BLOG: Concept of procedural glaucoma management evolving
Procedural management of glaucoma is clearly not a passing trend. In fact, it may be the new normal that patients will come to expect and that providers prefer because of the outcomes.
Any number of factors could be cited as influencing the shifting paradigm of treatment: safety and adherence concerns with medical therapy, introduction of laser platforms that offer similar IOP-lowering efficacy as drops but with a greater safety profile (and no compliance issues), and the advent of MIGS, etc. Altogether, we are moving closer to individualizing treatment choices with a wider array of options, as well as finally making it feasible to intervene earlier in the glaucoma continuum to halt or prevent progression.
One obvious consequence of this trend is that glaucoma specialists are spending more time in the OR. Because of the facility fee associated with these procedures, there is certainly financial incentive involved.
But then, last year, we found ourselves in the midst of a pandemic, a backlog of cases quickly grew, patients began to balk at the idea of surgery (and certainly incisional options with need for significant postop follow-up), and glaucoma care providers found themselves in need of in-office options that were patient-friendly yet effective and durable, associated with minimal downtime and a high degree of safety while still being financially viable for the practice.
MicroPulse transscleral laser therapy (TLT) with the MicroPulse P3 delivery device (Iridex) checks all of the items on that list. In response to COVID, and because of patients’ concerns for safety, we started offering MicroPulse TLT as an in-office option. The facts that the procedure requires no cutting and is associated with a reduced risk for infection were key. But what was born of a need to reduce facetime and move patients through the clinic efficiently turned out to be a durable procedure that allowed us to push out follow-ups. We also found that MicroPulse TLT had minimal impact on patients’ activity level after the procedure — the treated eye is patched for about 24 hours after the procedure, but there is no real restriction on activity.
One of the surprising lessons we learned over the past year is the amazing benefits to efficiency when travel time to a surgery center is minimized. Keeping patients in the same clinical space is not only safer, but it also makes them more comfortable. In fact, having another office-based option that is widely applicable to a range of glaucoma types and that is suitable for use in the office, especially when laser trabeculoplasty may not offer enough efficacy, is great. The revised MicroPulse P3 probe is ergonomic and easy to couple to the surface of the eye (I use lidocaine gel for this purpose), which helps deliver reliable, consistent and predictable outcomes.
Over the years, I have used MicroPulse TLT in both the office and surgical center. The newer probe is perhaps associated with a shorter learning curve; regardless, as my experience with MicroPulse TLT grows, patient outcomes continue to improve. As our practices evolve into a new normal, the viability idea of offering MicroPulse TLT in an office setting may turn out to be a fortuitous lesson learned during the pandemic.
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