Integrating MIGS Without Disrupting Efficiency

In 2011, I attended a lecture on MIGS that left me awestruck. At the time, glaucoma management was a daily challenge. Surgeons often had to make a dramatic leap from multiple topical IOP-lowering medications to trabeculectomy, with few steps in between other than argon laser trabeculoplasty.

That lecture was the first time I envisioned what might be possible: an intervention focused on the natural aqueous outflow pathway, the very site where glaucoma exerts its effect. That moment set the stage for the rest of my career and fueled my passion for interventional glaucoma.

As a new ophthalmologist, I assumed it would be easy to return to the office, adopt a new procedure, bring the team on board, and educate patients. I quickly learned that my passion alone was not enough. Each time I tried to introduce something new without a clear plan, confusion and disruption followed.

Although integrating interventional glaucoma into my practice involved some headaches and hiccups, the process ultimately made our team better. We improved our workflows, asked better questions, and became more deliberate about how we approach change. I became a better communicator and learned to slow down so that we can set our patients and ourselves up for success.

This article shares my experience-based advice on MIGS technology integration and education.

IDENTIFY COMMUNICATORS AND EDUCATORS 

When implementing a new procedure or technology, I find it helpful to identify one or two individuals who can see the big picture, implement change without fear, and bridge communication gaps by asking the right questions. Together, we evaluate the entire patient experience cycle. We are intentional about involving the front office, technicians, coders, surgical counselors, and ambulatory surgery center team. A well-trained, confident team is crucial for seamless MIGS integration.

STANDARDIZE THE PREOPERATIVE WORKUP AND SCHEDULING 

The foundation of efficient MIGS integration is a standardized preoperative pathway. During the initial consultation, all cataract patients with a glaucoma diagnosis or suspicious optic nerve findings are flagged, which triggers the appropriate testing, minimizes delays in diagnosis and decision-making, and saves patients and technicians time.

Our technicians are trained to go beyond documenting a patient’s topical IOP-lowering medications. They also ask patients about their quality of life, drug side effects, and adherence. This conversation begins the patient education process before I enter the room and introduce the possibility of lowering IOP via MIGS.

Educating and empowering our team are essential. We share success stories with them. We let them see how patients’ ocular surface health can improve, how their quality of vision can be enhanced, and how postoperative IOP can be better controlled. The team is a key part of interventional care. When team members are invested, they bring clarity and confidence to patient education from the start.

START SIMPLE AND BUILD CONFIDENCE 

When we began offering MIGS, we focused on straightforward cases: patients with open angles, mild to moderate glaucoma, and no significant angle pathology. We started with a single device to minimize variability and allow the team to refine the process.

We also scheduled MIGS cases together at the end of the day to build repetition. As everyone’s comfort and proficiency grew, we gradually expanded indications and device options. After each case, we talked as a team to identify opportunities for improvement.

Today, procedure-specific bins are selected in advance and labeled with the case and patient’s name. This allows the team to prepare before the patient enters the OR. We no longer schedule MIGS, combined MIGS, or standalone procedures in a rigid order. Instead, we conducted time studies, and our schedule now reflects the actual time required for each type of case.

START WITH COMBINED CATARACT SURGERY AND MIGS 

Every new procedure has a learning curve. Initially, I practiced the setup for all of my cataract patients. Achieving an en face view of the angle is critical for precision and proper setup. Using a gonioscopy prism in the OR is different from performing gonioscopy in the clinic. Becoming comfortable with the setup before the first MIGS case can shorten intraocular time.

Our team also learned that tilting the microscope 30° while the patient is being draped encourages success and helps prevent surgeon-related delays.

COMMUNICATE WITH PATIENTS AND COMANAGING PROVIDERS 

Clear communication is essential for successful MIGS integration. We provide patients with educational handouts and discuss the dual goals of cataract and glaucoma management. We also set realistic expectations for the postoperative course, including the possibility that IOP-lowering medications may still be required.

We send detailed operative notes to comanaging providers that outline the MIGS procedure performed, the postoperative IOP target, and any changes in medication. This information helps to ensure continuity of care and strengthen referral relationships.

CONCLUSION 

MIGS can be integrated into a busy cataract practice without sacrificing efficiency or outcomes. By standardizing processes, investing in team training, and communicating clearly, practices can offer the benefits of MIGS while preserving workflow.

For surgeons considering MIGS adoption, my advice is to start with straightforward cases, involve the team early, and continually refine the process. n