This document discusses minimally invasive glaucoma surgery (MIGS) procedures. It defines MIGS as glaucoma surgery that is ab interno, uses a small incision, spares the conjunctiva, causes minimal trauma and tissue disruption, has a high safety profile, allows for rapid visual recovery, and can be combined with cataract surgery. It then describes various MIGS procedures including trabecular micro-bypass stents, gonioscopy assisted transluminal trabeculotomy, excimer laser trabeculotomy, the iStent, and suprachoroidal shunts. It provides details on the mechanisms, surgical techniques, indications, and complications of these different MIGS procedures.

1. MINIMALLY INVASIVE
GLAUCOMA SURGERY
(MIGS)
DR.ANKITA MAHAPATRA

2. DEFINITION
• IOP-lowering surgery with the following characteristics that
distinguish it from traditional glaucoma surgery:
• Ab interno , small incision conjunctiva sparing
• Minimal trauma & tissue disruption
• High safety profile
• Rapid visual recovery
• Frequently combined with phaco
• Mod- high IOP lowering

3. • Currently targeted at patients with mild-to-moderate glaucoma.
• Indicated for patients with glaucoma less severe than that requiring
traditional incisional surgery
IOP reduction goal is modest
Newly diagnosed Glaucoma
ONH damage minimal
Poor adherence to medical
therapy

4. TRAECULAR OUTFLOW OR
SCHLEMMS CANAL SX
SUPACHOROID
OUTFLOW SX
AQUOUS HUMOUR
PRODUCTION SX
SUBCONJUNCTIVAL
FILRATION SURGERY

5. TRABECULAR OUTFLOW SX
TRABECUOLOTOMY BY
INTERNAL APPROCH
TRABECULAR MICRO-
BYPASS BY STENTS
TRABECTOME
(NEOMEDIX,
TUSTIN, CA)
GATT
(GONIOSCOPY
ASSISTED
TRANSLUMINAL
TRABECULOTOMY )
TRAB360 DEVICE
(SIGHT SCIENCES ,
MENLO PARK, CA)
EXCIMER
LASER
TRABECULOST
OMY
iStent
glaukos,
Laguna hills ,
CA
Hydrus Ivantis,
Irvine, CA)

6. Removing of 90-180 degree TM via a plasma thermocautery hand piece.

7. A clear
corneal
incision is
made.
Viscoelastic
Surgical tip is
advanced
under
gonioscopic
control to
engage nasal
meshwork
Ablation by
rotating the
tip parallel to
the iris just
anterior to
the scleral
spur.
Ablation with
continual
infusion and
aspiration is
performed
along an arc
of 30 ° to 60°
viscoelastic
removal
SURGICAL TECHNIQUE :

8. SIDE EFFECTS :
• Descemet’s injury
• Ciliary body injury
• Reflux bleeding, Hyphaema
• Zonule injury

11. GATT
(GONIOSCOPY ASSISTED
TRANSLUMINAL TRABECULOTOMY )
FAVOURABLE RESULTS :
Pigmentary , pseudo exfoliation glaucoma
Failed GDD, trab (open angle)
Steroid induced glaucoma
Angle recession glaucoma
CONTRAINDICATIONS :
• Pas
• Aberrant angle vessels
• Unstable IOL/bag complex

17. COMPLICATIONS
• Hyphema
• Cyclodialysis
• Iridodialysis

18. Excimer Laser Trabeculotomy:
• Energy of a xenon chloride pulsed excimer laser
connected to a quartz fiber optic probe.
• The procedure intends to enhance outflow facility by
creating microperforations in the TM and inner wall
of SC.
• The probe tip is beveled at 65 degrees to aid the
placement against the angle via gonioscopic or
endoscopic guidance .
• Eight to ten laser punctures are spaced over 90
degrees, each pulse delivering a mean energy of
1.2mJ over 80 ns duration.

19. iStent
FDA approved for use in combination
with cataract sx for mild-mod open
angle glaucoma using 1-3 drugs.
Ideal candidate : stable, well controlled
disease , to reduce dependency on
topical medications.

21. 1 mm x 0.33 mm
Snorkel: 0.25 mm x 120 µm (bore
diameter)
Weight: 60 µg
Surgical grade nonferromagnetic
titanium
Heparin-coated to prevent fibrosis and blockage.
Retention barbs hold the device in the canal.
iStent® is FDA approved in the U.S., C.E.

22. Mechanism :
• Designed to improve aqueous outflow
through the natural physiologic
pathway
• Creates a bypass through trabecular
meshwork to Schlemm’s canal

27. Mechanism & complications
• The stent dilates Schlemm canal by approximately 166 mm along the
length of device .
• It creates a maximum SC dilation of 241 mm or approximately 4-5
times the natural cross-sectional area of SC.
• Dilates Schlemm’s canal for approximately three clock hours in the
nasal quadrant, thereby enhancing aqueous outflow.

28. Surgical technique :

30. CyPass
• CyPass suprachoroidal shunt (Transcend Medical, Menlo Park, Calif.)
• 6.35mm long and has a single lumen of about 300 mm.
• Made of polyimide and designed to be both biocompatible and non biodegradable.
• Aqueous can enter the distal lumen residing in the anterior chamber , and pass into the
suprachoroidal space through multiple fenestrations along
the length of the implant.
• Optical coherence tomography has been used
to confirm device placement in the
supra- choroidal space with a surrounding
fluid pocket.

31. • Obstruction and encapsulation are possible sources of failure.

32. Endoscopic Cyclophotocoagulation :
Indications:
• in cases of refractory glaucoma
• patients on maximum medical therapy
showing continued progression of disease
• patients who had failed filtration surgery or
were considered at high risk for failure or
complications post-traditional filtration
procedures.
810-nm diode laser
Allows surgeon to precisely aim the laser to
cause effective cycloablation

33. MIGS fill a gap that has existed in the treatment algorithm for
glaucoma between medical therapy and laser at one end,
traditional filtering surgery at another.

34. THANK YOU