MOS. MIGS De-Coded

[00:00:04]We are live now doctor.

[00:00:05]>> All right.

[00:00:07]Good evening everyone. I Dr. Priti Kandar secretary of the Maharashtra of Society welcome all of you to this um series the next in our line that is MIGSD coded. The specialtity of this series is that each speaker is given 30 to 40 minutes to um address the topic in detail. And today we have none other than Dr. Tanoj Dad who is just the right person in India to uh tell us about MIGS. But before that let me invite Dr. Anaga Heru who is the president of Maharashtrathmological Society to address us. Dr. Anaga over to you please. Yes, thank you so much and very warm welcome to one and all. We welcome our esteemed speaker Dr. Tanu Zadasur and all the expert panelists here. Truly uh this is a very special session because this is a special procedure and I'm sure all of us are waiting and looking forward to hear you sir. In fact through MOS we have been doing one procedure per month webinars like this which are specialized and focused on only one procedure. So we can give a lot of attention to detail and we also send out Google forms to all our members to find out what exactly questions they have in mind so that we can address all their queries. So looking forward to a great session and thank you so much for being here.

[00:01:36]>> Thank you.

[00:01:38]>> Thank you Andaga and of course Dr. Tanush Dad needs no introduction. He is uh the head of the glaucoma services at all India institutes of medical science and RP center and he's done phenomenal research. You name it and he's done it.

[00:01:55]So that's why there's no one as I said earlier no one better to tell us about all the details of what MIGS than Dr. Tanoj. Welcome Dr. Tanoj and we are looking forward to listening to you. And we also have very good panelists a very esteemed glaucoma specialist from all over Maharashtra. Dr. Kanchchin who is a glaucoma specialist from Latur of course Dr. Mandar Paranche and Dr. Vidya Chelert very experienced glaucoma specialist from Pune Dr. Kitki Puricha who is again a glaucoma specialist like me from Bombay and Pujab who again a very experienced um glaucoma specialist from Mira. So without uh any further adu uh let me uh invite Dr. Tanojada for his talk but before that uh Mangala can you play the one um uh that one minute clip from Ajenta Far. Sure Dr. Yeah.

[00:03:44]Is it all right? Okay. So Dr. Tanish please go ahead with your talk.

[00:03:52]>> I just want to check can you see my slides?

[00:03:55]>> Yes yes yes we can.

[00:03:58]>> So thank you very much to all members of the Maharashtra Society and especially Dr. Priti for this kind invitation.

[00:04:07]So today's talk will be on minimally invasive gloma surgery and whatever I understand about its truths and myths.

[00:04:21]So I have no financial disclosure.

[00:04:27]So minimally invasive gluccom surgery is also called as microinas gluccom surgery.

[00:04:34]So this is a ab internal surgery where there is a self-sealing incision.

[00:04:40]It is a minimally traumatic surgery and why it is gaining popularity is because it has got a high safety profile and a rapid recovery as compared to the conventional gluccom surgery that we are used to that is a gluccom filtering surgery.

[00:04:58]So earlier for all forms of glaucoma you may have early glaucoma moderate or advanced patient has high IOP but no optic nerve damage. So we used to do tblectomy for all these conditions but over time there was a realization that because tblectomy is a high risk procedure with there there can be sightthreatening complications.

[00:05:22]So in patients who have got early glaucoma or just high pressure there is a need for a minimally invasive surgery that can lower IOP but not have the complications associated with tacoclectomy. So that is how the minimally invasive gluccom surgery came up to fill the gap for patients who are not controlled medically but do not need taclectomy because the gluccom is not very advanced. So that is what we mean by minimally inasog gluccom surgery that is basically a surgery on the tubular meshwork through ab internal root. Now there's another term which you need to know that is coming up that is called combination MIGs that means you combine two MIGS procedures. So it can be like dilation of the canal along with stenting or you can do surgery on the tacular meshwork combined with the endoscopic cyclophotoccoation. So you do combination of two MIGs dilating and stenting is the most physiological MIGs and the other kind of combinations is you have a combination of medical as well as surgical therapy. So you have the iDOS TR that is eye stent which has a s sustained release traverton.

[00:06:39]So in addition to your surgical ab internal stenting you are releasing the medical therapy and then you have very interesting technology called spy glass. So this is a well and in the optic haptic junction you have batopro sustain implants. So that is another advancement that is going to come up and the advantage of this is that of course you have the surgical efficacy but with sustained release of medications you are not worried about patient compliance and there is a sustained release of drug which may be active for 2 three years so patient doesn't need to take eye drops and it is good for the ocular surface so migs minimally basic lios has five minimum qualities. Four are very good, minimally invasive, minimum surgical time, minimal complications and minimal post-operative visit. So that is why it's very easy to do and very short follow-up is required in terms of medication.

[00:07:44]The negative part of MIGS is that it's also called as MEGS. MEG means minimally effective gluccom surgery. So it is also minimally effective. So that is the negative part and you must understand that why it is minimally effective what is the principle that why the surgery is not able to lower IOP as good as taclectomy.

[00:08:09]So in the initial part of the lecture I just want to make it clear that MIGS is not a good option for long-term control of IOP in any patient who has got moderate to advanced gluccom. So traclectomy remains the gold standard and second thing is all MIGS procedure have a short lifetime. They may survive for 2 3 5 years after that they will fail and then for subsequent IOP management you will require a tbeclectomy with mitoin because gluccom is a lifelong disease.

[00:08:44]So why is the reason that MIGS is not effective?

[00:08:49]There are three reasons. The first one is related to the outflow resistance beyond the tbacular meshwork. The second one is related to the fibrosis occurring in the tbacular meshwork. And the third one is related to the anatomy of the aquas outflow pathway. So I'll just explain all the three reasons.

[00:09:07]So this is very interesting study done on the outflow resistance in inate human eyes.

[00:09:15]So they took off the entire tacular meshwork. So if you took out 360° of the tbacular meshwork, how much was the resistance to aquas outflow eliminated?

[00:09:28]So it was 49%. That means if you take away the entire tbacular meshwork, 50% of the resistance to aquas outflow still remains in the eye. And that is because although there is a resistance in the tbacular meshwork a majority of the resistance is also there in the outflow pathways in the sclera that is beyond the canal of shleam. So if you just operate on the tbacular meshwork like we do in migs you are not going to eliminate the 50% of the resistance. So the IOP lowering efficacy of tbacular MIGs is very limited due to the unique physiology of the eye and the outflow resistant beyond the canal of shlam.

[00:10:14]That is the first principle to remember.

[00:10:19]Second very important principle all of us do taclectomy.

[00:10:24]Now I supposing I do very nice taclectomy after 3 months 6 months it is going to fail. Why it is going to fail due to fibrosis and for that we all use mitocin C. Now in MIGS when you're operating on the tbacular meshwork there is no anti- fibrotic agent that you use and that is the paradox of any gluccom surgery. So you are trying to cut or put stent in the tbacular meshwork. So you are very happily to see that you are cutting the TM and the canal is getting exposed.

[00:11:02]But as soon as you injure the tacular meshwork there is a immediate tracular wound healing and that is proportionate to the amount of bleeding because like blood is like a fibbrinous tissue. So the moment you leave an open wound in the eye, the human body is going to heal that and that is going to fibros and there is no drug to prevent tacular fibrosis as of today.

[00:11:28]So in the natural physiology there is going to be your incisions in the tracular meshwork are going to heal and there is going to be a rebound increase in intraocular pressure with MIGS failure and this is especially important in early part of disease where tbacular meshwork is still functional. So once you injure it, it is going to heal and you may get a IOP which is much more than what was there previously in the disease. And those who are interested can read this editorial tacular wound healing the nemesis of tbacular MIGs. So this nobody's talking about this. This is very important part of why MGS is not successful in the long term.

[00:12:10]So this was one of the studies.

[00:12:12]You can see the title turnback elevation of the intraocular pressure. So IOP is very well controlled after you have done your surgery with a KDP or with a micro hook. But you can see what happens over time. The success graphs keep on following.

[00:12:31]So they keep on decreasing over time and after 2 years there may be a rebound increase in IOP. So this is directly related to the fibrosis occurring in the canal. So if you follow up this patient over time there is a zippering effect.

[00:12:45]So you have opened the canal but gradually it closes and your IOP keeps on rising and the success keeps on following. So lot of studies are reporting one year two year results very good you will get but after 2 3 years you will get fibrosis and rebound increase in intraocular pressure and this occurs due to several reasons. So primarily there is a fibrosis of the canal and this is triggered by the injury to the outer wall. So these are very delicate tissue when you cut with a KDB or a hook or a 26K needle. You see in the video that you are cutting the TM but you are also injuring the outer wall of the canal. The moment you injure the outer wall of the canal or the scleral tissue it is rebound to have a effect on the wound healing. So there is a massive wound healing and your incisions are going to close to aquas outflow. In addition, you may have fusion of the remnant tacular leaflets. You have massive release of pigment that will block the outflow channels over time.

[00:13:49]There may be a membrane covering the canal and you are also damaging the outflow channel. So the tular mesh meshwork has got inlet and outlet valves. So those may be damaged by surgeries. So that is why over time your MIGs is going to fail.

[00:14:07]The third important reason is that we have been doing studies on aquas angography.

[00:14:12]So how does the aquas actually flow out of the eye and if you see this aquas angography pictures there are some areas where there is heavy concentration of aquis outflow pathways and some areas where there is hardly any aquas outflow pathway. So this is like a typical gluccom case. You can see in these two areas there is a con concentration of aquas outflow pathways. There is no pathway here, no pathway here. So supposing you put a ice tent in the area where there is no aquas drainage pathway though although you can put it correctly but if you operate on this area there is no outflow channel in this area. So it is not going to drain. So there's a peculiar anatomy. It is not that you have 360° flow of aquas. It is concentrated on certain areas. If you hit that area, you'll be successful. If you don't hit that area, you won't be successful. And this technique is not readily available because it's a very expensive OCT machine to do aquasography. So that is the reason why many of the stances may not actually be functioning although they're anatomically well placed because they're not in proximity to a collector channel.

[00:15:24]So these are three principle why MIGS is not very successful in lowering intraocular pressure over the long term.

[00:15:34]Now you all know in all talks of glaucoma there is issue of target IOP.

[00:15:41]So for any patient of gluccom whatever stage IOP always has to be below 18 and in a simplified nomogram we say early gluccom moderate gluccom advanced gluccom IOP should be less than 18 less than 15 less than 12. So these are the cut offs any gluccom patient at least whatever therapy you give who has got a visual field defect or should be less than 18.

[00:16:05]Just keep this figure in mind as my talk progresses that whatever is your intervention IOP should go below 18 for it to be successful for the gluccom patient and very good if if it goes 15 or 12.

[00:16:20]Now the first principle that everybody needs to know before doing MIGS is gonoscopy and that is something which is not normally done even in the OPD but you can get away in the OPD but in the operating table without a gonoscope it's not possible. So whoever is listening to the talk you please buy one interoperative gonoscope and every catact case you tilt the microscope and the head of the patient and just see what is happening in the canal. So this this patient is of course primary gentric lcom there is a anterior insertion of the iris.

[00:16:59]It's the prominent iris processes and we view this angle and then you make a incision just anterior to the eye that is called gonotomy. And now you can also do the gad procedure. So first principle if you want to do MIGS in any routine case in the OT you start doing gonoscopy and view the angle because that is very important and I'll come to it why it is important.

[00:17:26]Now one very interesting thing that uh I was doing one case in the OT and then so this was a gad surgery planned for P.

[00:17:40]So I am very nicely operating under the gonoscope I have created the incision in the tbacular meshwork and then my colleague in the side table I there was a break and the colleague took the gonoscope so I was left without gonoscope so now you can see very carefully now I'm going to operate gat without the gonoscope so this is called water gonoscopy you just tilt and there is a fluid here so with that fluid you can see the angle So here we are doing surgery without any gonoscope. This is called water gonoscopy. You can try it. Don't do surgery but just try to see the angle.

[00:18:19]You tilt the patient, put some BSS or saline and you will be able to see the angle structure with and your assistant has to keep on putting the saline and when you tilt there is automatically a crater created and the saline stays there. You can also put some visco elastic. So here you can see we could do the gat procedure that was a compulsion but I was very happy that without gonoscope I could do the procedure. So just see again this is without a goniocope you can see the angle and you can see the suture going into the canal of shle and it'll come back from the other side. So this is view of the angle without the need for gonoscope. So tomorrow in the you can all try this and you can see how the angle looks like.

[00:19:06]Now it's very important. You can see now the suture has come and I'll pull the suture and the gad will be completed.

[00:19:13]Okay. So you don't need gonoscope. Over time if you can do this very good but at least you start even if you don't have gonoscope start viewing the angle with this technique of water gonoscopy.

[00:19:27]Now so you have understood what is MIGS why it is not very successful due to physological reasons.

[00:19:36]The most important thing is to view the angle and learn to see the structures of the angle and identify the canal of slim. Now the next section is what are different types of MIGs and now there are so many techniques. So they are broadly classified into two categories. One is like tralectomy you have ab external filtration and the most famous implant is now preser flow. So all these innovations which are successful have been taken over by big pharma or surgical companies and then they are being marketed. So preser flow is now very popular in Europe. So it is number of centers it has replaced a blectomy though it is wrong I'll explain but it is the most important implant for subcontinental filtration and the actual MIGS is the ab internal MIGS so there are four categories one is you enhance tbacular outflow so you cut the TM or you disrupt the TM it can be takome GAD bank KDB or you put stents like the eye stent or the hydro The second technique is to enhance supraoroidal flow. So by creating a cyclloialysis cleft. So this can be done by initially what was cypass and now it is miniject. These are supraoidal implants to enhance supraoroidal flow.

[00:21:02]The third category is ab internation.

[00:21:07]So this is the zen implant and some minimally invasive microspherostomy.

[00:21:13]So here the implants are put from the antior chamber and out through the slea into the subcontinent table space.

[00:21:20]So this is the zen implant. Now it has lost popularity because of preserve flow and the results were not very good. It is still not come to India. There was talk five years since 5 years to bring this to India. And finally you have also a category that is not actually MIGS but it is still classified under MIGS that is to decrease the inflow. This is endoscopic cyclophotocoagulation. This has got specific uses as I explain later. So these are the different types of MIGs enhancing tracular outflow enhancing supraoral flow subcontration like trap ab internal or ab external and finally the endoscopic cyclopotogulation.

[00:22:01]So this pressure flow implant I'm just showing the concept why it is supposed to replacing tictoate. There is a this 8.5 mm tube with a 70 micron lumen.

[00:22:14]So this is called the pressure flow and with a zen it's a porine collision. So these are small tubular implants.

[00:22:23]So you just make incision put it in the AC no need for aridctomy and then slowly the implant will drain procedurally. So the basic principle is that short procedure no arctomy and there is a posterior flow. So you want to make a procedure ble. So the concept is very good and it is picking up. This has become very popular. Again I'm telling in Europe but the problem is that as compared to tblectomy it has much less success rate.

[00:22:56]So it is not comparable at present tlectomy. All studies have shown the IOP lowering efficacy is less and because of that it has not got the clearance from the FDA. So in USA this preser flow is not available and again I'm telling that you have a small lumen and the problem of fibrosis is there. So it is going to fail over time.

[00:23:21]So this is still not come to India and the Zen is the ab internal. Now the again the problem is that you are injecting mitocin over a small area where the tube will come out and when you inject localized mitoin that is like a time bomb. So you can get all the complications of mitoin including pleitis and the main problem with zen implant was again there was very high chance of fibrosis and bleb needling. So very high chance of failure. So both the zen and preserve flow have failed against tacoclectomy which has far exceeded the ioping efficacy of both these procedures.

[00:24:03]Now coming to what is the most popular technique among all anterior segment surgeons and now tbacular mis is more being done by the catact surgeon as compared to the gloma surgeon. So you have four categories one is tbacular stenting. The second one is tbacular cutting or tbacular disruption. Third is tbacular dilating and the fourth one is a combination that you dilate and then you cut the TM.

[00:24:30]So there is something very exciting coming up in MIGS and it is like having a flight without the need of a pilot and for all those who are not very good surgeons or who have left who have not started MIGS. So this is like doing surgery without the need for surgical expertise.

[00:24:50]So why I have put this air India flight because the name of the procedure is called flight. So this is very exciting advanced in MIGS. This is called phentoc laser image guided high precision ticottomy.

[00:25:07]So this is not done in the you don't require a sterile environment. You are not opening the eye. So this is a proprietary software. You dock this machine and on the screen this very nice OCT guided image with the gonoscopic guidance of TBCA meshwork comes and then you press a switch and it'll make a 500 micron width greater in the TBCA meshwork 200 micron in depth and because it's a phentoc laser the surrounding tissue is not damaged and there is very less tissue response. So you have this cleft which is created patent up to 2 years in the current studies.

[00:25:47]So here you are not using any surgical expertise. So any of your OT staff or anybody can be trained. You just dock this machine on the screen you get the TM and it'll focus and you just press and it will cut off 500 micron. So this is a very exciting advance the flight the phento laser imageguided trapotomy and another advance is you may have heard of the interstellar missions of NASA. This is the Voyager spacecraft which has now crossed the solar system beyond Pluto and it is very fascinating advance from NASA.

[00:26:28]So although it is not a MIGS but this is also a very recent advance which is definitely going to make a dent in opthalmic practice. This is the wiser system. So this is a non-contract SLT laser which was invented by Dr. Belkin from Israel and because it's a very promising technology now it has been taken over by Alcon and renamed as Voyager.

[00:26:52]So when you do SLT you have to make the patient sit on the sit lamp you put in a gonoscope and then you fire one shot here the the laser is being delivered through the sclera so the patient just sits like on the NCT machine and there's a default laser energy and it'll automatically focus and deliver 120 spots over 360° so in 2 to 3 minutes your entire surgery of the SLT is over and there is no need for the surgeon to put in a goniocope and focus. So this is another very advanced uh development in the field of delivery of lasers and it is going to impact because it doesn't require trained manpower. It can be done in rural setting or anywhere where trained opthalmology is not visible and the side effects are not like very less. So this is also something which is now going to come up as a non-invasive way of lowering intraocular pressure.

[00:27:58]Now there are many ways to cut the TM and but there are two new technologies.

[00:28:03]One is the this is from J&J Banlom the alios eximer laser. So this will be coupled with the FCO machine. So you have this probe which goes and put punches 10 micro holes of 10 210 micron diameter. So this again you are bypassing the TM and there is a semi-automated refination system. It is called mint minimary invasive nasal ticlotomy. So again these are going ab internal and making small holes in the TM to bypass the obstruction at the level of the tbacular meshwork and make aquas flow into the canal of schlen. So these are very precision instruments to make small holes in the tbacular meshwork which is a type of tracular cutting procedure.

[00:28:51]Now the second type of procedure is what I call visco dilotation of the canal. So first one is called ABIC AB internal canaloplasty. Here you're putting a limited probe and you are injecting just visco elastic to dilate. So it is trying to restore the physiological function.

[00:29:10]And then you have two new technologies from the ones uh new world medical which are making the MS gluccom val. So this is called the vis 360. So here you are injecting 360 visco elastic in the eye in one go and then you also have the option of cutting the entire 360 TM. So you are injecting visco elastic and then you also have the option to a 360° tilottomy and this is a new system which is called a streamline system. So here you are making punctures 150 micron punctures in the canal and on both sides you are dilating the canal with visco elastic.

[00:29:56]So this is a streamline technology where you're punching holes and injecting visco elastic on either side and this is the 360° canulation with viscolastic insection and followed by traotomy.

[00:30:12]So what we are doing with the suture that is GAD these are specific instrument designed to inject 360° vis elastic and then also cut the canal. So this is the via 360 system and previously you had the omni system. This was 180° on both sides. Now this is catering to entire 360 circumference in one go. And then the streamline system which is making 150 micronotomy and with each gonotomy it is injecting visco elastic to dilate the canal on either side. So this is the second technique visco dilate and then cut the canal.

[00:30:52]Now the third passage that is being used is supraoridal drainage. So here you are trying to insert implant between the sclera and the silary body. So you are making a cycllo diialysis clift to enhance the supraoroidal outflow.

[00:31:09]So there are two current implants. One is the mini jack. This is a silicon spacer. So these are basically your skills spacers to enhance flow. And the new one has come. This is the skittle alograph. So this is called aloof flow uvo. So you have first time use of a biospacer where they're using a sciral graft to create the cycllo diialysis and I just want to highlight that the use of although this has been highlighted as the first use of biopacer in gluccom surgery this was our publication in 2022 where we have tried to augment tevicctomy with a skiir graph from the patient's own sclera and then made it a round structure and used it as a spacer for a cycllo diialysis clft. So this was the use of a slea for a cycllo diialysis cleft in a patient of tblectomy to enhance long-term success of tbaclectomy. So it functions both as draining the apus as well as from the supraoridal space.

[00:32:18]Now this is a very new advance which is a totally different mode of action. This is called celioscle interpositioning device.

[00:32:27]So here the difference is that this is not connected to the anterior chamber.

[00:32:32]So you are making incision in the inferior part of the limbbus and then interpositioning this device which is acrylic device between the sira and the celery body. So this is supposed to enhance the supraoral flow or the supracillary flow. It is not connected to the anterior chamber. So there is no question of cornal endothelial loss or the creation of a bleps. superior area remains free from any surgery and you can use it for future tractomy. So this is a new concept of celio interpositioning device where there is it is not connected to the anterior chamber unlike the previous devices I showed you which are creating a cycllo diialysis and finally we have the endoscopic cyphotoccoation.

[00:33:19]So the disadvantage of this is very expensive machine. I think it is going to cost 70 75 lakhs. So no need to buy the machine and the probe is costing three lakhs. But since we have an RP center, I'm just showing you a small video where we are using it. This is primarily being used for patients of angle closure gluccom. So you have done the fico. You have put in a posterior chamber I then you put in an endoscopic probe and this is illuminated probe which delivers laser energy. So you have to focus on the monitor and then you will see the sary processes. So by directing the laser energy you can uplate the s3 processes one by one. So ideally more than if you achieve 180° or 270 that is very good for IP lowering.

[00:34:09]And this is especially helpful if you have patients of plate iris syndrome or where you don't want to do a combination surgery. There's a small pupil lot of inflammation. So there as a interim procedure you can do fo ECP and this was shared in the gluccom gsi group. This recently published our results of fico ECP as compared to fo alone. So definitely it can lower IOP and in patients who are not very advanced you may get away with a target IOP without the need for a subsequent tblectctomy.

[00:34:41]So now you have seen all the gamut of the MIGS procedure supraidal tractor MIGS decreasing inflow.

[00:34:50]So now the problem is what is known as problem of plenty. So you have so many devices and technologies available. So supposing this patient comes to your OBD tomorrow.

[00:35:05]Patient has got primary open eye gluccom cupping visual field defect and pressure is not controlled.

[00:35:12]So now you have options which are so many you can do stent hydras KDB bank micro get slt or you can just add medicine. So that is the current dilemma.

[00:35:26]And that is why doctors like me they are known as CMP. So Kchan are you hearing the talk Dr. Ken?

[00:35:36]>> Yes sir. Yes sir.

[00:35:37]>> So what is the meaning of CMP so anyway that is just to >> so gloma specialist like me are confused mass of protoplasm. Okay.

[00:35:55]because nobody knows what is to be done.

[00:35:57]Everybody's advocating. Somebody's advocating you do ice, somebody's advocating you do hydras, somebody's advocating you do KDB. So nobody actually knows what is right. So everybody has its own say. That is why the currently the gluccom or the opthalmic fraternity is utterly confused on what MIG is to use for which patient.

[00:36:15]Okay. So I am included in that CMP.

[00:36:20]So let us start with I stand most popular MIGS everybody you can see talking about stand now you have four generation you had stand one then you had stand inject then you had stand W and now you have stand infinite so there are four generations most valuable item as compared to the price and the small smallest implant in the human body so it is supposed to be inserted and bypass the obstruction the tacular mesh network. So very nicely videos look very nice. You are putting this small implant in the human eye and so it has got this drainage holes.

[00:37:02]So you puncture the TM put in the can the stents. So earlier two stand now three stents and it is supposed to lower IOP by bypassing the obstruction in the TM.

[00:37:14]Now just concentrate on this study. This is the compare trial. So they are comparing two eye stances versus hydras implant for lowering intraocular pressure.

[00:37:27]So success criteria was IOP less than 18 at one year followup.

[00:37:33]So you can see with two eyes how many patient got target IOP less than 18. It is only 9% of patients.

[00:37:43]And with hydras implant how many got less than 18? It is 30%.

[00:37:49]So that means even for early loma you are not going to achieve target IOP with either I stand or hydras and I stand it is worse and other thing is this is only one year result and you see these curves are falling down because of fibrosis.

[00:38:07]So what is going to happen 2 three four years you can see that if it at year one only 9% are going below 18 then what is going to be the impact on gluccom patient. So hardly they are going to achieve target IOP.

[00:38:20]So that is why whatever maybe the hype on MIGS tractomy remains gold standard.

[00:38:26]You see less than 18 at one year 9% and you see with mitoing see nearly 10 year followup 75% patients are going to achieve less than 18 as compared to 9% with eye stand. So there is no comparison of tracular MIGs. it is not going to achieve target IOP. Even for early gluccom and if patient has actually gluccom moderate to advanced or progressing early gluccom you have to do tbrectomy there is no MIGS that is going to work over the long term and all these are requiring long-term IP control one year two year there is no benefit and interestingly before came to India so I was uh I was sent this paper for writing a commentary entry and when I read the paper I was quite shocked because one year outcome of stand in the intervention group FCO plus 2 I stand IOP lowering was 8.7%.

[00:39:26]And the group published in control group IOP lowering is 15.2%. So I was quite shocked that what should I write I mean the intervention is worse than the control group.

[00:39:38]I think somebody's audio is on and I can see some background noise. You can check you can put your audio of them some siren I'm hearing. So anyway so I I knew this very senior author. So I called him and I said I have to give a commentary on this article and it is very atrocious outcome what you're reporting. So what should I write? So he was very gracious. He said listen I have stopped using I stand long time back. It is not useful. You can write the truth.

[00:40:07]So anyway I wrote wrote that what you are trying to report that FO with I stand is worse than just FCO alone. So it is causing very less IOP lowering 8.7% even combined with FCO.

[00:40:21]So then that is why I I never start I didn't start using the stand at all. I have not used in my practice ever the stand. The other problem is you are very happy to put it in the TM but you are not sure where actually it is. So many of the stands are buried within the tobaccular meshwork. They are not draining. So you can read this article analyzing the shortcomings of tbacular micro bypass tent and you can see what are the problems that nobody tells you when you use the ice tent.

[00:40:53]And then we tried to do this. Now we have put the ice tent and we are doing aquacography.

[00:40:57]So two stands very nicely placed but only one stent is draining. There is no drainage occurring from the second stent. Okay. So this is one stand. This is second stand. So in one stand there is drainage. In the second stand there is no drainage because there is no collector channel. So this is very important. So half the if two stands you have put one is not working. That means it is not going to have any effect on the IO lowering. So that is a inherent problem with the eye stand. It may not be close to a collector channel and it will not be functionally patent anatomically. It looks very nice.

[00:41:36]Now this new implant has come to India.

[00:41:38]The hydras intra canalicular stent. So it is going to dilate the canal over 3:00 hour. So it looks very impressive.

[00:41:46]It is very easy to put you puncture the TM and insert and then you can put your video on Facebook and you are feeling very happy.

[00:41:56]Very nice surgery you have done. So this implant is in the TM now. Okay. So very good. You have done very good surgery.

[00:42:06]But now spend one minute on this slide.

[00:42:08]So this is very nicely studied than done the horizontal.

[00:42:12]So this is comparing fico hydrris versus fico alone and they have reported five year results of what is the IOP lowering efficacy of the hydras implant as compared to fo alone. So you can see the difference in IOP between fico alone fo plus hydras. How much is the difference?

[00:42:37]04 mm difference in the IOP.

[00:42:41]04 difference in the medication. So how much was the additional percentage reduction due to hydras?

[00:42:50]2.3% additional IOP lowering as compared to FO alone. So just keep this figure in mind that you are spend spending lakhs of rupees and at 5 years you are getting 4 mm IOP difference as compared to Fico which is 2.3%.

[00:43:09]Okay.

[00:43:10]So why would you use it? You have to understand. And although there are reports of better visual field, better DAL IOP less progression but you concentrate on what is the IOP reduction. It is hardly anything. This is the like standard deviation of your measurement only.

[00:43:28]Now if you see what we have been taught in medical therapy, what is nonresponder in medical therapy? If a drug is causing less than 10% IO reduction from baseline, you will reject the drug. You will not use the drug. You will say this patient is nonresponder. Don't use the drug 10% less than 10%. So both ice and hydras you see the actual IOP lowering it is very less. So if it was medical therapy you would say don't ever use it.

[00:44:01]Now the thing is that if if the eye stand and hydras are so ineffective why everybody is using it why is so popular everywhere you go you say hydra stand hydra ice tent every conference hydra ice tent. So why is that?

[00:44:17]So the the issue is that currently MIGS is $1.8 billion market and the forecast is it is going to go to 4.2 billion.

[00:44:29]So now all your conferences are being going to be sponsored by these big multinational companies. So neither any society nor any conference you are going to have anything adverts or being mentioned about these devices. So everybody will say very they are all very good but you have to read the literature and see for yourself well how good they are. Okay.

[00:44:53]So MIGS they have four five minimal qualities and one quality is maximum income. So that is why they are so popular. It is not due to IOP lowering efficacy that you are thinking it is something else.

[00:45:08]And the studies being reported in literature some of them are reporting very good results. So one doctor analyzed these RCTs on MIGS and what they found very interesting 90% had industry funding 60% author were shareholders 80% authors reported industry association and in the author 60% were actually employees.

[00:45:35]So there is heavy bias in the publication of these devices. So you have to be very careful when you read literature and it better to ask colleagues who are not industry speakers how actually the device work.

[00:45:50]So when both these this was released I talked to a lot of my colleagues in USA and in Europe. So all of them said you please keep on doing your bang and get there much better. But in conference they will never speak or in webinar they will not speak. It is no good because heavy income is being generated by these devices and neither our societies will take a call on the actual truth because the society and the conference is being funded by these companies.

[00:46:24]So take home message is that how effective is texter MIG. So this is the American Academy report. I stand hydra KDP the reduction in IOP is in the category of your nonresponder. They will reduce IOP by 4 to 9%.

[00:46:41]That is the take-home message at 2 years from the American Academy and you can see at 5 years what happened IP reduction was 2.2%.

[00:46:52]And why MIGS is so successful? Because FDA gave approval. It has to be used along with catact surgery. Now the catact surgery alone reduces IOP by 20 to 28% at least up to 2 years. So that is why this is being added on to MIGS and you are getting that MIGS is causing 30% IP reduction 20% as good as trap.

[00:47:15]But that is not at all the picture. If you see American Academy report tacular MIGs reducing IOP 3.8 to 8.9% only rest is being caused by the catact surgery and how much medication reduction by MIGS only. 04 and then also they're reporting that there is a bias of the industry even with such small IOP. So keep that that in mind. So now if you take this American Academy report and MIG is very poor, very unsuccessful and you're not going to get target IOP.

[00:47:50]So there are two option either you modify the device or you modify the target. So now they said that 1815 is not a good target. So with MIGS it should be 21 mm.

[00:48:03]So this target is actually not for gluccom. I told you 1815 for gluccom.

[00:48:07]But they have moved the target above so that you get better quality in the papers for MIGS success.

[00:48:15]So for India like in RP center so we have been using lot of bank. So 26k needle under the gonoscope you peel the TM.

[00:48:27]Okay. So 100% it will give you as good a result as the or better than hydras or I stand and this is hardly any cost to the patient. And we modified this technique to viscope bank. So actually if you see the dimensions of tbula meshwork 26 gauge needle is too wide it will damage adjacent tissue. So we use 30 gauge needle that approximates the diameter of the tbacular meshwork. So first we make a nick. We inject visco elastic to dilate the canal and then cut the canal on both side. So this is called visco bang. So with simple devices you can innovate. You make a incision you inject visco elastic and then you cut the canal. You can cut either side or both sides. So you will see now you can see this air bubble and the visco elastic going inside and then I'm going to inside. So this is very simple technique visco bank and this is our IGO publication. So again this is giving up less than 15 with medication but this is combined with catact surgery. So that keep in mind so it is giving as good or better than all your eye stand or hydra the IOP outcome.

[00:49:39]Now last part of the talk is what is best for our country and best in IOP lowering efficacy that is the GAD procedure. If you have any disease of gluccom where the tbacular meshwork is faulty suda exfoliation pigment dispersion serious gluccom you have high IOP and mild to moary disease you can go ahead and do the gad procedure. So one procedure you must learn it has got definitely better outcome than the bang procedure. So any patient who has got moderate to advanced luccomoma do get and procedure just short video you have to canulate with five proline make a incision on top of the pigmented TM and then just insert the proline suture it will come from the other side and then you do 360° tblotomy and in patients who are not advanced you can just do 180° you don't need to do 360° degree. So this has got the highest IP lowering efficacy as compared to any other MIGS. You have to be careful in patients of advanced gluccom. You may get nonresponders because the outflow channels are blocked and even though you are removing the TM you can still get a steroid respond. If you use post-operative steroids in these patient you can get very high IOP. So be careful of using steroids.

[00:51:06]GAT will give you IOP in the low in the high teens. So if patient requires low target IOP still you have to do TECrectomy. It will not suffice for advanced lcom but steroid induced loma pigment gloma anything with a TM has a deposition it works very well. So this is the five-year outcome of the GAD published and you can see 80% success IOP less than 18 and 15 at IOP less than 15 53% success. This is with medication. So you can achieve a low target IOP over long-term which is unlike the procedures of ice and hydrris. The only major issue is you have when you canulate you must see the passage of the suture for at least two three clock hours. Sometime what's happens you is not clear you the suture keeps on going it is cutting through the iris and going under the iris and it will keep on going. So you measure the suture the circumference and then gradually inject so that it is not going in a in a wrong place.

[00:52:12]And very important thing to remember never dilate. So many of these procedures are being done with cat.

[00:52:19]Catact surgery we delayed the patient posttop or give tropical m. So when you're doing gad surgery or any MIGS don't delay it posttop because now you see this is we have done the gat and you can see this cleft.

[00:52:32]So in these patient if you dilate you will get this sinia formation very fast because you have a open wound of the TM.

[00:52:39]So in these patient you must give postoperative pyocarpine and here you can see inally one of the patient was dilated instead of pyocarpine and the iris has gone in the clif. So we had to go inside and you can see I'm removing the fibbrinous tissue and disengaging the iris from the clft. So this happens if you dilate. So after that you have to restrict the patient activity for two weeks head and elevation. Again I'm emphasizing use pyocopine for at least four to 6 weeks and restrict patient from gym activity or valva maneuver. So currently I think it is the most preferred MIGs hemigat or GAT you have to check for anticoulation always operate with the head end so that there is less chance of bleeding and use a high viscosity visco elastic and post-operatively patient should not have any valva coughing or constipation and don't dilate use pyocarpine so which MIGS is best this is a meta analysis of the efficacy of MIGS FO alone followed by FO Iceland followed by FO KDB. So KDB micro hook bank better than Icand hydras and the best one is fo gat. The only negative thing about fico gat is that it has got the highest hyphimma rate. So you have to warn the patient that there may be high feema and decrease in best corrective visual acquity.

[00:54:07]So to summarize if you have a patient with just high IOP no glaucoma who is very rich you can do whatever you want ice and hydras I am not doing for early gluccom you do not need to remove the entire TM you can use bang micro hook KDB or hemicat once patients reaches moderate gluccom or any high pressure gluccom where the TM is at fault like suda exfoliation steroids or even with field trap you attempt a 360° gap and this is also now the primary procedure for primary conental gluccom and jagg but once patient reaches advanced gluccom you should only try to do tbetine with mitoc you will achieve long-term IOP control what about angle closure gluccom here the efficacy of MIGS is very less as compared to PUAG and you would need to learn one extra procedure that is called gonioysis so you You have to lize the sneakia from to expose the TM and then you can do any MIGS procedure. I also told you about the endoscopic cycle especially for plateau iris or chronic ACG cases you can do. So this is a difference for ACG you need to do gonioysis and this is again aquas angography angle closure no flow and once we did the gonosullesis and bang you can see the outflow of aquas so even for angle closure migs can work if you do it after gonosulysis especially for early glaucoma. So in my opinion for early gluccom you can do bang or any instrument for cutting the TM to 90 120° but if you want to learn just one MIGS for all forms of glaucoma that should be g with fibop proline that is the most cost effective procedure much better in terms of IOP lowering efficacy as compared to any other expensive MIGs.

[00:56:08]So which MIGS is best? So there was very nice editorial that said beauty lies in the eye of the beholder but the problem is that the beholder's eye is colored by this money. So there is a disparity between the quality of evidence and actually how people are using MIGs right left and center.

[00:56:30]And of course this is very nice statement given by the father of our nation that the only tyrant I accept in this world is the still voice within me.

[00:56:41]So with so much options available for surgery and for making money you have to see who benefits is the company benefiting society benefiting you are benefiting or actually patient is benefiting or no. So this actually depends only on your conscience. What is your conscience?

[00:56:57]So you have to learn that it is all about ethics in MIGS and I leave you with the definition of ethics. It is knowing the difference between what you have a right to do and what is right to do. Thank you very much Jind.

[00:57:14]That was a master class and it was a very honest very critical lecture I have ever heard and uh so so many such clear views and so let me go ahead with the questions which people have uh can you ask the first question we have that now in our list >> yes ma'am actually sir has covered many >> yes but Let's ask you know.

[00:57:44]>> Yeah. Yeah.

[00:57:45]>> First question.

[00:57:46]>> First question is what are the risks of MIGS?

[00:57:50]>> Yeah.

[00:57:50]>> See I'll tell you one major risk. So once uh you are cutting the TM. Okay. So people are not doingcopy before. So I was in the OT and my very good SR was I was seeing her doing the bank quietly.

[00:58:06]So very very confidently she inserted the needle and went straight to the celery body. So she thought the silly body is a TM. So I was totally shocked that what is going on. So I told her so I thought she's because I have been doingcopy since year. So I very I know what is the TM but I don't know how the trainy sees the TM. So on the table they are hitting the wrong structure. Now if you poke the 26 needle into a wrong structure you can cause aridialysis. You can cause cyclloialysis, decimate membrane tear and intense bleeding.

[00:58:42]Okay. So first thing is you have to learn to see TM and that is why I shift it to GAD because GAD there is a mild suture. You cannot hit anything silly body with the suture. Okay. So that is why it is a safety margin. It will only progress it is it is in the canal.

[00:58:59]Whereas your needle is very sharp, your KDB is very sharp. Your it can go through any structure you want. So that is one thing and major problem is bleeding.

[00:59:09]If you're not careful many time in the OT you start and you write patient is not headend elevated and you leave the patient with low IOP.

[00:59:17]So there is there can be massive bleeding. So that is a problem you have to tell the patient you may have to go to OT again and warn the patient to have had an elevated in the home also that is the major problem with MIGS.

[00:59:31]>> So um then so those are the two. So one is learn your gonoscopy well before you even attempt it >> and the second is yes high fee. Uh so um uh Dr. Manda do you stop any uh um any blood thinners the patient is on before you do MIGS?

[00:59:51]>> Yes I do. And uh there are two class of blood thinners. Uh there is the ecosperin and the second is the clidog.

[00:59:59]If the patient is on ecosin uh generally eight days but clidtogrid is a difficult uh drug because even if you stop the drug there is no uh guarantee or the chances of intraop uh operative hyumi is still there. So I'll be a little wary of operating on patients who are on clidogra especially long-term clidogra.

[01:00:22]And now there is one lesson which I learned recently is a patient said he's not on blood thinner. Unfortunately patient was taking a statin which also has blood thinners and this the patient doesn't know. So please uh confirm see the prescription of the physician and uh check the contents of the tablet to see whether the the drug or the combination has a antiplatilate agent. But uh I just want to ask one question to sir uh in case you have such a situation how do you deal with it?

[01:00:57]>> No see the thing is that firstly when you you have done the surgery you will start getting bleeding. So don't leave the active bead on the table. Either you use AC container or like the you have seen DACA DMAC they put an air bubble and wait. So you put an air bubble and wait. There should be no active bleed on the table and keep the head and elevated and give the patients if you are scared of the IOP give some diam to the patient. Air bubble should be there and second thing is you have to counel the patient. It is not like you can it is like the RD silicon oil surgery. No, they have to be propped up. No activity, no head down, no heavy weight for 2 weeks otherwise definitely they can get rebuleed.

[01:01:45]So you have to warn the patient but it is not a major thing. We have had I think u I have to go to the OT for one or two cases to evacuate the high feema but it is not a very major deal.

[01:02:00]But you also do stop blood thinners.

[01:02:03]>> Yeah. Yeah. It is mandatory to stop. We have to check with cardiology and also monitor INR.

[01:02:09]>> True.

[01:02:10]>> So I want one question I have.

[01:02:12]>> Yes ma'am.

[01:02:12]>> Uh so micro hyphimma then later on also patients are seen like once they start anticoagulants they again can get micro in between spikes of IOP also are seen in them. What to do about that?

[01:02:26]>> So actually that that is what Dr. Mandar was saying anti-coagulate is a issue and especially you have to be careful that uh if IOP is very low so think you are done get and you are also giving medical therapy and IOP goes low it can re bleed so microphema is a issue so you have to discuss case by case pros and cons with the patient and the INR and the cardiologist so that risk will remain in any surgery even for tractomy DDD patients anticogulant they can bleed That is one issue. You want to ask the next question?

[01:03:02]>> Yes ma'am. So next question is how long do the benefits last?

[01:03:16]So puja has been doing a lot of gat you know. So puna you how long do you think the effect of gat lasts in your hands whenever you've been?

[01:03:25]>> So currently I'm seeing like till 2 years at least all of them are doing well but at the end of 2 years few of them say like 15 20% of them need one antlock medications that is the current thing but I think I'd like to ask sir like how long he has seen gap functioning and how long it has been effective in his hands. So actually patients who have got high IO and no optic nerve damage it'll function very well and it can function like you saw the study it can function two three five years beyond that I I have no followup so up to five years in literature it is functioning okay and if you want to be very cautious you keep on doing annual gonoscopy you will see how much of the angle is open how much is zippering up >> okay >> so and if the IOP start rising you have to escalate the medical therapy.

[01:04:17]>> Yeah. Right.

[01:04:18]>> So it is a tempon. It will definitely give IP lowering efficacy. IOP will keep on creeping over time as the as the cipher fibrosis occur. But it is the most efficacious of the all the MIGS devices. So it is the one thing you must do.

[01:04:37]>> Okay. Yeah. So it has the high the steepest learning curve but it is the most effective and I think one of the cheapest.

[01:04:46]>> Yes.

[01:04:47]>> 50 proline and of course the video scope and you have a tilted microscope. Yes.

[01:04:52]>> So now um what are the instrumentation for MIG? So VIA if somebody wants to start doing MIGS what is what are the instrumentation that they should have?

[01:05:03]>> So I think first thing do what I showed you. Next tomorrow in the OT you tilt the patient head put water and you will see the angle you will be very happy.

[01:05:12]>> Sir you have doing watercopy after years of experience.

[01:05:20]>> So you just try sometime you get very good view of the angle the routine case not case.

[01:05:25]>> Got it.

[01:05:26]>> Okay. So I tell my resident during cat surgery you put in a gonoscope and you just with the basically you touch the TM so that you know you're touching. So on they start touching the TM then you are can >> in size it. So I give them one small shinsky hook so they can make small incision. So then this we have micro hook 26 gauge 30 gauge. So then KDB so whatever you can start doing after you have touched the right structure >> right identified the ticular >> I think with 30 gauge needle or 26 gauge needle with visco elastic inside. Right.

[01:06:02]So visol elastic is very important because you see once you cut you will have bleed.

[01:06:07]>> H >> so immediately you can if you inject vis elastic your bleed gets tamponut right there.

[01:06:12]>> What do you use sir for the visco elastic >> actually for you helon or a high molecular weight or you use a regular uh visco elastic? What do you use as a visastic? So after getting this bleeding issue so now for get helon 5 or helon GV for all cases correct >> and for the injection inside the TM what should you vis bang it is plain helon.

[01:06:41]Okay sir, one question is about uh when do you do the mix procedure? Is it before starting FICO or after you finish FICO?

[01:06:51]>> Very very good question. So I always try to do for open angle gluccom before starting FO >> before >> before FO that time you have the pristine view and second is that your bleeding gets temporonary during surgery. So now you have done the catact now there is hypotenus eye and I is in place. So at that time when you do there is higher risk of bleeding because pressure is low and if bleeding occurs at that stage it can trickle through zules go into vitrius and third thing is that supposing case is hard or cat is not aminable you may get cornal edema and then your visualization may be poor so in p I always do before but that is personal preference for angle closure no choice you have to do after fico Go puja. When do you do gat? Because many times the concept is the catact is more important. Do it properly and then go in for gat. What do you do puja? Do you >> Yeah, like all I do it after the catact.

[01:08:01]It is more comfortable for me because the AC deepens and some blood is there in the schle canal identification is slightly better. So I always do it after the catact. Actually you should learn it to do before also because now many patients I have clear lenses. So we are doing like for jagg PCG suda exfoliation or pigmenting we don't do catact we just do cat.

[01:08:26]>> All right >> and you be careful that you don't hit the lens you put in you the pup the pup and then do so you learn to do in the fake eye also.

[01:08:37]uh so ma'am one question too sir like are the results of only GAT without removing the catact as good as fo cat no >> because I have done very few of them >> no see results will never be as good because I showed you IOP lowering efficacy of fico is 20%.

[01:08:56]Okay.

[01:08:57]>> But I I recently I'm telling you la last week like one month back only our sister's husband came so steroid use for last 3 months 40 40 pressures both eye clear lenses 66 vision >> so I had to do bilateral after three days one bilateral cat.

[01:09:18]So you have situations where the IOP is high optic now is normal clear lenses.

[01:09:24]So there you don't have the option of removing the lens but it's a early disease you will get very good outcomes in pristine is with outflow channels are not disrupted short-term disease you will get very good outlaw is very good so there it is very successful even without fo are there any strategies strategies that uh you use to prolong the effectiveness of any of these mix procedures like you want to keep the collector channels as patent as possible So uh drugs like rock inhibitors do they have any role uh in the post-operative regime?

[01:10:00]>> That is very very nice question actually that is coming up now that you give royal inhibitors and you then do the MIGS surgery so that it facilitates outflow.

[01:10:14]So in gloma surgery one thing I do which is kenan will know secret for prolonging surgery that is to pray to god before starting the surgery.

[01:10:25]>> Okay >> but it's not in your hands how the body is going to heal.

[01:10:30]>> So which steroid do you use post surgery? Actually when you're doing with catact it is routine catact posttop regimen but no dilating drops you have to give pyocarpine but some of the cases I have done especially for juvenile gluccom or they have had very high steroid response. So then I taper steroid at two weeks and start non-steroidal anti-inflammatory drugs.

[01:10:56]So this is a issue because normally you feel that you have taken out the TM. So why should steroid act but still you get very high IOP that is due to the steroid receptors in the output channels.

[01:11:09]>> Uh just one question um what are the outcomes of KDB versus bank versus GAT.

[01:11:17]So you have said that GAT is better but between KDB and bank uh what would you prefer?

[01:11:24]>> See if you can question which has been asked. Yeah, see the when you use the KDB instrument definitely the cutting is more smoother but the the technique I showed you that you use 30k needle you first put visco elastic why I'm again emphasizing because when you're cutting you are also damaging outer wall so that is going to cause fibrosis so you puncture you inject visco elastic and then you cut so once you get the need then no need for KDP you do with 30 gauge 26 needle you will get the similar result because it is a similar in action and maybe with dalidation you can get better result and also it will temperonaut the bleed right away >> right so that's a very useful tip Dr. and one question to Dr. Cape key when will you just not do an MIG?

[01:12:18]>> What is an absolute contra indication in your practice for MIGS?

[01:12:26]>> If the cona is hazy means you cannot see only the angle structure then we cannot go ahead with this.

[01:12:32]>> Correct. And uh uh I do not do it in very complicated cases where there is PAS like in neovascular glaucoma or something then I do not go for that >> right and also advanced glaucoma probably we will not do not do and that is very important to understand six months back I I got 11th in class 11th Jag patient came for second opinion so already trap was done and trap had failed.

[01:13:03]And next day patient was to was I stand was to be done.

[01:13:08]So God's grace patient landed in my OPD.

[01:13:11]So I was shocked that what is going on that crap has failed now is you are planning for ice tent. So you have to be very careful and ethical that uh in advanced gluccom TM is at fault but the outflow channels are all blocked so it won't work. Secondly, if it works, target IOP will be 18, you require 12, right?

[01:13:34]>> And thirdly, it will fail very fast and then you do trap. So you have done supposing GAT or KDB, now you have open wound, now you do trap after 3 months, you will get very massive reflux bleeding because fibrosis has not occurred. So don't be in a hurry to do trap after MIGs. It can cause very bad bleeding.

[01:13:56]>> All right, that that's a good tip. And you want to ask the next question Ki?

[01:14:00]>> Yes ma'am. Uh another question is what is the post-operative regimen after bank told already pyocarpine is very important.

[01:14:11]>> Yes. Yes.

[01:14:11]>> How many days do you continue the pyocarpine?

[01:14:14]>> Actually I am giving now for six weeks.

[01:14:17]>> Six weeks. Okay.

[01:14:19]But there will be there can be some inflammation.

[01:14:22]100% 100% see the thing is that you have to do the gonioscopy I showed you very happy and then you see posttop even for gluccom the entire iris is very nicely in that cl >> okay >> so inflammation is all that you are giving you are giving steroid but if it goes iris goes inside then surgery the next question is you can ask Where can we learn to do MS?

[01:14:54]>> Yeah, that is a question which so many people have asked.

[01:14:58]>> So you can go to professor Kanan and professor Kamar.

[01:15:03]>> So every MIGS you first do gonoscopy. It is not rocket science. You learn gonoscopy that is mandatory. And I told you start touching a TM with a canula or helon canula or visolastic canula. And then every conference there is a wet lab now on MIGS. And though I will not recommend you do surgery but you go to every vet lab of hydras and ice tent you have very good eyes where you can learn how you can poke the TM thousand times >> so you tell them that I want to learn but don't do in your OT >> so all right use resources wherever available right and vita you teach a lot of postgraduates so do you teach them how to do um MIGS also or first it would postgraduates and fellows also. So how do you teach them? Do you teach them MIGS or you restrict them to tracular tractomy?

[01:15:55]>> No. No 101% you have to make them self-sufficient for life. So I be I have my junior resident who is in second year.

[01:16:04]>> Mhm. Okay.

[01:16:06]>> First go he did get GAT.

[01:16:10]>> Okay. So because they're seeing every day we are doing lot of GAT.

[01:16:15]>> Correct. So, so I have to teach them three things. One is laser PI, one is tractomy and third is GAT. These three things I will teach them before they leave.

[01:16:25]>> That's wonderful. So they'll be complete glaucoma surgeons >> when they go out after they have done >> early gluccomma they can do get advanced gluccom they can do trap and angle closure they can do PI. So at least they will help the country.

[01:16:42]>> That's a wonderful thought Dr. Tanoj that yes it's not only >> I have sir >> yeah yeah yeah of course >> right sir how do we transition from KDB to GAT because GAT in general I mean there is a perception that it's a difficult surgery there can be blockage the future may not go forward so how do we overcome that fear and how do we convert or learn GAT >> see for the postgraduates for the >> see I tell you GAT know there is one very good that if your suture in the right place only then it will move forward.

[01:17:19]>> Yeah, >> with KDB and all you are doing any blockade. So once you have done KDB and all you just put a quarter and little blunting of the suture and just above the pigmented canal you make a incision and just make some posterior movement so you get a gap for the suture to go inside. Yeah.

[01:17:43]>> So in front of your visualization at least one or two clock the suture will go in you will see it is going in the canal otherwise it won't progress.

[01:17:51]>> So actually if you are doing or seeing every day like I never used to I have a very late transition into MIGS. Okay. I used to see Arvin people swati doing gad then I saw dinder grower. So I also used to think exactly like you it is very difficult procedure. Then my junior started doing.

[01:18:13]So it was very insulting for me that how come these people are doing and I am saying it is difficult procedure. It is not difficult. You do it one or two time because the canal is there. No, it will only go in the right place in front of a canal. So it is very easy actually. It is not difficult. I'm telling you junior residents are doing all here.

[01:18:34]Right. So I think first Armen you are >> get used to the tilting of the head and the microscope. Get used to the view like how Dr. Tanoj has said that touch it with the tra every catact patient touch the trabacular meshwork and then probably once you get used to handling it becomes easier. That's what um Dr. Tano has been saying. Uh hello just one or Yeah.

[01:19:07]Hello.

[01:19:11]Hello.

[01:19:12]>> Yes.

[01:19:14]>> Yeah, I can hear you. Although your video has become still >> frozen.

[01:19:21]I think >> we can hear you.

[01:19:24]>> Yeah, we can hear you.

[01:19:26]>> Are you able to hear me?

[01:19:27]>> Yes.

[01:19:28]>> Yes. Yes, ma'am. You're audible.

[01:19:31]>> One more important question. one uh someone has asked is there any role of MIGS in pediatric glaucom?

[01:19:40]So sir I think you have told already 360° gonotomy.

[01:19:44]>> Yeah. So we used to do initially >> when I trained every pediatric we used to do >> I think network >> trapottomy trapottomy mitoin C and then we shifted to ab external we used to have fiber optic we used to do ab internal tramy and even with the micro catheter but once you do start adult gat then in pediatric also you will so that is the best surgery if cornea is clear and abno gat is currently the first surgery to do not do trap MMC and all in a child's eye and there is no question of doing any eye stand or all these child's eye so that is the one thing to be done and it is three typical >> one more question is uh hydra implant versus ice tend pros cons cost and uh long-term efficacy I think that also So I hydras is better in IOP lowering efficacy than I stand inject and wend infinite launch to efficacy nearly equivalent to hydras.

[01:21:02]I told you what is the IOP outcome you please reply what is the fiveyear IOP lowering efficacy of hydras as compared to FO alone.

[01:21:13]I stand was 9% no 4 mm mercury 2.3%.

[01:21:25]>> Yes. Yes.

[01:21:35]I think everything is covered now. Ma'am questions are no more questions are left unanswered. sir has covered everything in his lecture.

[01:21:47]>> Sir, which go lens do you prefer?

[01:21:50]Because now you have the disposable ones as well as the reusable ones.

[01:21:55]>> Disposable ones to actually hydrangeup.

[01:22:03]>> Okay.

[01:22:05]And how how do you maintain those because those lenses are the the surfaces can get spoiled pretty fast.

[01:22:12]>> Actually that is the issue. So actually for RP center we initially got six seven lenses. So you have to handle them with care. That is no doubt about that and they get pigmented also. So that is one instrument you have to handle with care. And now you have uh gonoscopes which attach to the microscope like handsfree. You don't require assistant and there are lot of gonoscope now where you don't need to tilt the microscope.

[01:22:40]>> So there advances occurring but they are very expensive but you are all very doing very well in practice so you can buy.

[01:22:47]>> So I bought one where I don't have to tilt the microscope.

[01:22:51]>> Very good.

[01:22:52]>> It really makes life easier.

[01:22:54]>> Yes. Yes.

[01:22:54]>> Okay.

[01:22:56]>> But now with your hydrogoniocopy it seems nothing is required.

[01:23:01]>> Yeah. you will be very happy because you can do without gonoscope at least definitely gat is difficult but bang and all you can easily do >> okay so we used to remove the pooling of liquid now you'll tell the sister pull liquid there so >> and when you can put little bit disco elastic it won't it will give very good view you just try tomorrow >> sure do that totally definitely we'll try >> uh before we end the session um can we just play the clip from Ajenta Pharma please Mangulan.

[01:23:35]>> I'll do it right now madam.

[01:23:36]>> Oh yes thank you.

[01:23:41]>> So that was the very um >> they can't hear us correct?

[01:23:49]>> Yes ma'am.

[01:23:52]>> That was an amazing uh >> good you are medical sponsor. If you had surgical sponsor you would have tough time.

[01:24:03]It's such an honest uh lecture today.

[01:24:07]Wow.

[01:24:09]>> It was as clear as sunlight. So there was no ambiguity anyway. And I think that is what uh we need >> from leaders like you because otherwise the market forces are so strong.

[01:24:21]>> Now we need to rethink whether to do and what to do, which procedure to do.

[01:24:26]>> I think it was very clear.

[01:24:28]>> Yeah, very clear. KDB I mean bang and g >> that is all.

[01:24:34]Yeah, >> we were confused. Should we be starting or no? Are we missing something? Now we have a clear understanding. We don't have to try it.

[01:24:42]>> All done. Very nice.

[01:24:43]>> Should I go ahead madam?

[01:24:45]>> Uh uh it's over the >> No, no, I have to. Should I play?

[01:24:49]>> Yes, please.

[01:24:50]>> Yes. Yes.

[01:25:24]over.

[01:25:25]So uh before I take everyone's leave, it is my duty to thank everybody and I take great pleasure in it. Dr. Tanush Dada, it was an eye openener and a wonderful lecture as ever. There was no ambiguity, clearcut um clear-cut instructions what is good, what is not, what works, what doesn't.

[01:25:48]So and I thank Dr. Kchen for being an excellent co-odderator.

[01:25:53]Thank you for the opportunity >> and of course our panelists Dr. Kitki, Dr. Puja, Dr. Mandar, Dr. Vidya for bringing so much more to this webinar, of course the Ajenta Pharma for uh for facilitating the whole thing and of course Numerach for having such a seamless meeting. Uh Dr. Anaga I think is not here otherwise she would have joined me in thanking all of you. So till we meet again um we'll take this um lesson and I think MOS is blessed to have somebody like you teaching us. So thank you Dr. Tada.

[01:26:30]>> Thank you sir. Thank you so much.

[01:26:32]>> Good night everybody.

[01:26:33]>> Thank you everybody. Bye. Good night.

[01:26:35]>> Good night all.

[01:26:36]>> Good night everybody.