My MIGS of Choice, with Ken Lin

In 2015, I co-authored a paper that reported the safety and efficacy of the Trabectome as a method for reducing IOP in patients after failed glaucoma shunt surgery. During our study, we found patients’ IOP – 12 months after surgery – to be markedly reduced from their preoperative values (1), results that have since been corroborated by other studies (2). Additionally, the Trabectome has also been shown to have long-term success in contending with tube shunts, significantly improving visual acuity in the majority of patients, eight years after surgery (3). Although many of these patients continue to require topical medications, the results still indicate the promise of the Trabectome; the alternative would have been the placement of another glaucoma tube shunt or trabeculectomy.

I practice in a busy academic setting and, as such, receive many referrals for uveitic steroid-induced glaucoma. The etiology of rising IOP in the disease is primarily from the trabecular meshwork, and the Trabectome electrosurgical blade has been shown in many electron microscopy images to achieve meshwork ablation and exposure of the backwall of the Schlemm’s canal very cleanly and accurately. In addition, uveitic glaucoma patients tend to be younger and the Trabectome averts the need for these patients to undergo more invasive procedures, such as trabeculectomy and glaucoma drainage implants, which also come with lifetime risks of infection and exposure.

Another thing to take into consideration is patient satisfaction, which – in my experience – is high when performing irrigating goniectomy using the Trabectome. The surgical procedure is quick, taking only a few minutes, with faster vision recovery when compared with the tube shunt. It can be performed as a standalone procedure or in combination with cataract surgery. I personally appreciate being able to do all of my Trabectome cases with only topical anesthesia, which is unlike glaucoma drainage devices that require retrobulbar or sub-Tenon anesthesia. Patients require fewer post-op visits – a crucial benefit and not only in a pandemic.

If you were to draw a Venn diagram of MIGS devices, taking into consideration the factors of ease of use, variety of indications that can be treated, magnitude of post-operative care, hardware needed, and flexibility to be used with or independent of cataract surgery, you would likely find the Trabectome in the center. The device’s versatility allows me to provide enduring IOP reductions across the spectrum of glaucoma patients – and that makes it my choice MIGS.

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