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Minimally invasive Glaucoma surgery MIGS
This document discusses minimally invasive glaucoma surgery (MIGS) procedures. It defines MIGS as glaucoma surgery that is ab interno, uses a small incision, spares the conjunctiva, causes minimal trauma and tissue disruption, has a high safety profile, allows for rapid visual recovery, and can be combined with cataract surgery. It then describes various MIGS procedures including trabecular micro-bypass stents, gonioscopy assisted transluminal trabeculotomy, excimer laser trabeculotomy, the iStent, and suprachoroidal shunts. It provides details on the mechanisms, surgical techniques, indications, and complications of these different MIGS procedures.
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Minimally invasive Glaucoma surgery MIGS
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- 2. DEFINITION • IOP-lowering surgerywith the following characteristics that distinguish it from traditional glaucoma surgery: • Ab interno , small incision conjunctiva sparing • Minimal trauma & tissue disruption • High safety profile • Rapid visual recovery • Frequently combined with phaco • Mod- high IOP lowering
- 3. • Currently targetedat patients with mild-to-moderate glaucoma. • Indicated for patients with glaucoma less severe than that requiring traditional incisional surgery IOP reduction goal is modest Newly diagnosed Glaucoma ONH damage minimal Poor adherence to medical therapy
- 4. TRAECULAR OUTFLOW OR SCHLEMMSCANAL SX SUPACHOROID OUTFLOW SX AQUOUS HUMOUR PRODUCTION SX SUBCONJUNCTIVAL FILRATION SURGERY
- 5. TRABECULAR OUTFLOW SX TRABECUOLOTOMYBY INTERNAL APPROCH TRABECULAR MICRO- BYPASS BY STENTS TRABECTOME (NEOMEDIX, TUSTIN, CA) GATT (GONIOSCOPY ASSISTED TRANSLUMINAL TRABECULOTOMY ) TRAB360 DEVICE (SIGHT SCIENCES , MENLO PARK, CA) EXCIMER LASER TRABECULOST OMY iStent glaukos, Laguna hills , CA Hydrus Ivantis, Irvine, CA)
- 6. Removing of 90-180degree TM via a plasma thermocautery hand piece.
- 7. A clear corneal incision is made. Viscoelastic Surgicaltip is advanced under gonioscopic control to engage nasal meshwork Ablation by rotating the tip parallel to the iris just anterior to the scleral spur. Ablation with continual infusion and aspiration is performed along an arc of 30 ° to 60° viscoelastic removal SURGICAL TECHNIQUE :
- 8. SIDE EFFECTS : •Descemet’s injury • Ciliary body injury • Reflux bleeding, Hyphaema • Zonule injury
- 11. GATT (GONIOSCOPY ASSISTED TRANSLUMINAL TRABECULOTOMY) FAVOURABLE RESULTS : Pigmentary , pseudo exfoliation glaucoma Failed GDD, trab (open angle) Steroid induced glaucoma Angle recession glaucoma CONTRAINDICATIONS : • Pas • Aberrant angle vessels • Unstable IOL/bag complex
- 17. COMPLICATIONS • Hyphema • Cyclodialysis •Iridodialysis
- 18. Excimer Laser Trabeculotomy: •Energy of a xenon chloride pulsed excimer laser connected to a quartz fiber optic probe. • The procedure intends to enhance outflow facility by creating microperforations in the TM and inner wall of SC. • The probe tip is beveled at 65 degrees to aid the placement against the angle via gonioscopic or endoscopic guidance . • Eight to ten laser punctures are spaced over 90 degrees, each pulse delivering a mean energy of 1.2mJ over 80 ns duration.
- 19. iStent FDA approved foruse in combination with cataract sx for mild-mod open angle glaucoma using 1-3 drugs. Ideal candidate : stable, well controlled disease , to reduce dependency on topical medications.
- 21. 1 mm x0.33 mm Snorkel: 0.25 mm x 120 µm (bore diameter) Weight: 60 µg Surgical grade nonferromagnetic titanium Heparin-coated to prevent fibrosis and blockage. Retention barbs hold the device in the canal. iStent® is FDA approved in the U.S., C.E.
- 22. Mechanism : • Designedto improve aqueous outflow through the natural physiologic pathway • Creates a bypass through trabecular meshwork to Schlemm’s canal
- 27. Mechanism & complications •The stent dilates Schlemm canal by approximately 166 mm along the length of device . • It creates a maximum SC dilation of 241 mm or approximately 4-5 times the natural cross-sectional area of SC. • Dilates Schlemm’s canal for approximately three clock hours in the nasal quadrant, thereby enhancing aqueous outflow.
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- 30. CyPass • CyPass suprachoroidalshunt (Transcend Medical, Menlo Park, Calif.) • 6.35mm long and has a single lumen of about 300 mm. • Made of polyimide and designed to be both biocompatible and non biodegradable. • Aqueous can enter the distal lumen residing in the anterior chamber , and pass into the suprachoroidal space through multiple fenestrations along the length of the implant. • Optical coherence tomography has been used to confirm device placement in the supra- choroidal space with a surrounding fluid pocket.
- 31. • Obstruction andencapsulation are possible sources of failure.
- 32. Endoscopic Cyclophotocoagulation : Indications: •in cases of refractory glaucoma • patients on maximum medical therapy showing continued progression of disease • patients who had failed filtration surgery or were considered at high risk for failure or complications post-traditional filtration procedures. 810-nm diode laser Allows surgeon to precisely aim the laser to cause effective cycloablation
- 33. MIGS fill agap that has existed in the treatment algorithm for glaucoma between medical therapy and laser at one end, traditional filtering surgery at another.
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Editor's Notes
- #2 MICRO INCISIONAL , MICROINVASIVE