Sponsored by Glaukos
The advent of MIGS has significantly altered the glaucoma treatment paradigm, fostering a new approach known as interventional glaucoma where use of MIGS, procedural pharmaceuticals, and selective laser trabeculoplasty (SLT) earlier in the disease course is emphasized. In essence, interventional glaucoma describes a proactive mindset and a fundamentally patient-centered approach to glaucoma management. In fact, a growing body of literature supports that patients have better long-term outcomes—such as more consistent control of pressure, less visual field progression, and decreased rates of secondary surgical interventions—when procedural intervention is favored over medical therapy.
However, because interventional glaucoma is still a fairly new concept, many patients expect to be on drop therapy for their glaucoma and may not be aware of the benefits associated with procedural interventions. Thus, primary eye care providers are crucial in educating patients about interventional glaucoma and assuring they have access to specialist care.
Fortunately, eye care providers are already familiar with the principle of collaborative care from experiences comanaging cataract and refractive patients. And so, as this innovative way of treating glaucoma continues to grow, there is not a need to reinvent the wheel; instead, we need only refine the practices that have made us successful in collaborating in the care of patients with other disease states.
Information Sharing is Crucial for Successful Collaborative Care
From our perspective, the referring doctor or practice likely cannot overshare when it comes to clinical data, including imaging (which is useful for documenting progression, among other uses) and visual field testing (which is important for staging the disease for deciding which treatment is appropriate). We can certainly repeat testing done in the community, but it is much more efficient if we can “hit the ground running” and avoid redundant tests—especially for our patients traveling long distances. Documentation of previous procedures, Tmax, topical medications they have tried, and success rate is ideal.
Educating About Early Intervention
Patients do not need to be educated on specific procedures before being referred to a surgeon. Instead, referring doctors can set the stage by letting patients know generally what is available for clinical use and what might be recommended for their particular stage of disease—for example, it is sufficient to convey that there are different trabecular meshwork microstents and minimally invasive surgeries that help open up the drainage pathway.
The particulars of how patients are educated, and what they will be informed about, will, of course, be driven by the needs of the individual patient. Patients should be fully informed of the risks and benefits of all treatment options. Nevertheless, it is valuable to let patients know about the changing paradigm in glaucoma management with respect to procedural interventions. For example, patients being referred for a cataract surgery who also have glaucoma may not be aware of the opportunity to treat both conditions in a single operation.
In our experience, when patients arrive in our clinic educated on the concepts of interventional glaucoma by their primary eye care provider, we can have a more fruitful and efficient conversation about the details of their care. We also advise that referring eye care practitioners start a patient on glaucoma drop therapy—although medical therapy is often not an ideal long-term solution, insurance companies often want to know that a patient has at least attempted medical therapy before agreeing to cover MIGS.
Growing a Referral Network
At our practice, the vast majority of our marketing efforts are directed to our referral network, not necessarily direct to patients. We place great emphasis on building relationships with community practitioners, which, in turn, fosters the trust on both sides that is crucial for the successful collaborative care of patients. Those efforts include hosting an educational symposia twice a year, attending regional optometric meetings, and routinely visiting community practices with a practice development liaison. Ultimately, the goal is for referring practices to feel confident when they send patients to us. We also make it a point to invite members of our referral network to come to our surgery center to see what we do on a day-to-day basis and to get a sense of the patient experience—we have found that firsthand experience makes it easier to relay to patients what they will actually encounter when they are sent for a glaucoma consultation.
Closing Thoughts
The fundamental principle of interventional glaucoma is that early, proactive use of surgeries and devices, SLT, and procedural pharmaceuticals has benefits for the long-term management of glaucoma. Data supporting the use of SLT as a first-line therapy, as opposed to starting patients on drops, demonstrates that SLT had better preservation of visual field compared to patients prescribed medical therapy.1 What these and other data emphasize is that our patients do better when we adopt an interventional mindset from the start.
We firmly believe that optimal glaucoma management begins outside our clinic’s walls, when community partners facilitate conversations with patients regarding the evolving treatment paradigm. We believe primary eye care providers play a crucial role in identifying glaucoma patients early in their treatment journey so they can benefit from the advances in glaucoma care. As we have learned from experiences comanaging cataract and refractive surgery, and now interventional glaucoma, our patients benefit most when their team of providers work together to implement cutting-edge care.
