BLOG: How to drive MIGS adoption
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Every year I try to adopt at least one new procedure to keep my practice current. This takes effort. The easiest part is learning the technique and clinical scenarios in which the new procedure fits best. More challenging is educating my staff on ordering and paying for supplies, billing and reimbursement, and how clinical protocols need to change with the new procedure. But everyone in my practice feels good when the new offering begins to feel routine.
Adding MIGS — or adding different MIGS procedures if you already do one — is rewarding as well. And in the cover story of this issue of Ocular Surgery News, some noted colleagues explain the value of different MIGS procedures, how they can fit into your practice and why you might choose them. Having adopted MIGS in my practice during the earliest iStent (Glaukos) trials, we have learned a number of lessons in how to gain patient acceptance and create a win-win atmosphere with this new procedure.
1. Start the conversation early. Most of us begin counseling patients about cataract surgery long before it is needed. We explain their progressive visual changes and prepare them mentally for surgery, including refractive options where applicable. MIGS also belongs in this discussion for patients who are likely to qualify for these procedures. I explained that the added benefit of MIGS is that we can treat two diseases with one visit to the surgery center. While most patients say they don’t mind taking their drops, all agree life would be better without them.
2. Engage your staff. I encourage my staff to raise the subject of MIGS when talking to patients with developing cataracts who also take glaucoma drops. They explain the successes of sustained pressure lowering we typically see in other patients and how, from the patient’s perspective, MIGS most often is generally almost identical to routine cataract surgery alone. They encourage patients to ask their surgeon about MIGS when the time comes for cataract surgery.
3. Keep the conversation simple. Patients want a general sense of what the procedure will do and what additional risks or costs it carries. Generally, MIGS has few long-term risks and is covered by insurance, so this is easy. I explain that we have a two-thirds chance of eliminating one eye drop and a one-third chance of eliminating two eye drops, and the effect should be sustained. In my practice, this seems to be true with virtually all of the current MIGS procedures we perform. With implant procedures such as iStent and Hydrus (Ivantis), I explain that we are leaving a tiny implant in the eye to gauge the patient’s reaction to this. (Most have no objections at all because they are already receiving a lens implant.) Or, for procedures such as viscodilation (Omni, Sight Sciences) or goniotomy with Trabectome (NeoMedix) or Kahook Dual Blade (New World Medical), I explain in general terms how we are altering the anatomy for procedures that do not leave behind an implant. Generally, I do not explain the whole variety of different MIGS procedures or ask a patient to make a choice because most want me to make that choice based on my experience.
4. Afterward, tell them about their success. Patients don’t know what to expect after cataract surgery with MIGS. We typically keep patients on glaucoma drops until 6 weeks after surgery when we begin to withdraw them. I explain this is the normal progression, and we celebrate together when their pressure remains low without medication. Patients truly appreciate the added benefit of MIGS, but they need to be told that this doesn’t generally happen with cataract surgery alone.
Over the years, I have adopted virtually all of the approved MIGS procedures including iStent, Hydrus, Omni, goniotomy with a Kahook Dual Blade, Trabectome procedures and previously CyPass (Alcon) while it was approved. Generally, learning the first is the hardest step because of the need to visualize the angle, and each subsequent new procedure becomes easier to adopt. Each different procedure occupies its own niche in my patient care, and I certainly feel like a better eye surgeon for having adopted these techniques. And my patients would agree.
Disclosure: Hovanesian reports he is a consultant for Glaukos, Ivantis, Sight Sciences, Allergan and Alcon.