Interventional glaucoma mindset: when to intervene and access considerations
In part 3 of a 4-part panel discussion, optometrists Drs. Schweitzer, Bloomenstein, Dunbar, and Ibach talk about the growing trend toward interventional glaucoma practices and how each of them incorporates this into their practice.
Justin Schweitzer, OD:
What I want to talk about next, which is this interventional glaucoma mindset that we’re hearing all about, when do we intervene in the disease process? Those types of things include SLT, drug delivery, maybe MIGS, and let’s start with selective laser trabeculoplasty. Let’s start with SLT. When we think about SLT, I’d love to hear each of your guys’ perspective. Is this a first-line option? Should we be talking to patients about this being first-line, in front of medications, or equal to medications?
Marc Bloomenstein, OD:
The biggest challenge we have with giving a patient the diagnosis of glaucoma is getting them to believe that this is a real entity. They don’t see it, they don’t taste it, they can’t feel it, and we have to almost quasi-convince them that this is something important for them. Then the adherence to medications, if there are side effects associated with that, the cost associated with that is so much greater. We have an opportunity here to effectively lower the pressure with your patients not having to do anything. I mean, correct me if I’m wrong, you probably know better, but I think outside the United States, it’s more of a first-line treatment, and I just don’t know how we can’t wrap our arms around that here in the States.
Mark Troy Dunbar, OD:
I think it’s purely access. It would be interesting to know in states where optometry have laser privileges, I think if I could do it, and I’m in Florida where we can’t, it would be probably something I would pull the trigger on much sooner because to your point, obviously the data really shows that laser, as a first-line, is probably a little bit better than medication, certainly long-term, the data supports doing laser. The problem is, if you’re not able to do it, then it’s sending it to a glaucoma specialist. Trying to get access to a glaucoma specialist, in many places around the country, is very, very difficult. Then, just because you sent them doesn’t mean the glaucoma specialist is going to want to do it.
Now obviously, Justin and Mitch, you’re in a referral center, and you too, Marc, where, all right, we’ll do it. They know that within the practice, it’s easy to do. I don’t know that that’s what happens around the country. There’s frustration on my part, because yes, I think it may be a great first-line, but I know that getting a patient in, getting a glaucoma specialist to buy in.
Then really thirdly, if you give patients a choice, a laser versus medical therapy, where they’re fairly equivalent, I mean there’s some nuances there, but given a choice, when I’ve asked that question to patients, almost all of them will say, “I’ll take a prostaglandin. I don’t mind using, putting a drop at night.”
Mitch Ibach, OD:
I agree with Dr. Dunbar. I present it pretty equally alongside, and then I’ll always tell patients, “This is what I would do if it was my own eye.” I think that helps for a lot of patients, or this is what I would do if it was my family member. But there’s a lot of data to support that, patient surveys, when you ask patients on a survey, a lot of patients will still say they’ll choose drops as first-line treatment.
Marc Bloomenstein, OD:
What would you do now?
Justin Schweitzer, OD:
I mean, there’s data like the LiGHT trial, that says with these treatment-naive patients, so they’re the ideal patient for this LiGHT trial, almost 70% were drop-free at 6 years. Those are the perfect patients. They’re always not what we see in our clinics. But to your point, Dr. Dunbar, I think that the communication with a glaucoma specialist to make sure that you’re still managing the patient, I think that is a bit of a hindrance in making sure that there is that communication, that there is that back and forth. It’s a lot easier sometimes just to grab that drop. You know that patient’s staying in the clinic with you, you know they’re going to be back for that IOP check, most likely in 6 weeks, and you get to continue to manage that. But I think that there still has to be this thought process of driving that conversation moving forward. I interrupted you, Dr. Bloomenstein. I apologize.
Marc Bloomenstein, OD:
No, I was just going to say, Mitch said, “And this is what I would do.” What would you do?
Mitch Ibach, OD:
I would have SLT first…
Mark Troy Dunbar, OD:
I would too. I think you’re right. Absolutely, Mitch. I think that’s the key, if it was me, this is what I would do.
Marc Bloomenstein, OD:
Right. I feel that, because drops are the easy button, in a small sense, and especially as we’re talking about with our optometric colleagues, the reality is that all of us on here, and I’m assuming Justin, you’re going laser, you take laser?
Justin Schweitzer, OD:
I’d do SLT as well.
Marc Bloomenstein, OD:
I think it’s important for us to be able to convey that to our patients. To your point, Mark, I mean I would encourage all of us to work with other clinicians, maybe even other optometrists, or even general ophthalmologists, that they don’t have the time to manage these patients. I mean, to me, I don’t think that should be a barrier, but it is, and I agree with you, it is.
Justin Schweitzer, OD:
As we stick with this interventional kind of discussion, there’s really 2 newer products, one being around a little longer than the other, and that’s glaucoma drug delivery, more of a referral-based type of a procedure again. But we have an injectable pellet, that releases a prostaglandin bimatoprost. We now have a surgical procedure, where a device is placed in the eye that’s releasing travoprost. Drug delivery has made its mark on the scene. Mitch, I’ll throw it to you first. Where do you see these fitting in, and how much are you utilizing these in your practice right now?
Mitch Ibach, OD:
We’re in a practice setting where we have very quick access to having an ophthalmologist be able to do this for us. We do a lot of drug delivery in our practice. We do both, in the surgery center, drug delivery, which is currently travoprost sustained-release, is how we do it in our practice, and then we do a lot in clinic as well, with bimatoprost sustained-release. Practicing in South Dakota, almost all of my patients, come October, want to go see Marc or Mark in the state that they live. This is a lot of times a patient says, “Is there anything that I can do for winter? I’m going to snowbird for the winter. Is there something I can do to get off some drops?”
Another very common scenario is patients who say, “Gosh, I’m just not compliant with drops.” Maybe we’ve exhausted SLT, but we’re not ready to go into glaucoma surgery yet, and so this is a patient who often does well with drug delivery, patients who’s having ocular surface disease with glaucoma drops. Then a big one for our practice is patients who had maybe phaco plus MIGS, they lessened their glaucoma drop burden for 3, 5, 7 years. Now glaucoma pressure is starting to come back up, and this patient’s already had the freedom from drops, and so that’s a very quick drug delivery patient for me in my practice.
Marc Bloomenstein, OD:
I haven’t had a great success with it, not from the perspective of lowering the pressure, from getting any doctor to actually do it. I think it goes back to what Dunbar said earlier, is that access and generating revenue… I mean, it’s interesting because you, I wonder why MIGS aren’t utilized more often. I know Justin you’re going to mention MIGS in a second, but it almost comes back to are they generating, and I mean they, MDs, are they generating enough revenue to do this or is it easier for them just to stay on drops, also? I would love to see more uptake in the sustained-release or the pellets, because again, it goes back to what we said from the very beginning of this. This is a disease state by which quality of life should be forefront, and so if you can do anything we can to keep people off drops, to be able to manage the disease state 24 hours a day without doing something that they physically have to do, I think it’s great. But I haven’t had good luck. Mark, have you?
Mark Troy Dunbar, OD:
No, I haven’t, but I think it goes back to the patient profile. I mean, if you’re looking at somebody who’s got advanced disease that has already maximized, whether it’s an SLT or drops, I think conventional glaucoma surgeons are going to go what is trusted, tried and true, either a trab or a tube. I would like to see more, and unfortunately I haven’t. Same thing, I don’t see much of the pellets or anything else. I mean, obviously stents are great and we do a lot of those, and you alluded to that early, Marc, the cataract or early cataract patient who’s got early glaucoma, boy, that’s a perfect patient to have cataract surgery, put in an eye stent. Again, if we can relieve the burden of a drop, at least for a little while, that’s a win-win for everybody. But for these more advanced cases, I just think, I don’t really see many of these interventional treatments that you talked about, Justin.
Justin Schweitzer, OD:
I think you make a good point on the MIGS side of things. We’re diving into that here briefly for a few minutes, that if you have a patient with cataracts and mild to moderate glaucoma, I think doing some type of MIGS procedure makes sense. I’d be curious, in your guys’ practice from a standalone MIGS standpoint, where do you go with that? Do you exhaust medication first before making that referral, or are you now, with some of the data that’s come out around standalone MIGS procedures, going to that earlier than ever before?
Mark Troy Dunbar, OD:
You mean standalone minus without a cataract surgery or just a standalone?
Justin Schweitzer, OD:
My apologies. Yes, it’d be standalone without cataract surgery. A MIGS procedure that is not done in combination with cataract surgery.
Mark Troy Dunbar, OD:
Again, that’s younger glaucoma surgeons to me. I mean, yes, I refer some of those, and a handful get done. You really look at the pyramid and we’re looking at the base of that pyramid being typically topical laser, and then as you go really up to the tippy-top, it’s really some of these more interventional therapies as you’ve talked about. Yes, we’ve got some of the younger, more aggressive really trying out some of these, whether it’s interventional standalones, etc. But it’s certainly a minority.
Mitch Ibach, OD:
Justin and I practice with a fellowship-trained glaucoma surgeon, and so this is a conversation that we’re having every hour, probably even more with patients. For me, I think it’s just starting the conversation. I guess my ask for optometry or my colleagues would be just ask patients, is this something that you’re interested in? Then if you have someone that you can work with who’s willing to do it, at least it starts that snowball rolling down the hill, because the more we have these conversations, the more I have patients saying, “Well, I would be willing to try something. I would love to go from 3 drops to 2, or 2 drops to zero,” in some of these instances. I think it’s important to have that in our armamentarium, but it’s not for every patient.
Marc Bloomenstein, OD:
I think it’s really interesting is that when you think about how we’ve come, it’s almost like talking to patients about options. It’s anything we do in our practice. It’s like we have a lot of different options, but you have to have a colleague. What I mean by that, a glaucoma-trained fellow or a general ophthalmologist, somebody who shares with you the same type of vision so that when you have the discussion with patients, you feel confident that when you’re referring them to this doctor that they’re going to be on the same mind path that you are.
For me, I mean, I totally agree with you, Mitch. I love to say, “Look, these are all the options we have. Let’s start simple, and if we can’t, then we have other options we can go to.” But I would just want to make sure that whoever I’m referring them to that we’re in the same place. It’s almost like refractive surgery. I mean, you refer them to a place that you know what procedures they’re using, what they’re going to recommend, and so actually, it’s cooperative care. I think with optometry and glaucoma, it has to be that same cooperative care.
