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MIGS is changing the glaucoma comanagement continuum
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If you want to begin comanaging glaucoma or grow that part of your practice, this is a good time to do it. I have been comanaging glaucoma, cataract and retina cases for 30 years and see it as an integral aspect of practice as well as a mechanism to provide improved care to my patients.
While cataract and retina comanagement have been part of practice for the last several decades, glaucoma comanagement is now beginning to shine, as recently developed glaucoma treatments give both surgeons and primary care clinicians new opportunities to better serve patients.
Comanagement of glaucoma is different from cataract, which has clearly defined algorithms laid out by anatomy and consistent, uniformly high quality surgical outcomes. Comanaging glaucoma is more analogous to retina in that the level of disease state changes the complexity of the initial surgical therapy as well as the subsequent comprehensive care provided by the optometrist.
There are approximately 3 million people with glaucoma in the U.S., with a larger number of patients who present with ocular hypertension and/or as glaucoma suspect (AOA Optometric Clinical Practice Guidelines). Although some optometric practices choose not to comanage the disease because they are geared toward specialty care or have not invested in the technology needed to communicate with the comanaging surgeon, I find that most clinicians are.
Comanagement continuum
In the majority of glaucoma cases, initial treatment is medication, which is undertaken at the primary care level. A significant percentage of patients find success with this approach, but a surgical consultation is initiated when patients present with side effects from therapy, disease progression is detected, medications fail to control pressure or compliance becomes an issue.
Every clinician has a different threshold for primary management. We monitor the response to medication over time and assess success or failure based on target pressures for each patient. The question of where in the continuum of care a referral takes place is typically a shared philosophy between the primary therapeutic clinician and the glaucoma specialist. In some instances, patients may be referred when they require second or third medications due to failure to achieve control or when they cannot afford medications but the cost of surgery is covered by insurance.
Once I reach out for a surgical consultation, like other referrals, I initiate a conversation with the surgeon. Sharing optical coherence tomography scans, visual fields and other test results allows for the type of detailed assessment necessary in selecting a surgical option. After the consultation, we typically discuss the therapeutic plan and determine which therapy will both resolve the immediate problem and present the best long-term solution. To a large degree, this creates the comanagement framework that will be used going forward.
Transformational therapies
A string of new therapies makes this an exciting time for both surgeons and optometrists to treat glaucoma. A decade ago, treatment options began with medication, followed by selective laser trabeculoplasty (SLT), followed by trabeculectomy or tube shunt.
Now, micro-invasive glaucoma surgeries (MIGS) give surgeons a portfolio of devices that reduce intraocular pressure. These implanted devices drain fluid from the eye in a more titrated fashion and with less risk of complications than more invasive glaucoma surgeries.
Two MIGS devices are implanted during cataract surgery: iStent (Glaukos), a direct implantation through the trabeculum and into Schlemm’s canal, and Cypass (Alcon), which drains to the suprachoroidal space. Patients without cataracts can have a stand-alone MIGS procedure with the Xen Gel Stent (Allergan), which drains to the subconjunctival space.
Each device has different outcome endpoints. After a MIGS procedure, patients can be seen by the surgeon or the comanaging clinician, depending on the outcome and the level of interaction shared by the clinicians. In cases where complications present, the comanagement process is modified to maximize the resolution of the surgical treatment.
MIGS procedures also have a symbiosis with other therapies that creates a whole new palette of opportunities. Typically, MIGS devices do not preclude additional procedures and they can be performed after SLT, trabeculectomy or tube shunt. They have additive value with other procedures and medications, as well as with each other, in ways that promise tailored applications in the future that will continue to evolve the comanagement process.
Educating ourselves
In today’s environment, where new advances are broadening the alternatives for glaucoma treatment, optometrists who comanage require a thorough understanding of the treatment options available, from medical therapy through to surgery. It is also important to understand that glaucoma specialists are evolving as well, and many are in the initial phases of incorporating the latest technologies in their armamentarium. As a result, optometrists need a detailed understanding of the perioperative and postoperative processes to comfortably participate in comanagement.
It can be difficult to know which surgery is right for our patients, when a surgery is indicated and what the potential outcome variations are until we truly understand the procedures and how they are performed. For this reason, I strongly recommend spending time in the operating room with the surgeon with which you comanage to gain a deeper appreciation of the skills required on their part to consistently provide outstanding outcomes. This also serves as a basis for a better appreciation of how the procedures are accomplished and what to expect postoperatively.
As clinicians, the best way to develop the comanagement component of your practice is to model it after the cataract comanagement systems that have become an integral part of primary eye care. Establish channels of communication, educate your staff on the technology and continue to monitor the science at professional meetings to stay abreast of the latest developments.
- Reference:
- Fingeret M, et al. Optometric Clinical Practice Guideline: Care of the Patient with Open Angle Glaucoma. American Optometric Association. www.aoa.org/documents/optometrists/CPG-9.pdf. Revised 2010. Accessed June 26, 2017.
- For more information:
- J. James Thimons, OD, FAAO, ABO, is ophthalmic medical director at Ophthalmic Consultants of Connecticut, an adjunct clinical professor at the Pennsylvania College of Optometry and a Primary Care Optometry News Editorial Board member. He can be reached at jthimons@sbcglobal.net.
Disclosure: Thimons reports he is a speaker for Alcon, Allergan, Bausch + Lomb, Diopsys, PRN, Reichert, Shire, TearLab and Zeiss.
Perspective
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Robert Noecker, MD, MBA
I comanage glaucoma patients with Dr. Thimons at Ophthalmic Consultants of Connecticut.
Unlike cataract or LASIK, which are very predictable procedures with a small universe of problems, traditional glaucoma surgery (trabeculectomy) has had some variability in its outcomes. I think some optometrists are comfortable monitoring these patients long-term and others are not. Newer treatments make postoperative care easier.
MIGS procedures are less invasive than traditional glaucoma surgery and produce more stable, predictable outcomes. Their smaller downside gives us the exciting opportunity to treat patients in different stages and circumstances. That changes why and when optometrists consult us about moving from medication to a surgical procedure.
Of course, because complications are few and scary problems such as hypotony are rare, postoperative management of MIGS patients is simplified. In uncomplicated cases, I release MIGS patients right back to their optometrists because I do not anticipate any problems. The approach is good for patients, and it works well for me and for optometrists who like having their patients back.
A key to success is to visit the operating room and see the procedures. Videos are helpful, but they are not the same as being present for surgery. Optometrists who visit our practice and observe surgery are on the same page with us quickly, which makes postoperative decision-making much easier.
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