{"id":1584,"date":"2025-07-11T01:32:38","date_gmt":"2025-07-11T01:32:38","guid":{"rendered":"https:\/\/enfoca.com.mx\/?p=1584"},"modified":"2026-10-08T19:01:20","modified_gmt":"2026-10-08T19:01:20","slug":"cirugias-glaucoma-minima-invasiva-migs-mibs","status":"publish","type":"post","link":"https:\/\/enfoca.com.mx\/eng\/cirugias-glaucoma-minima-invasiva-migs-mibs\/","title":{"rendered":"MIGS and MIBS: Minimally Invasive Glaucoma Surgery | Samur A-I"},"content":{"rendered":"<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe title=\"SAMUR A-I #7: MIGS \/ MIBS SHOWDOWN\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/HdOg26mD7FI?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<p class=\"wp-block-paragraph translation-block\"><strong>Glaucoma<\/strong> is one of the leading causes of blindness worldwide, and its management has evolved significantly. Today, <strong>minimally invasive glaucoma surgeries (MIGS and MEPS)<\/strong> offer safer and more effective alternatives for controlling <strong>intraocular pressure (IOP)<\/strong>. This article explores the latest trends and technologies in the field, based on an analysis of the document \"SAMUR A-I #7: MIGS \/ MIBS SHOWDOWN\", with a focus on IOP reduction, safety profile, and patient selection.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading enfoca-tam-h3\">A Paradigm Shift in Glaucoma Treatment<\/h2>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Traditionally, <strong>trabeculectomy<\/strong> has been the gold standard for the surgical treatment of glaucoma. However, the current landscape has seen a \"radical shift\" toward less aggressive options. <strong>MIGS and MEPS<\/strong> aim to lower IOP to moderate ranges (between 10 and 16 mmHg) with a superior safety profile, offering a \"much broader and, overall, safer therapeutic arsenal than trabeculectomy\". The goal is to find the perfect balance between IOP reduction and safety, always selecting the <strong>ideal patient<\/strong> for each technique.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading enfoca-tam-h3\">Flow Pathways and Specific Technologies in Glaucoma Surgery<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Minimally invasive glaucoma surgeries are classified according to the flow pathway they seek to optimize:<\/p>\n\n\n\n<h3 class=\"wp-block-heading enfoca-tam-h4\">1. Improvement of Trabecular Flow (Natural Route)<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">These techniques facilitate the outflow of aqueous humor through its natural pathway: <strong>Schlemm's canal<\/strong> and the <strong>trabecular meshwork<\/strong>.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Implants\/Scaffolds:<\/strong>\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>iStent family:<\/strong> Implants designed to improve drainage. The newest versions allow multiple iStents to be placed for a greater effect.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Hydrus:<\/strong> A small scaffold inserted into Schlemm's canal to keep it open. There are comparative data with iStent that spark debate about its superiority.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Tissue Ablation\/Cutting:<\/strong>\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Trabectome:<\/strong> Uses electrocautery to ablate trabecular tissue.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Blade Goniotomies (Kahook Dual Blade, KDB):<\/strong> Allow precise cutting of the tissue.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Bang Bent of Internal Needle Goniotomy (BANG):<\/strong> An \"ingenious and accessible\" technique that uses a bent insulin needle to perform the goniotomy. It stands out for its <strong>cost-effectiveness<\/strong>. Combined with <strong>phacoemulsification<\/strong> (cataract surgery), it has shown a 27% reduction in IOP and a 55% reduction in medication use at 6 months.<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li><strong>Extensive Trabeculotomies:<\/strong>\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Transillumination-Assisted Goniotomy (GAT):<\/strong> A <strong>360-degree trabeculotomy<\/strong> that opens the entire canal. It achieves \"quite remarkable\" IOP reductions of approximately 9.3 mmHg. However, it has the highest rate of <strong>transient hyphema<\/strong> (bleeding inside the eye), almost 28%, because more tissue is cut.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>OMNI:<\/strong> Combines <strong>canaloplasty<\/strong> and trabeculotomy.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Internal AV Microhook:<\/strong> Has shown \"36-month data\", suggesting <strong>durability<\/strong>.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>HFDS:<\/strong> With \"impressive 6-year results\", which \"gives confidence in its durability\".<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">It is important to note that there is a clear \"efficacy-safety balance\": <strong>greater intervention in the trabecular meshwork<\/strong>, as with GAT or Microhook, often leads to a <strong>greater IOP reduction<\/strong>, but also a slightly higher risk of hyphema. In addition, if <strong>baseline IOP is high<\/strong>, the reduction tends to be greater in absolute numbers.<\/p>\n\n\n\n<h3 class=\"wp-block-heading enfoca-tam-h4\">2. Suprachoroidal Flow<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">This route creates an <strong>alternative pathway between the choroid and the sclera<\/strong>.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>MiniJet:<\/strong> The device currently available for this route, with \"5-year data\" and a 38% reduction in IOP, as well as a \"good safety profile\".<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Safety Considerations (The CyPass Lesson):<\/strong> The withdrawal of the <strong>CyPass<\/strong> device due to long-term endothelial cell loss was a \"hard lesson\" about the importance of long-term follow-up. It underscored that <strong>design, material, and monitoring<\/strong> of patients over years are vital. The success of MiniJet suggests that the suprachoroidal route is viable with the right design.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading enfoca-tam-h4\">3. Subconjunctival discharge (MIBS)<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">These techniques are closer to trabeculectomy, since they create a <strong>filtering bleb<\/strong> so that aqueous humor drains into the subconjunctival space.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Ex-Press Gel Stent, XEN63, and PreserFlo MicroShunt:<\/strong> Achieve \"more powerful\" IOP reductions, sometimes 40-55%, approaching the results of trabeculectomy. (Watch the PresserFlo episode by clicking <a href=\"https:\/\/enfoca.com.mx\/eng\/presserflo-latinoamerica\/\">here<\/a>)<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Bleb Management:<\/strong> Unlike trabecular MIGS, success here depends on healing of the outer conjunctiva. <strong>Mitomycin C<\/strong> is frequently used to prevent excessive scarring and, at times, <strong>needling<\/strong> is needed to keep the bleb functional.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Complication Profile:<\/strong> They introduce a different complication profile, with less risk of hyphema but a higher risk of bleb-related problems such as leaks, hypotony, or, rarely, infection.<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading enfoca-tam-h4\">4. Reduction of aqueous humor production<\/h3>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">These techniques act on the <strong>ciliary body<\/strong>, the \"factory\" of aqueous humor.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>Endoscopic Cyclophotocoagulation (ECP):<\/strong> Allows the ciliary body to be visualized and treated from the inside.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Micropuls TSPC:<\/strong> Delivers the treatment externally, with a technology that aims to be \"gentler and safer\" and less destructive than traditional cyclophotocoagulation. These techniques are particularly useful in <strong>very advanced or refractory glaucomas<\/strong>.<\/li>\n<\/ul>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading enfoca-tam-h3\">Key Findings and Future Implications in Glaucoma<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">The field of minimally invasive glaucoma surgery has advanced considerably, offering new hope to patients:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"translation-block\"><strong>A Broad and Safe Therapeutic Arsenal:<\/strong> Ophthalmologists have a \"much broader therapeutic arsenal\" that is, overall, safer than trabeculectomy for controlling IOP in moderate ranges (10-16 mmHg).<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Efficacy-Safety Balance:<\/strong> It is essential to understand that the most powerful techniques, such as GAT or MIBS, achieve greater IOP reductions but carry different risks (hyphema or bleb complications).<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Patient Selection Is Crucial:<\/strong> \"Patient selection is crucial\". Factors such as <strong>baseline IOP<\/strong>, the state of the <strong>iridocorneal angle<\/strong>, <strong>glaucoma severity<\/strong>, <strong>age<\/strong>, and the presence of <strong>cataract<\/strong> are decisive. <strong>Nomograms<\/strong> are being developed to help with this decision-making.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Long-Term Data and Durability:<\/strong> The experience with CyPass highlights the need for \"long-term data, always\". <strong>Durability<\/strong> and <strong>cost<\/strong> are essential factors in daily practice.<\/li>\n\n\n\n<li class=\"translation-block\"><strong>Continuous Innovation:<\/strong> Innovation does not stop, with examples such as BANK for its cost-effectiveness, MiniJet validating the suprachoroidal route, and Micropuls improving safety.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph translation-block\">Finally, a \"final reflection\" is raised: the role of <strong>Artificial Intelligence (AI)<\/strong>. AI could analyze various patient factors (OCT, medical history, genetics) to \"refine our ability to predict who will respond best to which technique\". This would take the <strong>personalization of glaucoma surgery<\/strong> to a new level, with the ability to \"predict individual response being the next big step\".<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>","protected":false},"excerpt":{"rendered":"<p>El glaucoma es una de las principales causas de ceguera a nivel mundial, y su manejo ha evolucionado significativamente. Hoy [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":1585,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center 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