Minimally invasive or minimal access surgery is now the standard of care in multiple specialities across the world of surgical therapeutics. Be it stents in cardiology to overcome blockage, or coils in neurosurgery to overcome aneurysms, or laparoscopic abdominal or gynaecological procedures. They are preferred for their safety, reduced hospital stay and rapid recovery—a win-win situation for the patient receiving such treatment. However, open-access surgery still has a role to play—mostly as a fallback in case of any complications, but also when affordability is an issue. Ophthalmology has also benefitted immensely with reduced incision size, as in cataract, from 11 to 8 mm in intra-capsular to extracapsular and now via 2.2 mm clear corneal incisions in minimally invasive cataract surgery. This has resulted in much better outcomes with reduced astigmatism. The world of keratoplasty has also made great strides—from open-sky corneal transplants penetrating keratoplasty (PK) to Descemet stripping or even Descemet membrane endothelial keratoplasty via very small incisions. The positive aspect of all these innovations is that the surgeries have become safer with rapid visual rehabilitation, potential serious complications and longer rehabilitation period being the hallmark of traditional open surgery. Along the same lines, in recent times, minimally invasive glaucoma surgery (MIGS) has brought about a paradigm change in the management of early mild-to-moderate glaucoma. Now, there are safer options available that can be offered to patients in early glaucoma, whenever there is uncontrolled intraocular pressure (IOP) or progressive glaucoma.1,2 Previously, such patients were often required to use additional anti-glaucoma medications (AGMs) on top of their existing treatment regimen. Increasingly, AGM is being recognised as the cause of ocular surface disease (OSD). OSD seems to be a leading factor for poor compliance and/or adherence to medications due to constant teary, watery, and red eyes. The presence of preservatives in AGM may be the most important cause of OSD, but the drug molecule per se, environmental and hormonal factors also contribute. To mitigate this, ocular lubricants are added, further adding to the burden of overall medications. The addition of bottles and the presence of symptomatic eyes interfere with the patient’s quality of life (QoL). Sometimes such patients are switched over to preservative-free (PF) drugs; however, formulations and availability of these are limited and may not be uniform throughout the country. Furthermore, no single use preservative free formulation is currently available in India. The situation may be further compounded by the sporadic development of allergies to the drug molecule itself. All these obstacles lead to questionable compliance and adherence, which remains one of the biggest barriers related to the effectiveness of medical therapy for the control of glaucoma, a blinding disease. Of course, the recurring cost of these medications also plays a major limiting role in the management of glaucoma in a developing economy like ours. MIGS, quite often, is believed to be synonymous with the expensive stenting devices, but includes all devices and procedures that target the natural physiological pathways. This is quite distinct from the traditional surgery, trabeculectomy, that aims to create an artificial sub-conjunctival filtration, producing a bleb, which is the root cause of most serious sight-threatening complications related to the surgery. Even though the full range of MIGS devices and procedures is still not available in India, and despite a continued reluctance to adopt new technology and techniques, there has been a recent push in the take-up of MIGS in India, powered by the younger brigade of new-age surgeons. In a recent poll of 770 members, conducted on the Glaucoma Society of India WhatsApp group, a total of 131 members responded (17%) positively in terms of doing some form of MIGS or other. In a subset of these members, who are part of the MIGS interest group (51 out of 120 members), the rate was approximately 40%, after excluding the members who voted in both groups, or members who are not practising in India. The overwhelming majority (>75%) seemed to be performing goniectomy via Kahook Dual Blade (KDB), Tanito or other hooks and/or bent angle needle goniectomy (BANG). The overall uptake of iStent Inject W was found to be 7% across both groups, 30 members in each group, comprising of 23% and 60%, respectively, responded positively to the use of iStent Inject W. The corresponding figures for suture gonioscopy-assisted transluminal trabeculotomy (GATT) are 5.5% overall, and 26% and 27% in each group, respectively. This is somewhat surprising as members are reluctant to implant devices (iStent inject W), citing expense, yet the uptake of the cost-effective suture GATT is lower, possibly reflecting members’ reluctance to destroy the entire 360° of the trabecular meshwork.3 This also aligns with the fact that segmental goniectomy of approximately a quadrant (90° or 25%) of the trabecular meshwork, as excised/incised with KDB, Tanito, BANG, and so on, is way more popular procedure with the members. Further, the uptake of endocyclophotocoagulation (ECP) has improved, albeit marginally, despite a tremendous bias against cycloablation—overall 1%–2% in the GSI and 10% in the MIGS WhatsApp group. ECP is very much part of MIGS, as included in the American Glaucoma Society MIGS position paper in 2020.4 It is the only procedure that reduces the inflow of aqueous, and in my opinion, it is the very first MIGS as described by Uram in the 1990s.5 ECP has all the pre-requisites of MIGS—small incision, can be combined with cataract surgery, gentle photo ablation under direct view of only one half of the pars plicata (100% of pars plana is untouched—so total only 25% of the CB is treated) leading to minimal trauma of the target tissue, adds only about 5 minutes to cataract surgery and very rapid visual rehabilitation like phaco, without any significant complications. It can be used irrespective of the status of the angle and irrespective of the stage of glaucoma.6,7 There is, therefore, some commonality between two destructive procedures: ECP and goniectomy—both preserve 3/4th or 75% of the tissue targeted. In the same breath, we need to understand the barriers to the uptake of MIGS. Although only 15% of the total membership of the GSI WhatsApp group and 40% of the MIGS interest group responded to the query of non-performance of MIGS, there did not appear to be much dichotomy in the reasons why they were not doing MIGS. Over 50% in both groups voted for lack of appropriate training and/or lack of opportunity. Interestingly, after this poll, the membership of the MIGS interest WhatsApp group swelled threefold. However, we still have miles to go. Publications have started appearing in literature on the Indian experience, but are markedly limited and originating from a few pockets, and certainly do not cover the range of MIGS available.8-25 In the quest to reduce morbidity due to glaucoma, we as a fraternity have a tremendous responsibility of diagnosing it early, such that in the timeline of this blinding disease, when patients undergo cataract surgery, it can be combined with MIGS, eliminating (or reducing) AGM, thereby “resetting” the AGM clock for these individuals. Glaucoma, being a progressive disease, reintroduction of AGM in future may be inevitable, but at least they could enjoy a drug-free interlude, and perhaps may even avoid any bleb-producing glaucoma altogether in their lifetime. This may not be a certainty, but at least it is a possibility. In the light of this, the poll reflects some ground covered in this journey in India, in the past few years, since the first suture GATT in 2018, the first commercial iStent (first generation) in September 2021 and now the Hydrus stent in December 2025. We have many more promises to fulfil, one step at a time, to enhance the QoL of our patients.
Vanita Pathak Ray (Thu,) studied this question.