Sarkisian urges earlier MIGS adoption

Minimally invasive glaucoma surgery — MIGS — is supposed to solve a very old problem. Glaucoma steals vision slowly, and the traditional treatment ladder often waits too long before surgery enters the picture. At ASCRS Glaucoma Day on April 10 in Washington, Steven R. Sarkisian Jr. used the Stephen A. Obstbaum Lecture to argue that the field should stop treating surgery as the last resort and start moving earlier. That is the actual news here — not a new device, but a push to change the timing of care. (eyeworldonsite.org) ### What is MIGS, exactly? MIGS is the catch-all term for less invasive glaucoma procedures that lower intraocular pressure with a lighter safety burden than older filtering surgeries like trabeculectomy or tube shunts. The whole appeal is basic — lower pressure earlier, with less tissue disruption, faster recovery, and a w(eyeworldonsite.org) deal in the first place. (mdpi.com) ### What did Sarkisian actually say? His lecture was titled “Velocity: My MIGS Manifesto,” and the theme was urgency. He framed glaucoma as something surgeons should treat before irreversible field loss piles up, not after. The line that captured the talk was simple: “Act BEFORE they go blind.” He also said the old sequence of maximum drops, then laser, then surgery is no longer the right default. (eyeworldonsite.org) ### Why is “earlier” the whole fight? Because glaucoma damage does not reverse. If a patient keeps losing retinal nerve fibers while everyone waits for medications to fail harder, the eventual surgery can lower pressure but cannot give vision back. Sarkisian’s point is that delay is not neutral — delay is disease progressio(eyeworldonsite.org)(glaucomaphysician.net) ### Why pair MIGS with cataract surgery? This is where the argument gets practical. Cataract surgery already puts the surgeon in the eye, and phacoemulsification by itself can lower pressure some, but that effect often fades. Adding MIGS during the same operation can push pressure lower and reduce medication burden more durably(glaucomaphysician.net)re he called offering phaco without MIGS “indefensible” for some treatable mild-to-moderate cases. (healio.com) ### Is he saying trabeculectomy is obsolete? No — but he is saying it is no longer the center of gravity. In the lecture coverage, he said the “reign of the trabeculectomy has ended,” while also acknowledging that some patients still need filtering surgery. Basically, the claim(healio.com)l surgery is the biggest one. (eyeworldonsite.org) ### Why does this matter beyond one speech? Because ASCRS Glaucoma Day is not a random hallway conversation. It is a major cataract-and-glaucoma meeting, and the 2026 program itself emphasized surgical innovation, interventional therapies, and advanced MIGS techniques. When a prominent surgeon uses that stage to push earlie(eyeworldonsite.org) as “too soon” for surgery. (subspecialityday.ascrs.org) ### What is the catch? The evidence base for MIGS is real but uneven. Different devices work through different outflow pathways, head-to-head comparisons are messy, and long-term durability is still stronger for some procedures than others. So “do MIGS earlier” is not the same as “do the same MIGS on everyone.” Even Sarkisian’s own framing stresses personalization rather than a fixed algorithm. (eyeworldonsite.org) ### So what changed? The field has been drifting this way for years, but Sarkisian used a marquee April 2026 lecture to say the quiet part out loud. Glaucoma, in his framing, is no longer mainly a medication disease with surgery waiting at the end. It is increasingly an interventional disease where the timing of surgery may matter as much as the choice of surgery. (glaucomaphysician.net) The bottom line is straightforward. Sarkisian is pushing MIGS out of the rescue lane and into earlier routine care — especially around cataract surgery. If that view keeps winning, the biggest change will not be a single gadget. It will be that glaucoma surgeons intervene sooner.