Minimally invasive glaucoma surgery (MIGS) is a group of procedures that minimizes the invasive rate of glaucoma with five characteristics: ab interno microincision, minimal trauma, more effective, high safety profile, and quick recovery. MIGS is a surgery that uses an incision in a clear cornea and is indicated in patients with mild to moderate open angle glaucoma. The technique of MIGS is based on several mechanisms, namely trabecular meshwork bypass stents including iStent, trabectome, and Hydrus microstent; Suprachoroidal implant using Cypass microstent; And subconjungtiva filtration using XEN gel stent. MIGS technology has potential advantages in glaucoma management by reducing the burden of treatment, improving patients quality of life, and cutting or delaying more invasive surgeries.

1. MINIMALLYINVASIVE
GLAUCOMASURGERY
(MIGS)
GLAUCOMA SUBDIVISION
DEPARTEMENT OF OPHTHALMOLOGY
MEDICAL FACULTY OF ANDALAS UNIVERSITY
DR. M . DJAMIL HOSPITAL PADANG
2020
MEIRONIWAIMIR
Literatur Review

2. INTRODUCTION
• Leading cause of irreversible blindness worldwide.
• The management  medical therapy, laser to
surgery.
The golden standard  Trabeculectomy 
Several potential complications.
This has triggered a lot of research and
development of new procedures that
effective in reducing IOP.
Glaucoma
Characterized by glaucomatous optic
neuropathy, visual field defect and can be
accompanied by increased intraocular
pressure (IOP).

3. INTRODUCTION
Ab interno
microincision
Minimal trauma More effective High safety
profile
Quick recovery
and relatively
easy to do
Minimally invasive glaucoma surgery or micro invasive glaucoma surgery (MIGS) 
group of procedures that minimizes the invasive rate of glaucoma.
The term MIGS is based on five characteristics:

4. Trabecular meshwork
bypass stents
Trabectome
iStent
Suprachoroidal implants
CyPass Microstent
Subconjungtiva
filtration
XEN gel stents
INTRODUCTION
Technique operation of MIGS has developed with different mechanisms.
Hydrus microstent
* MIGS modality that has been approved by the Food and Drugs Administration (US-FDA)

5. AnteriorChamberAngle
Roombetweencorneaandiris
 Anterior chamber is limited by
• Anterior: endothelium cornea
• Peripheral: trabecular meshwork, part of
the ciliary corpus, and iris roots
• Posterior: iris surface and pupil
 Structure:
• Schwalbe line
• Trabecular meshwork
• Scleral spur
• Ciliary body band
• Schlemm canal
• Peripheral iris

6. AnteriorChamberAngle
Schwalbe line located in the transition between cornea
and trabecular meshwork.
Trabecular meshwork is a connective tissue formed by
trabeculocytes.
 Uveal Meshwork
 Corneoscleral Meshwork
 Juxtacanalicular Meshwork
Scleral Spur is a fibrous ring which cross sectionally
shaped like a wedge.
• Consists of collagen types I, III and elastic tissue.
Ciliary body band is a part from ciliary corpus.
Processus Iris

7. SchlemmCanal
 Inner wall consists of irregular endothelial cell that
have giant vacuoles.
• Giant vacuoles formed in response to pressure
gradients from aqueous humor flow when the
endothelial canal wall is stretched due to
increased IOP.
Circular tubes resemble lymphatic vessels, located at
the border of the cornea and sclera.
 Outer wall consists of smooth horizontal cells and
channel that connect with episcleral vein.

8. CollectorChannel
• Schlemm canal  collector channel (intrascleral, episcleral, and sub-conjunctival venous
complexes).
• smooth muscle  able to constrict to regulate aqueous humor flow.
• Collector channel divided into:
• Direct channel: Greater canal, (4-6 channels) with
a diameter 70 micron  flows directly into the
episcleral vein.
• Indirect channel: Smaller canal (15-20 channels)
with a diameter 50 microns  forms intrasclera
plexus before it flows into the episclera vein.

9. AqueousHumorOutflow
Available 2 lane aqueous humor outflow:
o Conventional pathway (Trabecular outflow)
 involves the trabecular meshwork, Schlemm's
canal, and episcleral veins.
o Unconventional pathway (Uveoscleral outflow)
 through the anterior ciliary muscle and iris
stroma to reach the supracillary and
supracoroidal spaces.

10. There are three mechanisms which glaucoma implants can reduce IOP:
Trabecular Meshwork
Bypass Stents
Increased outflow to the
Schlemm canal  achieved by
creating a large direct pathway
between the AC and Schlemm
canal.
• iStent, trabectome, and
Hydrus microstent.
Increasing the uveoskleral
outflow into the
suprachoroidal space.
• CyPass microstent.
Suprachoroidal
Implant
MODALITYANDPROCEDURE
MINIMALLYINVASIVEGLAUCOMASURGERY
Subkonjungtiva
Filtration
Increase outflow by creating
new channels into the
subconjunctival space by
forming an external bleb.
• Xen gel stents.

11. TrabecularMeshworkBypassStents
ISTENT AND ISTENT INJECT

12. IStent and IStent Inject
Mild to moderate OAG that
using one to three ocular
hypotension drugs.
In patients with very narrow
angle it should be avoided
 more difficult and risk of
iris or endothelial damage.
Usually performed on
patients who have stable
disease and well-controlled
IOP.

13. IStent
• Coated heparin titanium implant, size 1 x
0.3 mm  implanted through TM into
the Schlemm canal.
• An "L" shaped device with a pointed tip
that can penetrate TM.
• the "snorkel" section facing the AC 
allows aqueous drainage from the AC to
the Schlemm canal
• Retention arches facing the TM 
keeping the stent in place.
• The half-cylinder pipe prevents
obstruction.
IStent

14. • Smaller than 1st generation device.
• Made of titanium coated heparin.
• Bullet shaped with a length only 360
microns.
• Easier to use  no displacement of
the stents needed for positioning.
• IStent inject can be implanted with
only one inserter.
IStentInject
2nd generation and has been
certified by FDA

15. • Aqueous humor flow into the Schlemm canal
by passing through the juxtacanalikular.
• The advantage  Patency of bypass outflow
because it has a heparin layer.
• Complications  mild hyphema of the
Schlemm canal, transient IOP elevation,
corneal edema, stenting malposition, lumen
obstruction by clots or iris.
• Decrease in IOP ≥20% in patients with open
angle glaucoma.
IStentandIStentInject

16. IStentimplantationprocedurewiththeguidanceofJacobGoniolens

17. TrabecularMeshworkBypassStents
HYDRUS MICROSTENT

18. HydrusMicrostent
• A device that is implanted through a clear
corneal incision into the Schlemm canal.
• Made from a material with very elastic
biocompatibility called nitinol (metal alloy
of nickel and titanium).
• Crescent-shaped with 8 mm length.
• There are three windows along the
surface.

19. • The ideal patients  Mild to moderate open
angle glaucoma and have moderate to dense
pigments in TM.
• Inserted into the Schlemm canal across the TM
using a manual inserter  gonioscopy guided.
HydrusMicrostent
• Reduces the resistance of aquous humor
outflow by two mechanisms.
1. Passing the trabecular meshwork which
is the place with the highest resistance.
2. Expand and install three windows to the
Schlemm canal.

20. TheHydrusmicrostentimplantationprocedure

21. Complications  subconjunctival bleeding,
hyphema, and focal peripheral anterior
synechia
• Pfeiffer et al
Hydrus implantation can reduce IOP 20% in
80% of OAG patients (from 26.3 ± 4.4 mmHg to
16.9 ± 3.3 mmHg).
HydrusMicrostent

22. TrabecularMeshworkBypassStents
TRABECTOME

23. Trabectome
• Procedure using high frequency
electrocautery performed under
gonioscopic to erode TM and the inner
walls of the Schlemm canal.
• Consists of a disposable hand piece used
for aspiration, irrigation and
electrocautery

24. • This procedure can be done 90 or 120 degrees
 thermal damage to the inner walls of the
Schlemm canal  make a direct connection
between the AC and the Schlemm canal.
• The advantage  Removes the area
of ​​greatest resistance of aquous humor
outflow and removes tissue that can
reduce inflammatory stimulation so that
potential scar tissue is formed.
• Performed in open-angle glaucoma 
Requires adequate visualization of TM.
Trabectome

25. • Trabectome generally achieves postoperative
IOP in the low to moderate range, with average
reduction of IOP around 30% after 6 months.
Trabectome
• Complications  a sudden decrease in IOP
on the first day, intraoperative blood reflux
from the Schlemm canal, goniosynechiae and
membrane growth.

26. SUPRACHOROIDALIMPLANT
CYPASS MICROSTENT

27. • Made with polyamides  biocompatible and
not biodegradable.
• It is 6.35 mm long and has a single lumen of
300 µm.
• Used in patients who want to reduce their
dependence on drugs for controlled IOP.
• Aqueous humor enters the supracillary space
through some of the fenestrations that exist
along the tool.
CyPassMicrostent

28. CyPassmicrostentimplantationprocedure

29. • Reduce IOP 30-35%.
• The CyPass Clinical Experiance Study
Reported a reduction in IOP of 26-37%.
• Complications  transient early
hypotension (13.8%), transient IOP
elevation (10.5%), and transient hyphema
(6%).
CyPassMicrostent

30. SUBKONJUNGTIVAFILTRATION
XEN GEL STENT

31. • Gelatin stents  allowing aqueous outflow from
AC to the subconjunctival space by a clear
corneal incision without conjunctival dissection.
Xen Gel Stent
• Soft flexible hydrophilic tube composed of gelatin
with glutaraldehyde.
• The length is 6 mm and the width varies by
model.

32. • Soft, biocompatible and non-inflammatory.
• Flexible when hydrated  softens within 1-2
minutes after implantation and can adjust to
the surrounding tissue.
• Implanted using an injector.
Selection criteria:
Schaffer grade 2 or wider and the conjunctiva can
accommodate bleb formation.
Xen Gel Stent

33. TheXenimplantationprocedure

34. Xen Gel Stent
A study of XEN implants combined with
cataract surgery  Reduction in IOP from
22.4 (+/- 4.2) mmHg to 15.4 (+/- 3.0) mmHg
at 12 months postoperative and there was a
reduction in drug use glaucoma from 2.5 +/-
1.4 to 0.9 +/- 1.0.
In another study using XEN implantation
alone (n = 49 eyes)  40% succeeded in
reducing IOP at 12 months post
implantation (IOP </ = 18mmHg and> / =
20% reduction in IOP).

35. CONCLUSION
• Minimally invasive glaucoma surgery (MIGS) is a group of procedures that minimizes the
invasive rate of glaucoma with five characteristics: ab interno microincision, minimal
trauma, more effective, high safety profile, and quick recovery.
• MIGS is a surgery that uses an incision in a clear cornea and is indicated in patients with
mild to moderate open angle glaucoma.

36. • The technique of MIGS is based on several mechanisms, namely trabecular meshwork
bypass stents including iStent, trabectome, and Hydrus microstent; Suprachoroidal
implant using Cypass microstent; And subconjungtiva filtration using XEN gel stent.
• MIGS technology has potential advantages in glaucoma management by reducing the
burden of treatment, improving patients quality of life, and cutting or delaying more
invasive surgeries.
CONCLUSION

37. THANK YOU
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