Who should do MIGS?

Should minimally invasive glaucoma surgery (MIGS) be limited to glaucoma specialists? Florent Aptel MD, PhD, argued that it should in a debate at ESCRS Glaucoma Day 2019 in Paris, France. Glaucoma and ocular hypertension are complex, lifelong diseases with multiple potential causes, and may progress rapidly or not at all depending on individual patient risk factors, said Dr Aptel, who is professor at Grenoble-Alpes University and University Hospital, Grenoble, France. And while MIGS has expanded options for early and intermediate cases, treatment decisions always must consider long-term implications, particularly any limits on future treatment. Some procedures are also technically complex, sometimes complicated by the use of anti-fibrotics such as mitomycin C. Therefore, “surgery is not the first treatment option,” Dr Aptel said, noting that 80 to 90 per cent of patients can be controlled with medication. Glaucoma patients also must be followed long-term to assess and quantify progression to determine the need for additional treatment, Dr Aptel added. This is a complex and subtle task, particularly for slowly progressing patients, and requires expert evaluation of both structural and functional parameters. Often, multiple surgical, laser and medical interventions are needed, and they may need maintenance such as needling – cataract surgery is not always appropriate, Dr Aptel said. Cataract surgeons with short-term patient relationships are not in a position to assess long-term needs and complex options, he added. “Clearly, only glaucoma surgeons are able to assess progression and decide what to do with surgery.” Meeting growing global need However, there are simply not enough glaucoma surgeons to address the growing global need for treatment, noted Alain Bron MD, professor at University Hospital, Dijon, France. He noted that worldwide, blindness due to glaucoma increased 62 per cent and visual impairment 83 per cent between 1990 and 2010. (Bourne R et al, Plos ONE 11(10):e0162229.) At the same time, the number of glaucoma surgeons has declined, with those performing trabeculectomy in France falling from 713 to 610 in just three years ending in 2014. (Bron AM et al. BJO, 2017;101:1500-1504.) Dr Bron argued that the transition to combining MIGS with cataract surgery is already well underway, with MIGS surgery growing exponentially in recent years. “Should we keep glaucoma surgery in the ghetto of glaucoma specialists? In my opinion, no, because glaucoma is for everybody,” Dr Bron said.