The field of ophthalmic surgery is fast paced and evolving.Minimally invasive glaucoma surgery (MIGS) is a confluence of technological advancements and ophthalmology. MIGS provides more options for glaucoma management while minimally disrupting the eye's anatomy. While the surgeon's skill is obviously vital, MIGS success relies on collaboration between the entire ophthalmology team. From preoperative to postoperative care, support staff plays a critical role in ensuring successful patient outcomes and preserving a better quality of life for the patient. The perfect combination of expertise, teamwork, and care contributes to efficacy and patient satisfaction.
The case for MIGS
According to the National Library of Medicine, glaucoma affects approximately 76 million patients worldwide and is the leading cause of irreversible vision loss. Traditionally, therapy for glaucoma has been topical eyedrops, laser trabeculectomy or device placement. Despite success, these surgical treatments can have long recoveries, involve numerous follow-ups, as well as other obstacles. These procedures are often reserved for patients with more severe diseases requiring aggressive interventions, often after other modalities have failed.
MIGS utilizes small incisions and specialty devices to improve aqueous outflow, thus reducing IOP. MIGS gives patients with mild to moderate glaucoma more options for their care. This may also benefit patients who respond well to medical therapies but struggle with other barriers to treatment, such as noncompliance with treatment plans, intolerance or allergies to medications, the fiscal burden of expensive medications, and/or physical limitations of administering their own eyedrops. MIGS aims to close these treatment gaps. These procedures involve different techniques for placement of tiny stinting devices or laser treatments, some of which I will discuss below.
MIGS devices
iStent (Glaukos)
At Minnesota Eye Consultants (MEC), which has five locations across the Twin Cities, glaucoma specialist and partner Dr. Christine Larsen says the majority of the MIGS she performs is the placement of the iStent. This type of MIGS requires placing a tiny medical device between the Schlemm's canal and the anterior chamber of the eye to facilitate the drainage of fluid. “If the patient needs cataract surgery for vision improvement and they have a glaucoma diagnoses, we are almost always doing (MIGS) in conjunction with cataract surgery,” she says.
The device is placed using the same incision created during cataract surgery. Dr. Larsen says these surgeries are performed together because a lot of her patients fall into the mild to moderate level of glaucoma and are therefore great candidates for this procedure. She says the low risk of MIGS is also part of the appeal and adds, “studies that led to approval show MIGS is not much riskier than cataract surgery alone.” She says as the iStent becomes more widely used, providers have seen more complications “like prolonged inflammation, bleeding, hyphemia, but the benefits still outweigh the risks.”
Dr. Larsen says the main reason she would avoid iStent placement concurrently with cataract surgery is if her patient is already pseudophakic, the patient has no signs of cataracts or if “the severity level of glaucoma is not enough to warrant (surgical) interventions.”
iStent infinite (Glaukos)
For those patients who may benefit from the iStent, but are pseudophakic or do not have cataracts yet, the iStent infinite provides the alternative option. This MIGS procedure is FDA approved for exclusive use independent of cataract surgery. The way this procedure works is three stents are placed during this standalone procedure as opposed to two stents per eye when done in combination with cataract surgery.
Hydrus Microstent (Alcon)
Glaucoma specialist at MEC, Dr. Clara Choo says there are different options for patients who may not be the best candidate for the iStent. In patients “with unstable mild to moderate glaucoma or have stable but severe glaucoma” she may decide to place the Hydrus Microstent implant. This involves implanting a small crescent-shaped stent into the Schlemm's canal. This enhances natural drainage pathways enabling better outflow of aqueous humor. This is considered a minimally invasive procedure because it is performed through a tiny incision in the cornea.
MicroPulse (Iridex)
Dr. Choo says an option for patients with end stage glaucoma is MicroPulse. This laser delivers brief surges of laser energy directly into the trabecular meshwork. Like the iStent, this helps improve the outflow of fluid from the eye. Each pulse is brief enough to allow the treatment zone to cool between pulses. This minimizes thermal damage to the surrounding tissues resulting in less complications. Dr. Choo says MicroPulse may also be used to treat early-stage glaucoma if the patient prefers to avoid interventions like eyedrops or selective laser trabeculoplasty. She says MicroPulse is also an option if a provider is “worried other glaucoma interventions will fail,” or the patient has other pathology like corneal scars.
Preoperative and postoperative care
Preoperative care starts with a comprehensive eye exam or glaucoma evaluation. The ophthalmology staff at MEC pay close attention to the patient’s medical history as well as any pharmaceutical medications and eyedrops. Technicians assist in performing diagnostic tests like optical coherence tomography to evaluate the optic nerve head and the retina. These results help the surgeon determine if the patient is a suitable candidate for MIGS. Informed consent is vital, consisting of patient education, counseling and managing the patients’ anxiety.
In addition, techs may also help facilitate pre-surgical decisions such as transportation arrangements and the coordination of postoperative medications and follow-ups. Technicians also ensure surgical instruments are sterile and ready for surgery. During the procedure, techs may assist with anesthesia (administering numbing eyedrops), handle surgical instruments and monitor equipment. Techs may hand instruments to the surgeon during the procedure or help manage laser devices.
Postoperative care involves closely monitoring eye pressure during follow-up appointments. An eyedrops regimen is likely prescribed. This will consist of anti-inflammatory and antibiotics ophthalmic drops. Patients are encouraged to get plenty of rest during recovery. Long term postoperative management with routine follow-up in the clinic is encouraged.
MIGS and the need for techs
As more providers adopt MIGS, there may be an increase in demand for experienced ophthalmic technicians. Skilled workers can advance their careers by taking on more responsibility in glaucoma clinics to gain expertise. By understanding MIGS and its benefits, support staff can thoroughly educate patients about their options. This helps patients make more informed decisions and enhances the quality of their care.
Employee Education is a top priority at MEC. This sort of high-level training is a comprehensive process combining education, hands-on practice and continuous learning. Technicians and other support staff are given regular opportunities for continuing education through classes lead by practice physicians or fellows. MEC also subscribes to online learning modules through the Joint Commission on Allied Health Personnel in Ophthalmology and supports technicians by encouraging them to attend yearly conferences. These classes include CE credits, allowing staff to invest in their careers, maintain various certifications or work toward higher levels of certification.
Conclusion
A broad understanding of MIGS enables ophthalmic technicians to collaborate more effectively with glaucoma providers and the ophthalmology team. MIGs provides major expansions in glaucoma treatment and ophthalmic support staff are vital to its success. By implementing knowledge of MIGS, technicians can enhance patient care, support surgical teams and contribute to better treatment outcomes.
As glaucoma surgeries evolve, remaining educated about technological advancements will not only benefit patients but also enhance the careers of ophthalmic technicians. OP
