How do you decide to use MIGS versus traditional surgical options like trabeculectomy or tube shunt placement in the management of glaucoma?

Current IOP and your IOP goal are key. Angle MIGS will typically reduce IOP from the low to mid-20s to the mid to upper teens.

I consider Xen a MIBS procedure. I’ve been able to use Xen as my bleb surgery of choice, even in patients who have had multiple prior ocular surgeries, including PPV, tube shunts, trabs, etc.

I agree with the other respondents that this question is so broad that it could take an entire textbook, fellowship, or career to give an adequate answer, and the answer will vary over time as more data become available and with each patient scenario. That said, in general, if a patient with mild or moderate glaucoma and cataract desires cataract surgery and has reasonably controlled glaucoma with a tolerable medical regimen, then MIGS may offer a better risk vs. reward profile. In patients with...

The scope of this question is entirely too broad to give a complete answer without a textbook.

In short, if visually symptomatic of NS. Likely hydrus with phaco for mild to moderate with IOPs under 30. Severe or high IOPs, consider Kahook with phaco. Even phaco alone is an outstanding IOP-lowering procedure.

For a stand-alone, I have a big discussion with the patient. But usually Kahook is okay with 2/3% long-term success for a minimally invasive approach with no FB left in the eye, and can stop...

Traditionally, MIGS were confined to the early to moderate stages of disease. Additionally, the iStent and Hydrus devices were initially approved for mid-moderate POAG in patients undergoing cataract surgery.

However, the MIGS armamentarium continues to expand, and patients who have more advanced disease may benefit from safer MIGS procedures. The iStent Infinite (3 stents) was approved in 2022 for advanced or refractory disease as a stand-alone procedure. Goniotomy and canaloplasty procedures c...