Endpoint‑driven selection for phaco‑MIGS recommended by Ophthalmology Times
- On October 29, 2025, Ophthalmology Times published a glaucoma roundtable where Thomas V. Johnson III, Leonard K. Seibold, and Kateki Vinod pushed more deliberate MIGS selection. - The practical hinge was simple: pick the goal first — lower IOP, reduce drops, or avoid filtering surgery — because most MIGS struggle below 15 mm Hg. - That matters as phaco-MIGS becomes routine, but device choice and postoperative judgment still often lag behind clearer endpoint-based planning.
Cataract surgery plus MIGS has become one of those combinations that can slide into habit. A patient has glaucoma, the cataract is ready, the surgeon adds a minimally invasive glaucoma procedure, and the chart says “phaco + MIGS.” But the Ophthalmology Times roundtable from October 29, 2025 makes a sharper point: that shorthand is not really a plan. The useful shift is to choose the endpoint first, then choose the procedure that best fits it. ### What is the actual argument here? It is not “do more MIGS” and it is not “pick your favorite device.” The argument is that combined cataract-glaucoma surgery should start with a concrete objective — better pressure control, fewer medications, or a less invasive bridge that delays filtering surgery. Once that endpoint is explicit, the operation becomes easier to judge afterward, because success or failure is tied to the stated goal rather than to vague enthusiasm about adding technology. That framing runs through the Ophthalmology Times discussion of how MIGS now fits into everyday glaucoma care. (ophthalmologytimes.com) ### Why does “endpoint first” matter so much? Because MIGS is a category, not a single outcome. Some procedures mainly help reduce drop burden. Some aim for modest IOP reduction with a strong safety profile. Some preserve future conjunctival options by avoiding more invasive filtering surgery now. If a surgeon never names which of those goals matters most for this patient, then almost any postoperative result can be rationalized after the fact. Endpoint-first planning closes that escape hatch. (ophthalmologytimes.com) ### Why is phaco-MIGS the place this shows up? Because cataract surgery is the natural moment to add MIGS. In the 2025 and 2026 Ophthalmology Times pieces, surgeons describe visually significant cataract as the biggest trigger for considering MIGS, especially in mild to moderate glaucoma. The appeal is obvious — one trip to the OR, faster recovery than traditional filtering surgery, and a chance to lower pressure or reduce drops without taking on trabeculectomy-level risk. That convenience is also the trap, because convenience can blur the reason for doing it. (ophthalmologytimes.com) ### What does this change in the OR note? It pushes surgeons to document the intended win in plain language. Not just “phaco + MIGS,” but something closer to: target modest IOP reduction, reduce medication burden, or preserve conjunctiva while delaying trabeculectomy. That sounds small, but it changes follow-up. If the stated aim was fewer drops and the patient is still on three agents, that is a miss even if the eye looks quiet. If the aim was safer early intervention rather than very low pressure, a pressure in the mid-teens may be exactly the point. (ophthalmologytimes.com) This is basically pre-registering the success metric. ### Why not just chase the lowest IOP? Because MIGS usually is not built for that. Johnson says he typically recommends MIGS when the target IOP is not below 15 mm Hg, since most MIGS have difficulty achieving that level of absolute reduction. Tatham makes the same distinction more broadly — MIGS has a better safety profile than traditional surgery, but the pressure-lowering effect is more modest and it is not really a substitute for trabeculectomy. That is the key reality check. (ophthalmologytimes.com) ### So is this anti-MIGS? No — it is pro-honesty. The same roundtable argues MIGS is now an integral part of treatment, and that many cataract patients with glaucoma can benefit from it. The point is that broader adoption needs clearer selection logic, not just more devices. Ophthalmology Times’ January 2026 coverage says the field still needs better guidance on patient selection, even as evidence and guidelines increasingly support MIGS’ role. (ophthalmologytimes.com) ### What is the bottom line? The smart change is simple: decide what success means before the first incision. In phaco-MIGS, that one discipline turns a trendy add-on into a strategy — and makes postoperative judgment a lot more honest. (ophthalmologytimes.com)
