Clinical Scorecard: Practical Pearls for Optimizing MIGS

At a Glance

Key Highlights

• Mastering surgical technique and device-specific nuances is critical for successful MIGS outcomes.
• Wound hydration and use of vasoconstrictors like Shugarcaine reduce postoperative hyphema and bleeding.
• Creating an optimal surgical environment, including use of bandage contact lenses and anti-fibrotic pockets, enhances healing and reduces postoperative interventions.

Guideline-Based Recommendations

Diagnosis

• Careful patient selection based on glaucoma type and suitability for MIGS.

Management

• Ensure firm and taut anterior chamber via wound hydration during surgery.
• Use Shugarcaine as a vasoconstrictor at the end of the procedure to minimize bleeding.
• Place a bandage contact lens routinely postoperatively to protect corneal surface and enhance comfort.
• Utilize Dextenza inserts for inflammatory control and ocular surface support.
• For goniotomy, achieve a wide en face view for optimal visualization.
• During trabeculotomy, proceed slowly and deliberately, adjusting gonioscope to minimize blind spots and monitor patient discomfort.
• In superciliary MIGS, use topical anesthesia with vasoconstrictors to control pain and bleeding.
• For subconjunctival MIGS, create an anti-fibrotic pocket to optimize device placement and reduce needling.

Monitoring & Follow-up

• Observe for postoperative hyphema and manage accordingly.
• Monitor patient comfort intraoperatively to avoid catheter misplacement or resistance.
• Follow up for signs of fibrosis or need for postoperative interventions such as needling.

Risks

• Potential for hyphema if wound hydration and vasoconstrictors are not optimized.
• Corneal abrasions from gonioprism use without protective bandage contact lens.
• Complications from pushing through resistance during trabeculotomy.
• Fibrosis leading to device failure if subconjunctival pocket is inadequately created.

Patient & Prescribing Data

Glaucoma patients undergoing minimally invasive glaucoma surgeries

Use of adjunctive agents like Shugarcaine and Dextenza can improve surgical outcomes and patient comfort; precise surgical technique tailored to device mechanism is essential.

Clinical Best Practices

• Master surgical techniques specific to each MIGS device and mechanism of action.
• Maintain a firm anterior chamber with wound hydration to reduce bleeding complications.
• Employ vasoconstrictors such as Shugarcaine to minimize intraoperative and postoperative hemorrhage.
• Use bandage contact lenses routinely to protect the cornea and enhance healing.
• Create appropriate surgical pockets with anti-fibrotic agents for subconjunctival devices to reduce postoperative interventions.
• Proceed slowly and monitor patient responses during procedures with limited visualization to avoid complications.
• Continuously update skills and knowledge through educational resources such as specialized surgical videos.

References

• 2025 American Academy of Ophthalmology Meeting - Practical Tips for Minimally Invasive Glaucoma Therapy
• The Building Blocks of Trabectome Surgery - Patient Selection by Constance Okeke, MD, MSCE