2977: MIGS to the Max for glaucoma
In this case, a 65 year-old female with longstanding advanced glaucoma presents with an intraocular pressure of 35 mmHg despite maximal medical therapy, to which she is largely intolerant. Our guest surgeon, Professor Ramesh Ayyala from USF in Tampa, tackles this challenge by combining four separate minimally invasive glaucoma surgery procedures in a single eye to maximize intraocular pressure control through different physiological mechanisms. The conventional outflow pathway is addressed via viscodilation and goniotomy, while the uveoscleral pathway is targeted using a slow release prostaglandin drug delivery device. Additionally, the supraciliary pathway is accessed via a ciliary body cleft implant, and aqueous production is decreased using endocyclophotocoagulation. At three weeks postoperative, the intraocular pressure is successfully reduced to 12 mmHg on zero medications. While this aggressive combination successfully achieves a sub fifteen pressure without a trabeculectomy, it raises an important financial question. The device costs alone total about $20,000 US, compared to a traditional trabeculectomy which costs about 1/10th that cost less for essentially identical pressure control. Note that the surgeon fee is about the same for doing “MIGS to the Max” as well as a classic trabeculectomy and the large cost difference is for the cost of the very expensive devices. Please comment your thoughts on this cost benefit analysis below. It is worth it?
1 month follow up on the patient who underwent all the possible MIGS in the same eye. See the gonio picture and the anterior segment OCT. It is interesting that the Alloflow scleral implant shrinkage is visible on gonio and the cleft space is visible on Anterior Segment OCT. IOP was 14 off all drops at 1 month.
