Sponsored by Glaukos
How Physicians Educate Patients About Procedural Intervention
Brian M. Shafer, MD
Interventional glaucoma is a mindset that encompass early detection and treatment, typically through advanced diagnostics and procedures including laser therapy, procedural pharmaceuticals, and MIGS, while utilizing topical medications as a bridge or supplemental therapy.
Making a Strong Recommendation From a Menu of Options
Prior to a visit to my clinic, patients receive customized videos that highlight the treatment modalities and interventions available to treat their glaucoma. When they present to the clinic, they are less surprised by the extensive workup as they’ve been briefed by the videos on what to expect. By the time I walk into the room, I have reviewed the necessary information and have a general sense of what is needed for each patient. I think of the glaucoma treatment algorithm as a chef's tasting menu, in that I show them what the entire menu looks like, but I decide when those meal courses come out.
I explain that our goal is to lower IOP to a level that is safe for the optic nerve and also to ensure comfort throughout the entire treatment journey. I describe that I typically start that journey with a laser procedure (selective laser trabeculoplasty) to rejuvenate the drainage structure of the eye and give it the best chance at using the natural system to get IOP under control.
As we move forward in the treatment journey, we will likely implement a variety of different techniques, such as placement of the procedural pharmaceutical iDose TR (travoprost intracameral implant) 75 mcg (Glaukos), with our goal of minimizing the number of topical drops needed over a lifetime to ensure the patient’s life is as minimally disrupted as possible.
The Impact of Drops on Quality of Life
We know that when we use eye drops every day as prescribed, they are effective, but the reality is that it is incredibly difficult for patients to remain compliant and adherent. I frame this conversation with patients in a way that is relatable. I tell them that even I would have trouble remembering to use them, and I do this for a living, so I can't expect my patients to be perfect.
With full medication compliance, the potential for side effects can be disruptive to a patient’s quality of life. I recently evaluated a man who will likely require incisional surgery, but his conjunctiva is so inflamed from eye drops that his eye is not safe to intervene. My approach then shifts to getting him off drops to allow his ocular surface to recover before I can proceed with a more invasive procedure to manage his disease.
The best way to gain better control of disease is to utilize an intervention rather than leave the patient in control. When a patient on drop therapy comes in with suboptimal pressure, it's easy to blame it on poor compliance. If I can take more control of the patient’s treatment, I can have a better sense of what is needed to get that patient to their goal pressure.
With iDose TR, we also have the opportunity to treat patients newly diagnosed with ocular hypertension or OAG before they start a topical therapy regimen, thereby avoiding any potential side effects of the drops while understanding and advising of the potential side effects with iDose TR.
Explaining the Benefits of Earlier Procedural Intervention
When there are multiple reasonable treatment options to manage glaucoma, it can be challenging to convince patients to accept what you believe is the best option for them. What it really comes down to is confidence and the ability to present the treatment in a way that sounds the most logical to the patient.
Interventional glaucoma uses logic-based medicine to provide better outcomes for our patients, and explaining the procedure confidently helps to get them to follow our treatment advice. The overwhelming majority of my patients go with the approach I recommend because I give a confident recommendation.
How Practice Staff Supports Patients Considering Procedural Intervention
Deborah Ristvedt, DO
Over the last decade, we have seen a dramatic shift in the care of glaucoma, with a focus on enhancing quality of life, lessening drops, optimizing the ocular surface, and offering earlier intervention in a safe and effective way—redefining treatment based on clinical data available.
When I started my journey as a comprehensive ophthalmologist treating glaucoma, seeing many of our patients struggling with eye drops, I became invested in improving the standard of care. This journey has provided opportunities to establish a new protocol for those who initially present to us with mild, moderate, and severe primary open-angle glaucoma.
Interventional glaucoma is a mindset that allows physicians to optimize treatment with earlier procedural intervention as the primary therapy, removing compliance and adherence issues associated with topical therapy with a safe and effective procedural approach, utilizing topical drops as a bridge or supplemental therapy.
Selective laser trabeculoplasty has traditionally enabled physicians to offer an alternative to topical drops. Procedural pharmaceuticals like iDose TR (travoprost intracameral implant) 75 mcg have demonstrated the benefits of sustained release medication as first-line therapy, avoiding the ocular surface side effects experienced with topical drops. Furthermore, interventional glaucoma approaches can be performed in combination with cataract surgery or a standalone procedure.
For patients who may already be on topical drop therapy, or newly diagnosed patients who have not yet undergone any treatments, our staff and our referral network know to ask specific questions regarding quality of life and compliance prior to a procedural intervention.
The Role of the Referral Network
I'm a third-generation ophthalmologist, so all the optometrists that refer to our practice have known my family for generations. They have seen the evolution of change in glaucoma treatment from drops, laser, trabeculectomy, and tube shunts to a whole new world of minimally invasive therapy.
With patient education, it really starts with that referral network. We help ensure our team is knowledgeable about interventional glaucoma by hosting symposia, educational dinners, and one-on-one meetings to explain the changing treatment algorithm.
Our referral network has risen to this new standard of care, and it is amazing to watch that trend in a smaller community really take off. We are all in this together.
The Role of Support Staff
Our support staff is also included in our symposia and educational dinners to learn more about changes in technology and treatment. When patients come in who have been referred from an optometrist in the community, our staff understands the importance of discussing quality of life.
Our staff is trained to fully understand a patient's individual treatment journey and potential hardships, such as economic burden or insurance coverage. Everyone understands the impact of earlier glaucoma intervention so we can prevent or otherwise minimize the drop burden for our patients.
Training and Technology
We see that topical medication over a long period of time can have a negative impact on the trabecular meshwork, where intracameral medication can have a positive impact on outflow.1,2 It is also reasonable to think that some medications may work more effectively after a MIGS procedure has restored physiologic outflow. These innovations have enabled glaucoma physicians to become proactive instead of reactive when it comes to managing disease.
When we bring a new technology into the practice, we explain to the entire office how we will use it to better help our patients. For example, when iDose TR was approved by the FDA, we convened as a group to educate staff about procedural pharmaceuticals, how the iDose TR is implanted, and how we will manage patients who have had this procedure. We recognize that we must over-communicate changes to the treatment paradigm to ensure everyone on the team is on the same page.
Our staff sees firsthand the positive effect on quality of life when we relieve or prevent a patient’s drop burden. Everyone in the practice has a role to play. Our staff is compassionate and recognizes that the biggest factor in successful treatment is understanding what our patients experience and having confidence in discussing new treatment options.
