SpringerLink
Log in

Minimally Invasive Glaucoma Surgery: Where We Are, and What the Future Holds

  • Ophthalmologic Surgery (R Shwamy and L Schocket, Section Editors)
  • Published:
Current Surgery Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Minimally invasive glaucoma surgery, or MIGS, has revolutionized the glaucoma surgical space in the past 15 years. The high safety profile and moderate efficacy of MIGS has enabled earlier surgical intervention for glaucoma, providing safe and sight-saving care sooner. This review aims to examine the latest evidence on available devices and techniques.

Recent Findings

Trabecular outflow remains a mainstay for MIGS targets, with distal outflow enhancement and alternative drainage pathways showing efficacy. Comparisons of various MIGS devices and techniques are emerging, which will enable glaucoma surgeons to better design individualized care for their patients. While no single MIGS has emerged as significantly superior to others; some MIGS may be better suited for some types of glaucoma, however.

Summary

Minimally invasive glaucoma surgeries provide safe and effective alternatives to traditional filtering glaucoma surgeries in many patients. The high safety profile of MIGS enable earlier surgical interventions, which can improve visual outcome and patients’ quality of life. There is an abundance of evidence showing the efficacy and safety of various MIGS, with innovations continuing to advance the surgical treatment of glaucoma.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Tham YC, Li X, Wong TY, et al. Global prevalence of glaucoma and projections of glaucoma burden through 2040; a systemic review and meta-analysis. Ophthalmology. 2014;121:2081–90.

    PubMed  Google Scholar 

  2. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90(3):262–7.

    CAS  PubMed Central  PubMed  Google Scholar 

  3. Leske MC, Heikl A, Hyman L, et al. Predictors of long-term progression in the early manifest glaucoma trial. Ophthalmology. 2007;114:1965–72.

    PubMed  Google Scholar 

  4. Drance S, Anderson DR, Schulzer M. Risk factors for progression of visual field abnormalities in normal-tension glaucoma. Am J Ophthalmol. 2001;131:699–708.

    CAS  PubMed  Google Scholar 

  5. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that preduct the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120:714–20.

    PubMed  Google Scholar 

  6. Chauhan BC, Mikelberg FS, Balaszi AG, LeBlanc RP, Lesk MR, Trope GE, Canadian Glaucoma Study Group. Canadian Glaucoma Study: 2. Risk factors for the progression of open-angle glaucoma. Arch Ophthalmol. 2008;126(8):1030–6.

    PubMed  Google Scholar 

  7. The AGIS Investigators. Investigators (2000) The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. Am J Ophthalmol. 2000;130(4):429–40.

    Google Scholar 

  8. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the tube versus trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol. 2012;153:789-803.e2.

    PubMed Central  PubMed  Google Scholar 

  9. • Saheb H, Ahmed I. Micro-invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol. 2012;23(2):96–104. This paper defined what MIGS entails for the field.

    PubMed  Google Scholar 

  10. Fea AM. Phacoemulsification versus phacoemulsification with micro-bypass stent implantation in primary open-angle glaucoma: randomized double-masked clinical trial. J Cataract Refract Surg. 2010;36:407–12.

    PubMed  Google Scholar 

  11. •• Samuelson TW, Katz LJ, Wells JM, Duh YJ, Giamporcaro JE. Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology. 2011;118(3):459–67. This is the first randomized controlled trial of a MIGS device and the pivotal trial for istent.

    PubMed  Google Scholar 

  12. Samuelson TW, Sarkisian SR Jr, Lubeck DM, Stiles MC, Duh YJ, Romo EA, et al. Prospective, randomized, controlled pivotal trial of an ab interno implanted trabecular micro-bypass in primary open-angle glaucoma and cataract: two-year results. Ophthalmology. 2019;126(6):811–21.

    PubMed  Google Scholar 

  13. Samuelson TW, Chang DF, Marquis R, Flowers B, Lim KS, Ahmed IIK, et al. A schlemm canal microstent for intraocular pressure reduction in primary open-angle glaucoma and cataract: the HORIZON Study. Ophthalmology. 2019;126(1):29–37.

    PubMed  Google Scholar 

  14. •• Ahmed IK, Rhee DJ, Jones J, Sing IP, Radcliffe N, Gazzard G, Samuelson TW, Ong J, Singh K, Horizon investigators. Three-year findings of the HORIZON trial: a schlemm canal microstent for pressure reduction in primary open-angle glaucoma and cataract. Ophthalmology. 2021;128(6):857–65. This is the pivotal trial for Hydrus.

    PubMed  Google Scholar 

  15. Pfeiffer N, Garcia-Feijon J, Martinez-de-la-Casa JM, et al. A randomized trial of a Schlemm’s canal microstent with phacoemulsification for reducing intraocular pressure in open-angle glaucoma. Ophthalmology. 2015;122:1283–93.

    PubMed  Google Scholar 

  16. • Ahmed IIK, Fea A, Au L, Ang RE, Harasymowycz P, Jampel HD, Samuelson TW, Chang DF, Rhee DJ. A prospective randomized trial comparing hydrus and iStent microinvasive glaucoma surgery implants for standalone treatment of open-angle glaucoma: the COMPARE Study. Ophthalmology. 2020;127(1):52–61. This is a randomzied prospective study that compares istent and Hydrus stents-prospective comparisons of MIGS devices are much needed.

    PubMed  Google Scholar 

  17. Otarola F, Virgili G, Shah A, Hu K, Bunce C, Gazzard G. Ab interno trabecular bypass surgery with Schlemms canal microstent (Hydrus) for open angle glaucoma. Cochrane Database Syst Rev. 2020;3(3):CD012740.

    PubMed  Google Scholar 

  18. Jea SY, Francis BA, Vakili G, Filippopoulos T, Rhee DJ. Ab interno trabeculectomy versus trabeculectomy for open-angle glaucoma. Ophthalmology. 2012;119(1):36–42.

    PubMed  Google Scholar 

  19. Kaplowitz K, Schuman JS, Loewen NA. Techniques and outcomes of minimally invasive trabecular ablation and bypass surgery. Br J Ophthalmol. 2014;98(5):579–85.

    PubMed  Google Scholar 

  20. •• Minckler D, Baerveldt G, Ramirez MA, Mosaed S, Wilson R, Shaarawy T, Zack B, Dustin L, Francis B. Clinical results with the trabectome, a novel surgical device for treatment of open-angle glaucoma. Trans Am Ophthal Soc. 2006;104:40–50. This is the first randomized controlled trial of a MIGS procedure, the trabectome.

    PubMed Central  PubMed  Google Scholar 

  21. Ting JL, Damji KF, Stiles MC. Ab interno trabeculectomy: outcomes in exfoliation versus primary open-angle glaucoma. J Cataract Refract Surg. 2012;38:315–23.

    PubMed  Google Scholar 

  22. Francis BA, Minckler D, Dustin L, et al. Combined cataract extraction and trabeculotomy by the internal approach for coexisting cataract and open-angle glaucoma: initial results. J Cataract Refract Surg. 2008;34:1096–103.

    PubMed  Google Scholar 

  23. Neiweem AE, Bussel II, Schuman JS, Brown EN, Loewen NA. Glaucoma surgery calculator: limited additive effect of phacoemulsification on intraocular pressure in ab interno trabeculectomy. PLoS ONE. 2016. https://doi.org/10.1371/journal.pone.0153585.

    Article  PubMed Central  PubMed  Google Scholar 

  24. • Dorairaj S, Tam MD, Balasubramani GK. Twelve-month outcomes of excisional goniotomy using the Kahook Dual Blade® in eyes with angle-closure glaucoma. Clin Ophthalmol. 2019;10(13):1779–85. This is important because they compare efficacy between MIGS procedures, an area that is still in progress as we determine which type of device or method is better for different types of glaucomas.

    Google Scholar 

  25. • Hirabayashi MT, Lee D, King JT, Thomsen S, An JA. Comparison of surgical outcomes of 360° circumferential trabeculotomy versus sectoral excisional goniotomy with the Kahook dual blade at 6 months. Clin Ophthalmol. 2019;15(13):2017–24. This is important because they compare efficacy between MIGS procedures, an area that is still in progress as we determine which type of device or method is better for different types of glaucomas.

    Google Scholar 

  26. Greenwood M, Seibold L, Radcliffe N, Dorairaj S, Aref A, Roman L-GG, Darlington J, Abdullah S, Jasek M, Bahjri K, Berdahl J. Goniotomy with a single-use dual blade: short term results. J Cataract Refract Surg. 2017;43:1197–201.

    PubMed  Google Scholar 

  27. Le C, Kazaryan S, Hubbell M, Zurakowski D, Ayyala RS. Surgical outcomes of phacoemulsification followed by iStent implantation versus goniotomy with the Kahook dual blade in patients with mild primary open-angle glaucoma with a minimum of 12-month follow-up. J Glaucoma. 2019;28(5):411–4.

    PubMed  Google Scholar 

  28. ElMallah MK, Berdahl JP, Williamson BK, Dorairaj SK, Kahook MY, Gallardo MJ, Mahootchi A, Smith SN, Rappaport LA, Diaz-Robles D, Lazcano-Gomez GS. Twelve-month outcomes of stand-alone excisional goniotomy in mild to severe glaucoma. Clin Ophthalmol. 2020;3(14):1891–7.

    Google Scholar 

  29. ElMallah MK, Seibold LK, Kahook MY, Williamson BK, Singh IP, Dorairaj SK. 12-month retrospective comparison of Kahook dual blade excisional goniotomy with iStent trabecular bypass device implantation in glaucomatous eyes at the time of cataract surgery. Adv Ther. 2019;36(9):2515–27.

    PubMed Central  PubMed  Google Scholar 

  30. Laroche D, Nkrumah G, Ugoh P, Ng C. Real world outcomes of Kahook dual blade goniotomy in Black and Afro-Latinx adult patients with glaucoma: a 6-month retrospective study. J Natl Med Assoc. 2021;113(2):230–6.

    PubMed  Google Scholar 

  31. Berdahl JP, Gallardo MJ, ElMallah MK, Williamson BK, Kahook MY, Mahootchi A, Rappaport LA, Lazcano-Gomez GS, Díaz-Robles D, Dorairaj SK. Six-month outcomes of goniotomy performed with the kahook dual blade as a stand-alone glaucoma procedure. Adv Ther. 2018;35(11):2093–102. https://doi.org/10.1007/s12325-018-0803-0.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  32. Salinas L, Chaudhary A, Berdahl JP, Lazcano-Gomez GS, Williamson BK, Dorairaj SK, Seibold LK, Smith S, Aref AA, Darlington JK, Jimenez-Roman J, Mahootchi A, Boucekine M, Mansouri K. Goniotomy using the Kahook dual blade in severe and refractory glaucoma: 6-month outcomes. J Glaucoma. 2018;27(10):849–55.

    PubMed  Google Scholar 

  33. Falkenberry S, Singh IP, Crane CJ, Haider MA, Morgan MG, Grenier CP, Brubaker JW, Balasubramani GK, Dorairaj S. Excisional goniotomy vs trabecular microbypass stent implantation: a prospective randomized clinical trial in eyes with mild to moderate open-angle glaucoma. J Cataract Refract Surg. 2020;46(8):1165–71.

    PubMed  Google Scholar 

  34. •• Grover DS, Godfrey DG, Smith O, et al. Gonioscopy-associated transluminal trabeculotomy, ab interno trabeculotomy: technique report and preliminary results. Ophthalmology. 2014;121:855–61. This is the landmark paper describing GATT.

    PubMed  Google Scholar 

  35. Grover DS, Godfrey DG, Smith O, et al. Outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) in eyes with prior incisional glaucoma surgery. J Glaucoma. 2017;26:41–5.

    PubMed  Google Scholar 

  36. Grover DS, Smith O, Fellman RL, Godfrey DG, Butler MR. Gonioscopy assisted transluminal trabeculotomy: an ab interno circumferential trabeculotomy for the treatment of primary congenital glaucoma and juvenile open angle glaucoma. Br J Ophthalmol. 2015;99(8):1092–6.

    PubMed  Google Scholar 

  37. Vold SD, et al. Canaloplasty and trabeculotomy with the OMNI system in pseudophakic patients with open angle glaucoma: the ROMEO study. Ophthalmol Glaucoma. 2021;4:173–81.

    PubMed  Google Scholar 

  38. Hirabayashi MT, Lee D, King JT, Thomsen S, An JA. Comparison of surgical outcomes of 360° circumferential trabeculotomy versus sectoral excisional goniotomy with the Kahook dual blade at 6 months. Clin Ophthalmol. 2019;13:2017–24.

    PubMed Central  PubMed  Google Scholar 

  39. Huang AS, Saraswathy S, Dastiridou A, Begian A, Legaspi H, Mohindroo C, Tan JC, Francis BA, Caprioli J, Hinton DR, Weinreb RN. Aqueous angiography with fluorescein and indocyanine green in bovine eyes. Transl Vis Sci Technol. 2016;5(6):5.

    PubMed Central  PubMed  Google Scholar 

  40. •• Gallardo MJ, Supnet RA, Ahmed IIK. Viscodilation of Schlemm’s canal for the reduction of IOP via an ab-interno approach. Clin Ophthalmol. 2018;12:2149–55. This is the paper first describing Ab interno canaloplasty using the microcatheter.

    PubMed Central  PubMed  Google Scholar 

  41. Gallardo MJ, Supnet RA, Ahmed IIK. Circumferential viscodilation of Schlemm’s canal for open-angle glaucoma: ab-interno vs ab-externo canaloplasty with tensioning suture. Clin Ophthalmol. 2018;5(12):2493–8.

    Google Scholar 

  42. Ondrejka S, Körber N. 360° ab-interno Schlemm’s canal viscodilation in primary open-angle glaucoma. Clin Ophthalmol. 2019;15(13):1235–46.

    Google Scholar 

  43. Hughes T, Traynor M. Clinical results of ab interno canaloplasty in patients with open-angle glaucoma. Clin Ophthalmol. 2020;29(14):3641–50.

    Google Scholar 

  44. Reiss G, Clifford B, Vold S, He J, Hamilton C, Dickerson J, Lane S. Safety and effectiveness of CyPass supraciliary micro-stent in primary open-angle glaucoma: 5-year results from the COMPASS XT study. Am J Ophthalmol. 2019;208:219–25.

    PubMed  Google Scholar 

  45. Lass JH, Benetz BA, He J, et al. Corneal endothelial cell loss and morphometric changes 5 years after phacoemulsification with or without CyPass Micro-Stent. Am J Ophthalmol. 2019. https://doi.org/10.1016/j.ajo.2019.07.016.

    Article  PubMed Central  PubMed  Google Scholar 

  46. https://www.fda.gov/medical-devices/safety-communications/update-potential-eye-damage-alcon-cypass-micro-stent-used-treat-open-angle-glaucoma-fda-safety

  47. Junemann A. Twelve-month outcomes following ab interno implantation of suprachoroidal stent and postoperative administration of travoprost to treat open angle glaucoma 31st Congress of the European Society of Cataract and Refractive Surgeons, Amsterdam, Netherlands (2013)

  48. Denis P, Hirneiß C, Durr GM, Reddy KP, Kamarthy A, Calvo E, Hussain Z, Ahmed IK. Two-year outcomes of the MINIject drainage system for uncontrolled glaucoma from the STAR-I first-in-human trial. Br J Ophthalmol. 2020;106:65–70.

    PubMed  Google Scholar 

  49. Grover DS, Flynn WJ, Bashford KP, Lewis RA, Duh YJ, Nangi RS, Niksch B. Performance and safety of a new ab interno gelatin stent in refractory glaucoma at 12 months. Am J Ophthalmology. 2017;183:25–36.

    Google Scholar 

  50. • Mansouri K, Guidotti J, Rao HL, et al. Prospective evaluation of standalone XEN gel implant and combined phacoemulsification-XEN gel implant surgery: 1-year results. J Glaucoma. 2018;27(2):140–7. Prospective trial examing results of the Xen gel stent versus combined with cataract surgery.

    PubMed  Google Scholar 

  51. Smith OU, Grover DS, Emanuel ME, Godfrey DG, Fellman RL. XEN gel stent in pediatric glaucoma. J Glaucoma. 2020;29(4):e19–22.

    PubMed  Google Scholar 

  52. Arad T, Hoffmann EM, Prokosch-Willing V, Pfeiffer N, Grehn F. XEN-augmented baerveldt implantation for refractory childhood glaucoma: a retrospective case series. J Glaucoma. 2019;28(11):1015–8.

    PubMed  Google Scholar 

  53. Tan NE, Tracer N, Terraciano A, Parikh HA, Panerelli JF, Radcliffe NM. Comparison of safety and efficacy between ab interno and ab externo Approaches to XEN gel stent placement. Clin Ophthalmol. 2021;15:299–305. https://doi.org/10.2147/OPTH.S292007.

    Article  PubMed Central  PubMed  Google Scholar 

  54. Yuan L, Lai G, Raiciulescu S, Kim W. Outcomes of ab interno placement versus ab externo transconjunctival placement of Xen 45 gel stents. Presented at the American Glaucoma Society Annual Meeting; February 27; 2020; Washington, DC

  55. Gallardo M, Porter M, Vincent L, et al. Outcomes following implantation of an anterior segment drainage device (Xen45 Gel Stent) via an ab-interno or ab-externo approach in patients with uncontrolled open angle glaucoma. Presented at the American Glaucoma Society Annual Meeting February 27; 2020; Washington, DC.

  56. Purgert RJ, Lin MM, Mehren N, et al. Outcomes of ab interno versus ab externo XEN gel stent implantation. Presented at the American Glaucoma Society Annual Meeting February 27; 2020; Washington, DC.

  57. Batlle JF, Corona A, Albuquerque R. Long-term results of the PRESERFLO microshunt in patients with primary open-angle glaucoma from a single-center nonrandomized study. J Glaucoma. 2021;30(3):281–6.

    PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Ophthalmology, Tulane School of Medicine, 131 S. Robertson St, 12th Floor, New Orleans, LA, 70112, USA

    Fareed Rifai, Crystal P. Le, Lauren Lim & Ze Zhang

Authors
  1. Fareed Rifai
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Crystal P. Le
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lauren Lim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ze Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ze Zhang.

Ethics declarations

Conflict of interest

None of the authors have any conflicts of interest.

Research Involving Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical collection on Ophthalmologic Surgery.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rifai, F., Le, C.P., Lim, L. et al. Minimally Invasive Glaucoma Surgery: Where We Are, and What the Future Holds. Curr Surg Rep 10, 35–49 (2022). https://doi.org/10.1007/s40137-022-00311-2

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40137-022-00311-2

Keywords

Search

Navigation