Within MIGS options, two general strategies exist: goniotomy (incisional) and stenting (implant).

Goniotomy means making a small opening or removing a strip in the eye’s trabecular meshwork (the main resistance point for fluid), essentially creating a direct pathway for fluid to exit into the drainage canal. This can be done with instruments like the Kahook Dual Blade or OMNI, and it leaves no permanent device.

Stenting involves placing a tiny tube or scaffold to hold a drainage pathway open – examples include the iStent inject (one or more tiny snorkel-like tubes) or the Hydrus (a micro-scaffold that spans part of the canal).

Each has its merits. Which is better? It depends on your glaucoma.

If you have a higher pressure or a lot of pigment clogging the drain, a goniotomy (cutting out the clogged mesh) can lower pressure a bit more aggressively. In fact, one study found that a Kahook blade goniotomy achieved a lower eye pressure on average than an iStent inject in similar patients. However, goniotomy tends to cause a brief period of more intraocular bleeding (a little blood in the eye, called a hyphema, which usually absorbs), whereas stents tend to have less of that. So, if someone is on blood thinners or cannot tolerate even short-term blood in the eye, a stent might be preferred. Stents are very useful if the goal is moderate pressure reduction with a very quick recovery. Goniotomy might be chosen if the surgeon feels simply removing the tissue will be more effective (for example, in juvenile or pigmentary glaucoma, which often have a lot of clogging material).

Another consideration: if you’ve had prior glaucoma laser or surgery and the angle anatomy is altered, one method may suit better. It’s not really a battle – in some cases surgeons even do both (a stent plus a goniotomy) for a combined effect, especially in moderate glaucoma where a single MIGS might not be enough. The phrase “matches your glaucoma” means the surgeon will tailor the MIGS to your disease severity and type: for mild glaucoma with cataract, a single iStent might suffice; for moderate glaucoma, they might lean towards a more robust approach like removing more tissue (goniotomy) or placing a larger device. Also, certain MIGS like the Xen Gel Stent (a different type that creates an external drain) or endoscopic cyclophotocoagulation (laser treatment to reduce fluid production) could be considered instead – all depending on what your eye needs.

Rest assured, your doctor will consider factors like target pressure, prior surgeries, and even your tolerance for using eye drops when recommending one over the other. Visual suggestion: a split schematic: one side showing a goniotomy (tiny blade cutting the meshwork) and the other showing a stent device in place. This could be augmented by a simple chart of pros/cons (e.g., “Goniotomy: no implant, slightly more pressure reduction, temporary blood; Stent: tiny implant, less initial blood, slightly less pressure drop in some cases”) to help patients visually compare.