The evolving role of minimally invasive glaucoma surgery in glaucoma treatment: A shift toward personalized and predictive medicine
Year: 2025
Type: article
Abstract: Glaucoma is a leading cause of irreversible blindness worldwide, affecting an estimated 76 million people globally in 2020, with projections reaching 111.8 million by 2040.[1] Its management has traditionally encompassed a spectrum of interventions, including pharmacologic therapy, laser treatments, and surgical procedures, each tailored to disease severity and patient-specific factors.[2] This highlights the need for continued advancements in its management strategies.[3] Minimally Invasive Glaucoma Surgery (MIGS) has emerged as a transformative option, offering less invasive alternatives to traditional surgeries like trabeculectomy and tube shunts, with growing evidence supporting its role in earlier intervention and safer surgical outcomes.[4] However, the effectiveness of MIGS is influenced by factors beyond intraocular pressure (IOP) reduction, including patient selection, systemic health considerations, and surgeon expertise, all of which contribute to its variability in outcomes.[5] Understanding these variables is crucial for optimizing patient outcomes and advancing toward personalized glaucoma care, integrating precision medicine and patient-specific treatment strategies.[4] ADVANCES IN MIGS PROCEDURES AND THEIR COMPARISON WITH TRABECULECTOMY AND TUBE SHUNTS Unlike traditional surgeries like trabeculectomy and tube shunts that create external drainage pathways, MIGS primarily enhances the eye’s physiological outflow structures, such as the trabecular meshwork and Schlemm’s canal, aiming to lower IOP while minimizing tissue disruption by using less invasive micro-incisions, serving as an intermediate approach between pharmacologic therapy and traditional surgical interventions. With quicker recovery times and fewer complications, MIGS offers a balance between efficacy and safety, demonstrating promising results in patients with mild-to-moderate glaucoma, by yielding moderate yet sustained IOP reduction and favorable safety profiles across multiple randomized clinical trials, making them a favorable alternative to traditional glaucoma surgeries.[4,6,7] While traditional trabeculectomy and tube shunts remain the gold standard surgical management for moderate-to-severe glaucoma, providing robust IOP reduction;[8] These procedures carry a high risk of complications, including hypotony, bleb-related infections, and long-term scarring.[9] MIGS, in contrast, prioritizes patient safety but often requires careful patient selection to ensure sustained efficacy.[4,7] This tradeoff underscores the need for individualized treatment pathways based on disease severity, anatomical considerations, and a comprehensive risk-benefit analysis.[7] A growing trend in glaucoma management is the combination of MIGS with cataract surgery, which has demonstrated enhanced IOP reduction compared with cataract surgery alone, making it an attractive option for phakic patients with mild-to-moderate glaucoma.[6] THE HUMAN FACTOR IN MIGS: SURGEON PROFICIENCY AND CHALLENGES IN PATIENT SELECTION AND LONG-TERM EFFICACY While much of the research on MIGS focuses on device efficacy, one of the most underappreciated aspects of surgical outcomes is the role of the surgeon and the patient. MIGS outcomes are not solely dictated by device choice but also by how well a particular procedure aligns with the patient’s anatomy, lifestyle, and systemic health profile.[10] One of the critical aspects of MIGS success lies in proper patient selection, as trabeculectomy is widely used for advanced glaucoma while MIGS is generally recommended for patients with mild to moderate disease, where factors such as angle anatomy, prior ocular surgeries, and individual response to IOP-lowering procedures influence long-term outcomes and must be carefully evaluated.[4,11] Moreover, some patients may require additional procedures over time, as MIGS does not provide the same degree of IOP lowering as traditional filtering surgeries; while MIGS offers quicker recovery and fewer complications, their long-term efficacy in preventing glaucoma progression remains a topic of ongoing investigation and requires further validation.[6] Another major factor influencing MIGS outcomes is the variability in surgical skill and experience among ophthalmologists as each MIGS device requires a different implantation technique and learning curve, and surgeons proficient in certain MIGS procedures may achieve better results than those with limited experience, emphasizing the role of surgical training and expertise in optimizing patient outcomes.[10] A MIGS procedure performed by an experienced surgeon comfortable with a specific device is more likely to achieve optimal outcomes than one performed by a less experienced operator.[10,12] This is particularly relevant in the case of the XEN Gel Stent (XEN; Allergan, an AbbVie Company, Irvine, CA, USA) and glaucoma drainage devices (GDDs), where studies have highlighted that complication rates are higher among surgeons still in training, such as fellows learning the procedure.[12] Surgeons performing XEN implantation in fellowship-training programs can face a higher rate of complications in the early postoperative period, underscoring the need for structured training and competency benchmarks in MIGS.[12] This variability raises important questions about how surgical training should be standardized for MIGS procedures. As more ophthalmologists adopt MIGS into their surgical practice, establishing structured training and competency benchmarks will be critical in maintaining consistent and high-quality patient care in MIGS.[7,12,13] Future research evaluating MIGS should account for this human factor—not just the device itself but also the level of proficiency in its use, and whether training programs should provide structured MIGS exposure.[7,13] SYSTEMIC HEALTH CONSIDERATIONS IN MIGS AND GLAUCOMA MANAGEMENT Glaucoma is influenced by systemic health factors. Comorbidities such as diabetes, hypertension, autoimmune diseases, and obstructive sleep apnea (OSA) have been implicated in glaucoma progression and response to treatment.[14–16] Patients with vascular dysfunction, for instance, may be more susceptible to IOP fluctuations postglaucoma surgery, necessitating individualized surgical planning.[17] The interplay between systemic health and glaucoma progression suggests that treatment decisions should be guided by broader patient health considerations.[14] Emerging data suggest that neurodegenerative diseases like Parkinson’s and Alzheimer’s may share common pathophysiological pathways with glaucoma.[18] As our understanding of these systemic connections deepens, future treatment algorithms may incorporate neuroprotective strategies alongside traditional IOP-lowering therapies. This shift toward holistic patient management could significantly affect how MIGS and other glaucoma treatments are tailored to individual needs.[19] DISPARITIES IN MIGS UTILIZATION: RACIAL, GEOGRAPHIC, AND SOCIOECONOMIC BARRIERS Despite the advancements MIGS offers in glaucoma treatment, access to these procedures remains uneven due to racial, geographic, and socioeconomic disparities. These inequities can limit the availability of MIGS to certain populations, ultimately affecting glaucoma outcomes and exacerbating health disparities.[20] Studies have shown that African American and Hispanic patients receive MIGS at lower rates than White patients, despite having a higher prevalence of glaucoma and an increased risk of disease progression.[21] Several factors may contribute to this disparity, including differences in referral patterns, socioeconomic status, healthcare provider biases, and access to specialty care. A large-scale IRIS® Registry analysis confirmed that racial minority groups remain less likely to receive MIGS, even after controlling for disease severity, insurance status, and socioeconomic variables.[22] In addition to racial inequities, geographic disparities pose significant challenges for MIGS accessibility. Patients in urban centers with well-equipped ophthalmic surgical facilities have greater access to MIGS, whereas those in rural or underserved areas face significant obstacles, such as a lower concentration of glaucoma subspecialists and the need for long-distance travel to high-volume surgical centers.[23,24] A 2025 study on the geographic distribution of ophthalmic subspecialists found a significant shortage of trained glaucoma surgeons in rural areas. This lack of specialists contributes to delayed surgical interventions and increased reliance on medical therapy.[24] The cost-effectiveness of glaucoma interventions also varies between urban and rural settings, further influencing treatment choices and patient outcomes.[25] Beyond racial and geographic factors, socioeconomic status plays a critical role in determining access to MIGS. Lower-income populations often face barriers such as insurance coverage limitations, high out-of-pocket costs, and reduced access to subspecialists.[20] Even though MIGS can be a cost-effective alternative to long-term glaucoma medication, its higher upfront costs may discourage utilization among socioeconomically disadvantaged groups.[25] Addressing these barriers requires policy-driven interventions, such as expanding insurance coverage and increasing financial support for MIGS procedures. Incentivizing MIGS adoption among at-risk populations could improve access and reduce disparities, advancing equitable glaucoma care.[20,22] In addition, both systemic and community-based solutions, such as training more glaucoma surgeons in underserved areas, developing community-based outreach programs to educate at-risk populations on glaucoma and available treatment options, addressing misinformation and promoting early intervention, and strengthening teleophthalmology initiatives to facilitate earlier glaucoma referrals and remote consultations for patients with limited access to subspecialists. EFFECT OF THE COVID-19 PANDEMIC ON MIGS ACCESS The COVID-19 pandemic significantly disrupted access to glaucoma surgical care, particularly for patients in rural and socioeconomically disadvantaged communities who already faced barriers to specialty care. Elective procedures, including traditional glaucoma surgeries, were drastically reduced as healthcare systems prioritized emergency care and minimized in-person visits to curb viral transmission.[26] In response to these limitations, there was a notable shift toward MIGS procedures, as they generally involve shorter surgical times, fewer postoperative complications, and reduced follow-up requirements compared with trabeculectomy and tube shunt surgeries.[26] Surgical volumes among fellowship-trained glaucoma subspecialists had a significant decline during the pandemic, with a global trend toward adopting less invasive options such as MIGS due to its ability to minimize healthcare visits while still providing effective IOP control.[26,27] The pandemic underscored the vulnerability of surgical glaucoma care in times of healthcare crises and emphasized the need for resilient policies that ensure equitable access to sight-preserving procedures. THE ROLE OF ARTIFICIAL INTELLIGENCE IN PERSONALIZED GLAUCOMA MANAGEMENT Artificial intelligence (AI) is revolutionizing glaucoma care by enabling early disease detection, risk stratification, and personalized treatment planning. AI-driven algorithms have demonstrated remarkable accuracy in analyzing large datasets, including optical coherence tomography (OCT) scans, fundus photographs, and visual field tests, to identify glaucomatous damage and predict disease progression.[28,29] These models offer clinicians real-time decision support, facilitating earlier interventions and improved patient outcomes. AI has also demonstrated significant applications in cataract surgery, a procedure commonly performed alongside MIGS. AI is used to calculate intraocular lens (IOL) power and predict postoperative visual outcomes.[30] Intraoperatively, AI-driven guidance systems can enhance surgical precision, particularly in cataract surgery, potentially leading to better control of IOP and improved visual outcomes.[30,31] AI-driven models are being explored to enhance personalized glaucoma treatment strategies. By integrating predictive analytics with systemic and ocular health data, AI may provide valuable insights into individualized MIGS outcomes.[32] Furthermore, AI-powered virtual surgical simulators are being incorporated into ophthalmology training programs, providing risk-free environments to refine surgical techniques. These tools enhance hands-on learning, potentially improving precision and patient outcomes in MIGS and other ophthalmic procedures.[32] As AI technologies continue to evolve, their integration into glaucoma management—particularly in diagnosis, disease monitoring, and personalized treatment planning—is poised to become a cornerstone of precision medicine. These advancements offer tailored solutions that address the unique needs of each patient, ultimately improving treatment efficacy and patient satisfaction.[29] REDEFINING GLAUCOMA CARE: THE FUTURE OF PERSONALIZED AND PREDICTIVE MEDICINE The future of glaucoma management is shifting from reactive treatment strategies to proactive, personalized care. Advances in genetic testing, imaging, and AI are paving the way for precision medicine in ophthalmology, enabling earlier detection, improved risk stratification, and more individualized treatment approaches.[28,29] Genetic markers associated with glaucoma susceptibility are being explored for integration into clinical decision-making. Certain genetic variants linked to IOP regulation and optic nerve resilience—such as thioredoxin reductase 2 (TXNRD2), ataxin 2 (ATXN2), and forkhead box C1 (FOXC1)—may help stratify patients based on their risk of disease progression.[33] By combining genetic risk profiling with AI-powered predictive analytics, ophthalmologists could refine treatment algorithms and offer truly personalized glaucoma management tailored to an individual’s genetic predisposition and disease trajectory.[28,33] The future of MIGS will not be defined solely by device innovation but also by refining patient selection, enhancing surgeon training, and leveraging emerging technologies to optimize outcomes.[7] An important consideration is whether MIGS, particularly devices like the XEN Gel Stent, could one day replace trabeculectomy in certain settings. In developing regions, where access to highly experienced glaucoma surgeons is limited, MIGS may serve as a safer, more scalable solution compared with trabeculectomy, reducing the burden of postoperative complications and intensive follow-up requirements.[24] However, further studies are needed to evaluate the long-term sustainability of MIGS as a trabeculectomy replacement in such settings.[7] Moreover, patient counseling should play a more prominent role in MIGS decision-making, as it can significantly affect adherence to postoperative care and overall patient satisfaction. Ensuring that patients are well-informed about the variability in surgical outcomes, potential risks, and realistic expectations can enhance their engagement in the treatment process and improve long-term outcomes. Patients must be informed not only about expected outcomes but also about the variability in response due to individual anatomical and systemic factors. A more personalized approach to patient education may improve surgical satisfaction and adherence to postoperative care.[34] Future strategies should focus on expanding teleophthalmology, streamlining postoperative care models, and reinforcing healthcare infrastructure in underserved regions to mitigate disparities in surgical glaucoma management.[35]
Source: Kerala Journal of Ophthalmology
Language: English
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4409623857