Clinical Report: Barriers to MIGS Adoption Among Cataract Surgeons

Overview

Despite the availability and patient acceptance of minimally invasive glaucoma surgery (MIGS), nearly half of glaucoma patients undergoing cataract surgery do not receive concomitant glaucoma treatment. Surgeon hesitation, discomfort with gonioscopy, and prior complications are key factors limiting broader MIGS adoption.

Background

Since the FDA approval of the iStent in 2012, MIGS has expanded as a treatment option for glaucoma patients undergoing cataract surgery. However, many surgeons avoid offering MIGS, resulting in underutilization despite patient willingness. Barriers include surgeon preference to refer glaucoma care, lack of comfort with gonioscopic techniques, and concerns following complications. Emerging technologies aim to address these issues by simplifying glaucoma treatment integration during cataract surgery.

Data Highlights

It is estimated that nearly 50% of glaucoma patients undergoing cataract surgery do not receive any concomitant glaucoma treatment, including MIGS.

Key Findings

• Approximately half of glaucoma patients having cataract surgery do not receive MIGS or other glaucoma treatments concurrently.
• Some surgeons prefer not to treat glaucoma themselves, opting to refer patients to glaucoma specialists.
• Discomfort with gonioscopy limits some surgeons from performing MIGS procedures.
• Complications experienced during MIGS can lead to surgeon reluctance or discontinuation of these procedures.
• New technologies such as direct selective laser trabeculoplasty, intraocular lens drug-delivery platforms, and automated femtosecond laser trabeculotomy may reduce barriers related to gonioscopy and surgical complexity.
• Drug-delivery systems like SpyGlass and iDose TR offer alternatives with favorable safety profiles and may appeal to surgeons hesitant about angle surgery.

Clinical Implications

Clinicians should recognize that surgeon hesitation, rather than patient refusal, is a major barrier to MIGS adoption. Education and training in gonioscopy remain important, but emerging technologies may enable more cataract surgeons to integrate glaucoma treatment safely and effectively. Offering these new options could improve glaucoma management outcomes during cataract surgery.

Conclusion

While some cataract surgeons avoid MIGS due to personal preference or technical challenges, advances in glaucoma treatment technologies are expanding accessible options. These innovations have the potential to increase surgeon participation in glaucoma care and benefit patients undergoing cataract surgery.

Related Resources & Content

1. Radcliffe NM, Glaucoma Physician, 2024 -- Why Do Half of Cataract Surgeons Avoid MIGS?