Clinical Report: Practical Pearls for Optimizing MIGS Outcomes

Overview

Dr. Constance Okeke highlights key surgical techniques and device-specific tips to optimize outcomes in minimally invasive glaucoma surgery (MIGS). Emphasis is placed on patient selection, wound hydration, use of vasoconstrictors, and tailored approaches for different MIGS mechanisms.

Background

Minimally invasive glaucoma surgeries (MIGS) have rapidly expanded as treatment options for glaucoma, offering safer and less invasive alternatives to traditional surgeries. Success in MIGS depends on both appropriate patient selection and mastery of surgical techniques. Different MIGS devices operate via distinct mechanisms, requiring specific procedural nuances to maximize efficacy and minimize complications. Dr. Okeke, a glaucoma and cataract specialist, provides practical pearls to enhance surgical outcomes across MIGS types.

Data Highlights

Key procedural tips include routine wound hydration to maintain a firm anterior chamber, use of Shugarcaine as a vasoconstrictor to reduce postoperative hyphema, and placement of a bandage contact lens to promote corneal healing. Device-specific pearls address visualization for goniotomy, slow and deliberate catheter movement for trabeculotomy, heme and pain control for superciliary MIGS, and creation of an antifibrotic pocket for subconjunctival MIGS.

Key Findings

• Wound hydration is critical to maintain anterior chamber firmness and reduce postoperative hyphema.
• Use of Shugarcaine (containing epinephrine) at case end helps vasoconstriction and anesthesia, improving heme and pain control.
• Bandage contact lenses prevent corneal abrasions from gonioprism use and enhance patient comfort and healing.
• For goniotomy, achieving a wide, en face view is essential for procedural success.
• During trabeculotomy, slow, steady, and deliberate catheter movement with careful visualization minimizes complications.
• In subconjunctival MIGS, creating a proper antifibrotic pocket for device placement reduces postoperative needling interventions.

Clinical Implications

Surgeons performing MIGS should prioritize meticulous surgical technique including wound hydration and vasoconstrictor use to minimize bleeding and improve outcomes. Tailoring the approach to the specific MIGS mechanism—such as optimizing visualization for goniotomy or careful catheter manipulation for trabeculotomy—can reduce complications. Routine use of bandage contact lenses and antifibrotic pockets further enhance healing and reduce postoperative interventions.

Conclusion

Mastery of MIGS requires not only selecting the appropriate device but also understanding and applying precise surgical techniques tailored to each mechanism of action. Continuous learning and refinement of these pearls can improve patient outcomes as MIGS options expand.

References

1. Okeke C. 2025 AAO Meeting -- Practical Tips for Minimally Invasive Glaucoma Therapy