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Glaucoma Editorial Microinvasive Glaucoma Surgery—A New Chapter in Glaucoma Management Mina B Pantcheva University of Colorado Health Eye Center, Aurora, Colorado, US Abstract The continuous search for techniques and devices that lower the intraocular pressure without the complications associated with our gold standard trabeculectomy procedure has led to some promising developments in glaucoma surgery. The newly emerging technologies place improved patient safety as a priority. This article offers a brief overview of the current status and future innovations of the microinvasive glaucoma surgery (MIGS) and its role in our glaucoma practice. Keywords microinvasive, ab interno, glaucoma, surgery, cataract, open-angle glaucoma Disclosure: Mina B Pantcheva has no conflicts of interest to declare. No funding was received in the publication of this article. This article is a short opinion piece and has not been submitted to external peer reviewers. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: February 21, 2016 Published Online: 17 March, 2016 Citation: US Ophthalmic Review, 2016;9(1):30–1 Correspondence: Mina B Pantcheva, University of Colorado Health Eye Center, 1675 Aurora Court, Aurora, CO 80045, US. E: The development of innovative microinvasive glaucoma surgery (MIGS) procedures has given us an opportunity to fill a long-existing niche in the glaucoma management. Traditionally, the treatment for mild to moderate glaucoma includes noninvasive and relatively safe topical medications and laser trabeculoplasty. MIGS offers new options for patients with mild to moderate open-angle glaucoma (OAG) who have failed medical or laser therapy but whose disease is not so advanced to warrant filtering surgeries, which pose a risk of vision-threatening complications from the surgery itself. This article offers a glimpse at the current and latest developments of MIGS. MIGS procedures involve an ab interno, microincisional, conjunctiva- sparing approach with minimal tissue trauma and disruption of normal anatomy and physiology. 1 The devices used for implantation exhibit a high level of biocompatibility. MIGS achieves moderate to high intraocular pressure (IOP) lowering efficacy, resulting in IOP in the mid-teens. The surgical techniques have a very good safety profile and allow for rapid recovery by the patient. All MIGS procedures are performed under gonioscopic view through a small side port incision. The ab interno techniques include removing trabecular meshwork tissue or implanting a shunt device. Trabectome Ab interno trabeculotomy by the Trabectome ® device (NeoMedix, Tustin, USA) uses a high frequency electrocautery to remove a strip of trabecular meshwork and the inner wall of Schlemm’s canal (SC). 2 The rationale for this angle surgery is the removal of the area of greatest resistance to aqueous outflow while achieving some retraction of the incision 30 edges by heat effect and consequently reducing potential scarring. The device consists of a disposable hand piece, controlled via a 3-stage Foot Pedal Control that initiates irrigation, aspiration and electrocautery in sequence. No randomized controlled trials have been performed to date. Several studies have shown that the Trabectome alone and combined with phacoemulsification results in IOP levels ranging from 13.5 to 17.9 mmHg with greater reduction in patients with higher preoperative IOP and medication reduction from 21% to 38%. 3–6 Jea and coworkers compared the safety and efficacy of the Trabectome to trabeculectomy with mitomycin C and concluded that the success rate of Trabectome was significantly lower. However, its excellent safety profile makes it a viable option for patients in which the risks of trabeculectomy are of particular concern, and patients in early disease stage, which typically involves more modest IOP goals. 7 iStent The iStent ® trabecular micro-bypass stent (Glaukos, Laguna Hills, CA, USA) is a heparin-coated, non-ferromagnetic titanium device with a snorkel shape to facilitate implantation into SC and three retention arches in its outer surface to ensure secure placement. It is approximately 1x0.3 mm in size. It is placed using a single-use sterile inserter and directly connects the anterior chamber with SC. A systematic review and meta-analysis has shown that the iStent as a solo procedure without concurrent cataract surgery does lower IOP and reduces the dependency on glaucoma medications for up to 18 months post surgery. 8 Although the data are limited, it suggests that the IOP decrease correlates with the number of iStents implanted. A 22% IOP reduction from baseline occurred at 18 months after one iStent implant, 30% at 6 months after implantations TOUCH ME D ICA L ME D IA