Important Patient Safety Information: Coronavirus (COVID-19)

View Menu

Minimally Invasive Glaucoma Surgery (MIGS)

When patients are experiencing symptoms from visually significant cataracts, it is an excellent time to address both the cataract and glaucoma conditions simultaneously. If a patient is on one or more eye medications for glaucoma, a glaucoma procedure should be performed at the time of cataract surgery. There are options of traditional glaucoma surgeries or the newer glaucoma surgeries called Minimally Invasive Glaucoma Surgery (MIGS).

The goal of glaucoma surgery is to lower intraocular pressure. This is either performed by decreasing aqueous fluid inflow or increasing aqueous fluid outflow. Historically, invasive procedures such as trabeculectomy and tube shunt implantation, which created new outflow passages made of either the patient’s natural tissue or via a silicone tube, respectively, were the only surgical options available. Due to higher risks, these procedures were not routinely performed at the time of cataract surgery. If patients had uncontrolled intraocular pressure, these surgeries would be performed during a separate visit to the operating room.

In the last 20 years, several new glaucoma procedures termed Minimally Invasive Glaucoma Surgery (MIGS) have emerged. Most of these MIGS procedures can be performed in conjunction with cataract surgery or by itself. After the cataract is extracted and the intraocular lens is implanted, a gonioscopy lens is used to visualize the trabecular meshwork. These have the advantage of using micro-incisions through the cornea that cause less trauma and scarring to the surrounding conjunctival and scleral tissues. These procedures do not exclude the possibility of traditional surgeries in the future if needed. MIGS include endocyclophotocoagulation (ECP), an endoscopic laser to the ciliary body that decreases aqueous inflow. MIGS also include procedures that increase aqueous fluid outflow, such as iStent inject implantation, OMNI system viscodilation and trabeculotomy, and Xen 45 gel stent implantation.

iStent inject implantation involves placing two 0.3mm titanium stents in the trabecular meshwork, which allow direct flow to Schlemm’s canal. The OMNI system viscodilation involves threading a microcatheter into Schlemm’s canal to dilate it with viscoelastic jelly. During the same surgery, the microcatheter can be inserted again into Schlemm’s canal and used to cut through the trabecular meshwork allowing aqueous fluid to directly access Schlemm’s canal. Xen 45 gel stent is a 6mm implant designed to enter the subconjunctival space and create an alternative space for the aqueous fluid to leave the eye. These new tools to our glaucoma surgery armamentarium have drastically fewer risks than traditional glaucoma surgery.

Employing a MIGS procedure concurrently with cataract surgery may mean decreasing intraocular pressures to goal levels for some patients or it may allow other patients to stop using one or more eye drops. If glaucoma is treated during cataract surgery, it may help avoid the need for a separate glaucoma surgery in the future. With new advents in glaucoma surgery, having cataract surgery can be an excellent opportunity for improved glaucoma control.