Collaborative Glaucoma Care in the Era of Standalone MIGS

Sponsored by Sight Sciences

The collaborative care model has been remarkably successful in advancing the care of cataract and refractive surgery patients. Overall, sharing the management of these patients has broadened the pool of eligible candidates, established the conditions for managing a high volume of cases, and has facilitated a paradigm of earlier intervention. It is time to take those lessons learned from those examples and apply them to the care of patients with glaucoma so that the recognized benefits of MIGS become available earlier in the disease history for a greater number of people.

What Makes Successful Partnerships?

The Collaborative Approach: Opportunities for Improving Care

James T. Murphy, MD

At some level, the concept of sharing the responsibility for helping a patient manage glaucoma is an answer to a numbers game: An OD or MD serving as the primary eye care provider frees up time and focus for the glaucoma specialist to manage more complicated cases. Such an efficient model of care will undoubtedly become more important to accommodate the growing number of patients being diagnosed with glaucoma. However, we can also recognize that a team approach to glaucoma care is an opportunity to elevate the standard of care.

Three Benefits to a Team Approach

Beyond the simple fact of helping to streamline care, a team approach to glaucoma management may allow us to more readily realize the benefits of early diagnosis and management.

1. Prompt recognition of progression

Having partners in the community who perform visual fields, OCT, and other diagnostic and imaging for glaucoma patients creates opportunities to recognize early signs of disease progression.

2. Improved identification of compliance issues

Primary eye care providers, at the front lines of patient care, are the first to notice warning signs that compliance is becoming an issue—and we are learning that suboptimal compliance may be an issue driving disease progression.

3. Greater ability to educate on the benefits of early intervention

Conversations in the clinic about the risks and benefits of MIGS can be more fruitful when our partners in the community start the educational process early in the patient’s journey.

To this last point, there is growing evidence that intervening with a surgery that helps re-establish physiologic outflow in eyes with mild-to-moderate glaucoma has long-term benefits. Most MIGS procedures target the conventional outflow pathway, but work in one or two locations at most. It is currently not possible, however, to identify the specific areas of outflow resistance in a glaucomatous eye with in-vivo diagnostic testing. The most reasonable surgical approach therefore is one that can address all three sources of physiological outflow resistance rather than targeting one or two potential areas of blockage. The OMNI Surgical System (Sight Sciences) is unique in that it combines two ab interno procedures—canaloplasty and trabeculotomy—in a single procedure.¹ A recent study by Vold et al evaluated the effectiveness of OMNI when used as a standalone procedure in pseudophakic eyes.² In patients with a baseline IOP of greater than 22 mm Hg, a significant reduction of 8.8 mm Hg was observed. In addition to achieving stable pressure independent of patients’ compliance, any time we can reduce or eliminate medication is a definite win.

Standalone MIGS: Potential Real-World Impact

The safety profile associated with MIGS has opened a new opportunity to offer patients surgical intervention earlier in the treatment paradigm of glaucoma. Standalone MIGS, which is really the next evolution in the interventional mindset, would extend the numerous benefits associated with early intervention to both phakic and pseudophakic patients with mild-to-moderate glaucoma. Indeed, the patients who would benefit from standalone MIGS are already in most of our practices, and they are certainly already in the practices of the referral network. As standalone MIGS grows in popularity, it may be that more cases are performed by anterior segment surgeons, which would further extend the concept of shared care in the life of a glaucoma patient. In the end, a collaborative approach to care offers myriad benefits, and it will be patients who gain the most from options that offer stable IOP control with great potential to reduce or eliminate medication burden, irrespective of the status of their lens.

The Growing Role of Optometry in MIGS

Thomas R. Conrod, OD

A team-based approach to glaucoma management means there are more options available for the patient, and it maintains the focus on achieving the best outcome possible. I have referred many patients over the years for MIGS procedures; they come back to my clinic with lowered IOP and, frequently, on fewer or no drops. It is rewarding to know I was part of a successful outcome for those individuals. From a practical perspective, because the compliance factor is largely addressed, those patients are decidedly less complicated to follow over time.

Facilitating early intervention for glaucoma patients does not need to be difficult, but it might require some consideration about how we interact with patients. Below are three points to consider for optometrists thinking about more actively educating their patients about MIGS.

Three Points for Patient Education

1. Take an active role in patient identification

We have a growing number of patients asking about surgical options for their glaucoma, and other candidates are identified based on unpromoted discussions—for example, about cost and difficulties accessing their medications. More frequently, though, patients who would benefit from a MIGS procedure are found by directing questions that unmask issues with drop therapy. We take an active role in educating and motivating patients to take medicines according to the schedules we recommend. However, we are also realistic enough to know those efforts will only be moderately effective, and so at every visit we ask questions about whether the prescription was refilled, how often, and whether and how the drops were used on schedule. That conversation lays the foundation for the clinical examination, where we can look for signs of progression that may correlate with poor compliance.

2. It’s never too early to educate about MIGS

Patients who are engaged in their eye care are just more likely to have a more favorable outcome. Thus, our role as primary eye care providers is to ensure patients are aware of the benefits of early glaucoma intervention, as well as the safety and efficacy associated with MIGS. One of the unintended consequences of early diagnosis is that patients will now be treated for glaucoma for a longer period of time, and so we also need to be thinking two and three steps ahead along that patient’s journey (for instance, being on the lookout for ocular surface issues in our patients taking glaucoma drops). For our patients undergoing cataract surgery, we can let them know that their glaucoma can be addressed at the same time. And for patients with progressing glaucoma who previously had cataract surgery, or in whom cataract surgery is not yet needed, we can discuss options that will offer better overall disease control.

3. Offer practical information and relate it to what’s important to the patient

The safety associated with MIGS is perhaps its greatest benefit; however, the prospect of ocular surgery can induce anxiety in patients. If we overwhelm patients with too much information, we risk them missing the salient points and getting stuck in analysis paralysis. In this respect, the referring optometrist can play a huge role in ensuring patients have the best information available to make a decision about whether or not to proceed with a surgical intervention.

I like to frame the conversation in terms of the risk-benefit ratio—what is the risk of staying on a current treatment, and what benefit could an intervention provide? There are some analogies to refractive surgery: Patients using contact lenses for a long period of time risk ocular surface issues, especially if their compliance with cleaning and replacement protocols is suboptimal, and so LASIK is an option to fix the underlying refractive error. In a similar fashion, patients with glaucoma may be deriving benefit from drop therapy, but a surgery that could eliminate drops altogether would reduce the risk of ocular surface issues while also addressing any cost burden or access issues the patient may be experiencing.

Conclusion

There are a number of practical benefits associated with the collaborative care model, including the potential for increased efficiency and the ability to extend access to more patients. But ultimately, it will be patients who will reap the greatest reward when we figure out how to work together as a team to help them navigate their glaucoma treatment options.

1. Brown RH, Tsegaw S, Dhamdhere K. Viscodilation of Schlemm canal and trabeculotomy combined with cataract surgery for reducing intraocular pressure in open-angle glaucoma. J Cat Refract Surg. 2020;46(4):644-645.

2. Vold SD, Williamson BK, Hirsch L, et al. Canaloplasty and trabeculotomy with the OMNI System in pseudophakic patients with open-angle glaucoma: The ROMEO Study. Ophthalmol Glaucoma. 2021;4:173-181.

OMNI is a registered trademark of Sight Sciences, Inc.

Dr. James T. Murphy is a paid consultant of Sight Sciences, Inc.

Dr. Thomas R. Conrod is a paid consultant of Sight Sciences, Inc.<