Science: Updates on the Diagnosis and Management of Glaucoma (includes discussion of new MIGS options)
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18 months ago
david 4.3k

This is a very recent article that gives a fantastic overview of everything in glaucoma, from medications to traditional (incisional) surgeries to the newer minimally invasive surgical options (MIGS).
December 2022 publication date.


Glaucoma is the leading cause of blindness throughout the world (after cataracts); therefore, general physicians should be familiar with the diagnosis and management of affected patients.

Glaucomas are usually categorized by the anatomy of the anterior chamber angle (open vs narrow/closed), rapidity of onset (acute vs chronic), and major etiology (primary vs secondary).

Most glaucomas are primary (ie, without a contributing comorbidity); however, several coexisting ophthalmic conditions may serve as the underlying etiologies of secondary glaucomas. Chronic glaucoma occurs most commonly; thus, regular eye examinations should be performed in at-risk patients to prevent the insidious loss of vision that can develop before diagnosis.

Glaucoma damages the optic nerve and retinal nerve fiber layer, leading to peripheral and central visual field defects. Elevated intraocular pressure (IOP), a crucial determinant of disease progression, remains the only modifiable risk factor; thus, all current treatments (medications, lasers, and operations) aim to reduce the IOP.

Pharmacotherapy is the usual first-line therapy, but noncompliance, undesirable adverse effects, and cost limit effectiveness. Laser and surgical treatments may lower IOP significantly over long periods and may be more cost effective than pharmacotherapy, but they are plagued by greater procedural risks and frequent treatment failures.

Traditional incisional procedures have recently been replaced by several novel, minimally invasive glaucoma surgeries with improved safety profiles and only minimal decreases in efficacy. Minimally invasive glaucoma surgeries have dramatically transformed the surgical management of glaucoma; nevertheless, large, randomized trials are required to assess their long-term efficacy.

Article Highlights

  • Glaucoma, a leading cause of blindness throughout the world, presents with an open or closed anterior chamber angle, structural damage to the optic nerve (seen in all stages), and visual field defects (seen in later stages). Glaucoma may be asymptomatic until the late stages, thereby emphasizing the need for general physicians to understand important diagnostic criteria and management options.

  • The progression of glaucoma is mitigated by lowering the intraocular pressure, which is done with topical medications, laser procedures, or incisional operations.

  • Minimally invasive glaucoma surgery, with a favorable safety profile and efficacy that rivals traditional incisional procedures, has transformed glaucoma care.


The last section of the paper discusses three categories of MIGS. Here is a short summary. Many of you will enjoy reading this section (or the whole paper).

  • MIGSs Targeting the Trabecular Outflow Pathway. Angle-based MIGS procedures are easy to perform and have favorable safety profiles, but compared with traditional trabeculectomy, they have more limited abilities to lower IOP.
  • MIGSs Targeting the Subconjunctival Space. Minimally invasive glaucoma surgeries devices within this category work similarly to trabeculectomy by diverting the aqueous humor flow directly into the subconjunctival space.
  • The third category of MIGSs aims to increase the uveoscleral outflow. Most suprachoroidal MIGSs are still under investigation.

Publication Information

laser-surgery glaucoma surgery • 528 views

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