Customizing Care and Minimizing Risk With MIGS

Ike Ahmed (00:00): This is Ike Ahmed.

Arsham Sheybani (00:01): And I'm Arsham Sheybani.

Ike Ahmed (00:03): And we want to welcome you to GT: The podcast.

Arsham Sheybani (00:06): We’re bringing this to you together with BMC and Glaucoma Today.

Ike Ahmed (00:10): To offer audible insights into current topics in glaucoma care.

Arsham Sheybani (00:14): Presented by the authors of our latest, most-read GT articles.

Ike Ahmed (00:19): Check it out.

Speaker 3 (00:20): Welcome to GT: The Podcast. In this episode, Drs. Reay H. Brown and Shibandri Das each present a scenario that highlights how minimally invasive procedures can be used to address specific obstacles in glaucoma management. The two patient cases were featured in their article, “Customizing Care and Minimizing Risk with MIGS,” which was written with Dr. Shivani Kamat and featured in the May/June issue of glaucoma today. First, Dr. Brown shares a case involving a 61-year-old patient with pseudoexfoliation glaucoma and Alzheimer's disease and discusses how surgical intervention helped to alleviate concerns about medication compliance and decrease the risk of vision loss. Later, Dr. Das shares a case of a 24-year-old patient with keratoconus who underwent angle surgery for steroid-induced glaucoma after penetrating keratoplasty. First, we hear from Dr. Brown.

Reay H. Brown (01:23): A 61-year-old white man with pseudoexfoliation glaucoma underwent cataract surgery with placement of a posterior chamber IOL in both eyes in 2020. He did not undergo a glaucoma procedure in either eye. At the time of the surgery, the therapeutic regimen for both eyes consisted of a fixed combination of timolol 0.2% and brimonidine 0.5%, latanoprost, and dorzolamide. Two years later, selective laser trabeculoplasty was performed on both eyes, but no medications were discontinued after the procedure. His visual fields were normal. The patient was referred for glaucoma management in 2024, one year after he was diagnosed with Alzheimer disease. His vision was 20/20 OU, and the intraocular pressure was 16 mm Hg in the right eye and 17 mm Hg in the left eye. His glaucoma medication regimen had not changed since his cataract surgery. The cup-to-disc ratio was 0.5 in the right eye and 0.7 in the left eye.

(02:57): OCT imaging showed a normal retinal nerve fiber layer, thickness in the right eye, and borderline nerve fiber layer thickness in the left eye. Humphrey visual field testing was normal in the right eye and showed a probable nasal step in the left eye. A review of the patient's records showed that his intraocular pressure had consistently been in a normal range in the right eye but had sometimes reached the low 20s mm Hg in the left eye. One year later, the patient's pressure status had not changed, but visual field testing showed mean defects of 9.86 in the right eye and 16.51 in the left eye. Both tests seemed highly unreliable with large numbers of false positives and false negatives. OCT imaging was again normal in the right eye and showed stable disease in the left eye. The patient's Alzheimer disease, however, made his adherence to prescribed medical therapy a major concern.

(04:16): His wife accompanied him to his appointments, but she admitted that some doses of his drops had been missed. The disease in the patient's left eye seemed to be progressing from pre-parametric glaucoma to real visual field loss. Uncertain patient adherence and visual field loss indicated that the right eye required treatment. Canaloplasty and goniotomy using the OMNI Surgical System combined with placement of an intracameral travoprost implant were recommended for both eyes. Surgery was performed 6 months ago on the left eye and 5 months ago on the right eye. His postoperative pressures have been in the low teens bilaterally on a fixed combination of timolol and dorzolamide administered twice daily. For this patient with Alzheimer disease, surgical intervention addressed compliance issues and decreased the risk of vision loss.

Speaker 3 (05:29): Here's Dr. Das to present the next case.

Shibandri Das (05:36): A 24-year-old man with keratoconus underwent penetrating keratoplasty in his left eye in January 2024 and developed steroid-induced glaucoma during the following 18 months. Despite maximally tolerated medical therapy, including pilocarpine dosed four times daily, brimonidine three times daily, a combination of dorzolamide and timolol ophthalmic solution twice daily, netarsudil daily, as well as latanoprost nightly, and oral acetazolamide 500 mg two times a day. His IOP remained poorly controlled. The patient experienced drug intolerance and difficulty managing the medication load. And the IOP ranged from 26 to 45 mm Hg across visits. When the patient was referred for glaucoma management, his best corrected visual acuity was 20/50 in the left eye. A slit lamp examination showed a posterior subcapsular cataract in the left eye and cup to disc asymmetry with a ratio of 0.2 in the right eye and 0.55 with inferior thinning in the left eye, likely secondary to the prolonged corticosteroid use in the left eye.

(06:48): Gonioscopy showed open angles with visibility of the scleral spur and a 1+ pigmented trabecular meshwork in the left eye. OCT showed diffuse RNFL thinning in the left eye. Reliable visual field tests could not be obtained. Given the patient's young age, conservative measures were initially attempted. Selective laser trabeculoplasty was performed in May of 2025, but the treatment was limited by poor visualization through the PKP graft. At the time of the procedure, the IOP was 26 mm Hg on maximum tolerated medical therapy. One month later, the IOP had improved to 18 mm Hg and the graft was clearer. Maximum tolerated medical therapy, however, was still required. Given the need for consistent IOP control, the high medication burden, and the patient's increasing intolerance of therapy, further surgical intervention was discussed. Both he and our team wanted to avoid incisional surgery in the setting of the recent PKP graft.

(07:52): Considering the improved graft clarity and the reported success of gonioscopy-assisted transluminal trabeculotomy in steroid-induced glaucoma, phacoemulsification, IOL implantation, and a 360 degree goniotomy and canaloplasty using the eye track were planned. The patient underwent uncomplicated cataract extraction, IOL implantation and MIGS in September of 2025. Intraoperative visualization was challenging because of the honeycomb epitheliopathy likely related to the long-term use of netarsudil. The illuminated eye tract microcatheter facilitated visualization within Schlemm's canal, and the 360 degree goniotomy and canaloplasty were successfully performed. Subsequent follow-up visits demonstrated a sustained reduction of IOP and the medication burden in the left eye. On postoperative day 1, the patient's visual acuity was 20/70 in the left eye and IOP was 14 mm Hg on the combination of dorzolamide and timolol drops administered twice daily. And there was a microhyphema which was evident. One week later, his visual acuity had declined to hand motion, owing to increased hyphema, and the IOP remained well controlled.

(09:10): By postoperative week three, his visual acuity had improved to 20/40 and the IOP was 15 mm Hg on the combination of dorzolamide-timolol instilled twice daily. In October of 2025, the IOP measured 11 mm Hg. The graft was clear and there was no evidence of rejection or edema. The fixed combination drug was discontinued because of the ocular surface irritation and replaced with latanoprost administered once at night. At his most recent visit in April of 2026, the patient's uncorrected visual acuity was 20/25 in the left eye. The IOP was well controlled and the PKP graft was clear and compact. This case highlights the benefit of 360-degree goniotomy and canaloplasty in managing refractory steroid-induced glaucoma after PKP. Traditional incisional surgery after PKP poses a substantial risk to graft survival and is associated with higher complication rates. In this patient, angle surgery achieved sustained IOP control on fewer medications, preserved the PKP graft integrity, and avoided the risks of incisional glaucoma surgery.

Speaker 5 (10:22): Thank you for tuning in to this episode of GT: The Podcast. If you have any feedback or topic suggestions, find us on Instagram, LinkedIn, Facebook, or Twitter. And stay tuned for more hot topics in glaucoma care on GT: The Podcast.