An ever-growing roster of MIGS devices is pushing outcomes in glaucoma patients to previously-unimaginable heights. But progress comes with a price. As devices get smaller and procedures more delicate, the onus is on surgeons to keep up with an increasingly steep learning curve. The new GONIO ready® (OCULUS Optikgeräte GmbH, Wetzlar, Germany) claims to help surgeons beat the MIGS heat with a slew of technical innovations, and MIGS expert Prof. Fritz Hengerer, chief physician at the Bürgerhospital Frankfurt Augenklinik, explained why that just might be the case.
The adage in skill-intensive endeavors has long been to blame the carpenter and not the tools. And in the high-stakes world of ophthalmic surgery, glaucoma procedures — and specifically MIGS, are about as skill-intensive as it gets. Small devices, delicate anatomical structures and maneuvers that demand intense, one-handed fine motor skills are all in the cards for MIGS surgeons. And all this with patients’ sight at stake makes for a daunting task.
Despite the aforementioned carpenter aphorism, OCULUS believes that it has made a tool that can literally lend MIGS practitioners a hand. The GONIO ready® is an intraoperative gonioscopy lens with an innovative pressure-sensitive design that allows surgeons to keep both hands free during MIGS operations. The device is already drawing rave reviews from some of the best in the glaucoma subspecialty, including Prof. Ike Ahmed. And in a recent video review of the GONIO ready®, Prof. Hengerer, a long-time MIGS maestro, added his voice to the chorus.
Flexing its muscles
At the heart of the GONIO ready® is the device’s patented Flex System, which, when combined with an adjustable height mechanism, allows the gonioscopy lens to float securely on top of the eye without being held in place by the surgeon.
In a MIGS operating room, surgeons know that everything is in perpetual motion. From the patient’s head to the gonioscopy lens and the eye itself, the resultant micro-adjustments that must be constantly made by the surgeon are a major reason for the high skill cap of these procedures. And minimizing these is what the GONIO ready® is all about.
Prof. Hengerer acknowledged the massive impact this has had on his own surgeries. “The Flex System is able to respond a little bit to eye movements, and is able to absorb pressure and some of the small movements of the patient’s head during the procedure,” he noted. “[This] provides you, as a surgeon, a stable situation without having to readjust the whole system.”
The power of position
The knock-on effects of this added stability are noteworthy in their own right. In the video review, Prof. Hengerer reflected on how critical this is in the game of inches that is MIGS surgery. “The lens position is a very important part of [MIGS] surgery… When the lens is tilted, you lose your view of the anterior chamber angle and you cannot see where you want to place your device,” he related.
This was another area that the GONIO ready® really made an impression on Prof. Hengerer. “With the GONIO ready®, it’s easy to get the lens into place and maintain its position during surgery,” he explained. And mise en place in the OR is a recipe for success, as the surgeon is then free to focus their attention on more important things.
All hands on deck
One such thing that surgeons equipped with the GONIO ready® can use this extra bandwidth on is what to do with their other hand. The GONIO ready®’s primary calling card is the device’s ability to free up the surgeon’s other hand by autonomously keeping the lens safely in place. And after its introduction, the minds of surgeons around the world are flush with the endless possibilities an extra hand can provide.
Prof. Hengerer shared one way that he makes use of another hand to push patient outcomes beyond. For him, it’s all about one word that appears time and time again. “When I first used it and thought about my left hand, I thought, better to have a side port incision 60-degrees available from the main port,” he shared. “That way I can use a second instrument to stabilize the eye — and the results are better.”
Safety over all
When it comes to any ophthalmic surgery, results are quite literally in the eye of the beholder. Any procedure is done in the name of preserving vision, and MIGS is no exception. Glaucoma surgeons around the world are always on the hunt for novel techniques, procedures, and devices that can give them the edge in their mission to save sight. In Prof. Hengerer’s view, the GONIO ready® and its technical wizardry can provide such an edge.
Under it all, however, there is one concept underpinning the design philosophy of the GONIO ready®. The stability, the extra hand, the enhanced viewing angle — for OCULUS and its international sales manager Sascha Ruecker, these all fall under the umbrella of safety. And in the end, that’s what the GONIO ready® is all about, with the next generation of MIGS offering unprecedented opportunities — and challenges that will define the future of glaucoma surgery. “It’s all about one word,” commented Mr. Ruecker. “Safety… for the patient.”
“[With the GONIO ready®] when I’m entering [the anterior chamber] with my devices, I have a brilliant view of the structures inside without touching the lens or the cornea. Then I can move on further viewing the chamber angle, focusing down with the microscope with this brilliant view of the structures I want to access,” concluded Prof. Hengerer.
Editor’s Note: This article was first published in CAKE magazine Issue 19.