Slightly More than MIGS

Minimally invasive glaucoma surgery (MIGS) is a relatively new therapeutic category that has dramatically expanded since the term was first introduced in 2009, providing surgeons with an amazing set of tools. A look at the investigational pipeline reveals there is much more to look forward to, including a new category of surgical options that can be thought of as MIGS+ or ‘SMMIGS (slightly more than MIGS).’

The MIGS pipeline comprises surgical sustained release systems and procedures targeting the conventional outflow pathway, explained Rachel G Simpson MD.

Surgical sustained release devices under investigation include two devices from Glaukos: iDose TRIO and iDose TREX. iDose TRIO is a next-generation version of iDose TR that is designed to eventually facilitate in-office administration. It is being evaluated in a phase 3b trial and anticipated for possible approval in the US in 2027. iDose TREX has the same external footprint as iDose TR but carries twice the drug load with the promise of doubling the efficacy duration. It was investigated in a completed phase 2a study.

Other sustained release drug delivery systems are being developed by SpyGlass Pharma, including a bimatoprost-IOL system, which is in phase 3 trials, and a drug ring system delivering bimatoprost for at least three years. The ring is designed to be injected, removable, and replaceable, offering lifetime treatment potential. It is in early development.

“The ring is designed to answer the question, ‘What happens when the footplates on the IOL dissolve after three years?’,” Dr Simpson said.

The conventional outflow pipeline includes a device from eyeFlow that combines canal stenting with sustained drug delivery. In early clinical trials, the dual-action stent/drug delivery is designed to minimise tissue trauma during injection and enhance aqueous access to the collector channels while releasing a prostaglandin analogue over a period of 12 months.

There are also three laser-based procedures in development. The laser options all aim to create full thickness channels in the trabecular meshwork, but they do so using different laser types and approaches. This category includes an excimer laser (ELIOS, Bausch + Lomb), which is approved outside the US and used in the operating room with or without cataract surgery; a femtosecond laser from ViaLase used in a standalone procedure termed LIGHT (Laser Image Guided High precision Trabeculotomy) that can be performed in an ambulatory surgery centre; and a pico-green laser (PicoLumen, EyeX Solutions) that also represents a standalone procedure that could be performed in the clinic.

“A nice thing about the pico laser is that it accesses all four quadrants of the eye, giving 360-degree access to the collector channels,” Dr Simpson said.

The ‘SMMIGS’ category has a single entry—a conjunctival sparing ab externo supraciliary implant (InterCil, Ciliatech) that uses the uveoscleral outflow pathway via controlled separation of the ciliary body and sclera. Dr Simpson described results of initial clinical trials as “very, very promising”, reporting they showed 41.6% reduction in IOP, 71% reduction in medication use, and 70% of patients becoming medication free.

Dr Simpson spoke at the 2026 ASCRS meeting in Washington, DC.

Rachel G Simpson MD is Assistant Professor of Ophthalmology and Visual Sciences, Moran Eye Center, University of Utah School of Medicine, Salt Lake City, US. rachel.simpson@hsc.utah.edu