Rethinking minimally invasive glaucoma surgery training in India - Skill, structure and standards

India is entering a defining era in glaucoma surgical education. As ophthalmic innovation accelerates, the demand to train surgeons in minimally invasive glaucoma surgery (MIGS) has become increasingly important. These procedures generally preserve conjunctival tissue, are commonly performed through an ab-interno approach, often combine well with cataract surgery, and allow faster visual recovery with fewer postoperative visits. Their patient-friendly nature makes them especially relevant in contemporary glaucoma care. Published studies have shown average intraocular pressure reductions in the range of 25%–40%, with medication reduction frequently reaching 50% or more in selected cohorts. These advantages make MIGS highly relevant in present-day glaucoma practice.[1] MIGS represents a paradigm shift in glaucoma management, emphasizing safety, precision, and tissue preservation. However, its successful adoption requires a fundamentally different training approach. Unlike conventional glaucoma surgeries, MIGS is highly dependent on angle anatomy visualization, intraoperative judgment, and fine motor skills under gonioscopic guidance – skills that cannot be acquired through volume alone.[2] THE VALUE OF COMPREHENSIVE SURGICAL EXPOSURE Institutions that integrate MIGS training alongside phacoemulsification and posterior segment exposure offer a significant advantage. Such integration allows trainees to understand the interplay between cataract surgery, intraocular pressure control, and retinal status. For instance, planning combined cataract–MIGS procedures in patients with coexisting glaucoma requires not just technical execution but strategic decision-making – selecting the appropriate MIGS procedure, timing the intervention, and anticipating postoperative outcomes. TRAINING THE MODERN MINIMALLY INVASIVE GLAUCOMA SURGERY SURGEON Structured MIGS education should begin with mastery of gonioscopy. Intraoperative angle surgery demands a skill set not traditionally emphasized in most training programs. The learning curve of MIGS remains a recurring theme in published studies. The American Glaucoma Society Position Paper emphasized that MIGS requires advanced surgical gonioscopy, fine bimanual coordination, and adaptation to a new proprioceptive skill set, making formal training during residency and fellowship essential.[3] Surgeons must learn direct gonioscopic visualization, identification of trabecular landmarks, microscope tilt adjustments, patient head positioning, temporal operating posture, and coordinated bimanual control under magnification. For many trainees, this represents a significant departure from standard cataract or filtration surgery ergonomics.[4] Recent Indian evidence from the SKIBI study demonstrated that successful outcomes were achievable across five different MIGS techniques, reinforcing the importance of training surgeons in multiple device-based and nondevice angle procedures rather than relying on a single platform.[5] THE ROLE OF SIMULATION AND WET LAB TRAINING Simulation-based training is particularly crucial for MIGS. High-fidelity simulators, virtual reality platforms, and three-dimensional visualization tools allow repeated practice of angle-based maneuvers in a risk-free environment. Given the steep learning curve associated with intraoperative gonioscopy, simulation should be considered foundational rather than supplementary. Wet labs further enhance tactile familiarity, while video-based analytics enable objective feedback on surgical performance [Figures 1 and 2].[6,7]Figure 1: Mentor-supervised minimally invasive glaucoma surgery in the operating theaterFigure 2: Minimally invasive glaucoma surgery wet-lab training in a simulated settingFROM VOLUME-BASED TRAINING TO COMPETENCY-BASED EDUCATION Yet, access to such training remains inconsistent across India. While some centers provide hands-on MIGS exposure, many trainees encounter it only theoretically. This disparity highlights the urgent need for competency-based frameworks, where progression is determined by demonstrable proficiency in angle anatomy assessment, device handling, and complication management, rather than procedural counts alone. Equally important is structured mentorship. MIGS training requires experienced surgeons who can guide trainees through the nuances of intraoperative decision-making – adjusting approach based on angle configuration, recognizing subtle anatomical cues, and managing complications such as hyphema or device malposition. A culture that encourages open discussion of surgical challenges is essential to accelerate learning and build confidence. Subspecialty integration is another crucial element. For example, they should learn about invasive glaucoma surgery as part of their basic glaucoma training, not just as an extra thing they can learn later. Moreover, they should learn about surgical decision-making, including appropriate timing and procedure selection. THE INDIAN ROADMAP FORWARD India also requires a practical and cost-sensitive MIGS training model. In many centers, low-cost adaptations of established MIGS concepts are already emerging. From an Indian perspective, cost and accessibility remain the major determinants of adoption. Equitable access to MIGS requires proactive health system planning rather than passive adoption. Important strategies include context-appropriate pricing, wider insurance reimbursement, structured surgical training, and the generation of local real-world evidence to guide policy. Inclusion of MIGS within public and private insurance schemes could significantly improve affordability and adoption. Expansion of MIGS beyond tertiary centers may be achievable by training competent general ophthalmologists in selected procedures, thereby increasing glaucoma surgical capacity in underserved areas. However, robust data on outcomes, safety, and cost-effectiveness from low- and middle-income countries are essential, as findings from high-income settings may not be directly generalizable.[8] Contemporary reviews note that while implant-based MIGS may be expensive, low-cost nondevice angle surgeries such as GATT, bent ab-interno needle goniotomy, and trabeculotomy-based procedures may offer more scalable solutions for developing healthcare systems.[9] India has consistently demonstrated adaptability in surgical innovation, and with the right combination of a lot of surgical experience, structured training, and exposure to different areas of eye surgery, the country can set new standards for eye surgery education. Institutions already implementing such integrated models may serve as valuable frameworks for future surgical education. The goal is clear: we want to produce surgeons who can not just do surgeries, but also think critically, adapt to evolving clinical challenges, and lead others. To do this, Indian ophthalmic surgical training already possesses a strong foundation; the need now is for structured refinement. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.