What's your take on MIGS

[mjohnsonets]

What's everyone's take on MIGS?

I hear varied opinions and was looking for more open discussion feedback. I know some glaucoma surgeons who like them, some who absolutely hate them. I know there are many devices/procedures at this point. Any stand outs?

Also, besides the patient care perspective, what's reimbursements like? I know istent and more of the 1st gen MIGS have been reduced to almost nothing. I know quite a few practices who seem to be supplementing declining cataract reimbursments with them.

Seems like the pace of development has slowed down too in the last year or so.

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[eyeeye_captain]

My take is they’re fine for what they are. They’re not great, but they’re adequate in helping control mostly mild glaucoma and potentially cutting down on patients’ drop burden. They also create some access to care given the lack of surgeons willing to take on tubes and trabs, but they are no substitute for incisional surgery in bad glaucoma. I can see how they’re at least a decent godsend for the glaucoma folks who understandably don’t want to babysit blebs if they can help it.

Between my residency and fellowship, one program loved them, the other hated them. Since I don’t do them, I can’t give you the standouts, development, or reimbursement. You can argue if it was necessary, but Cypass and Xen already have had recalls which may have stagnated the market a little on top of declining pay.

I’ve seen/heard of people supplementing. If it’s appropriate, by all means, but I think we all have the one local person who puts multifocal IOLs and iStents in 0.3 cup patients with a Tmax of 17. PITA letting them know that their 20/80 AMD that was ignored pre-op pretty much negates their investment, but at least their “glaucoma” is cured. They can discuss it with the surgeon at their next monthly Botox/filler appointment.

 

[i-doctor]

There is a role for them. I have tried many of them. I personally believe that those that perform Goniotomy are better and longer lasting than those that are strictly for Canaloplasty. And I also prefer no longer using stents (such as iStent or Hydrus), which are marginally effective, but which can also be subject to recall or complications. So I now use a straight goniotomy procedure or the Omni, which can be used to perform a 180 or even 360 degree goniotomy (more important than its primary indication as a Canaloplasty procedure).