traverso MD is the Director of Eye Clinic, Department of Neurosciences, Ophthalmology and Genetics, University of Genoa, Italy. carloenrico.traverso@hsanmartino.it

Karl Mercieca MD, FRCOphth is a consultant ophthalmic surgeon at the University of Bonn Eye Clinic, Germany. Karl.Mercieca@ukbonn.de