Considerations in co-management of glaucoma
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Nick Bruns, OD:
All right, everybody. Thank you so much for joining us today. My name’s Dr. Nick Bruns. I practice in Milwaukee, Wisconsin at a surgical practice. We do a lot of MIGS surgery and refractive surgery, and I’d like to welcome my friend My Le Shaw. My Le Shaw is a glaucoma specialist, and we had the pleasure of working together for many years back in Michigan, so it’s fun to reconnect and get to do this with her. So Dr. Shaw, why don’t you take it away and introduce yourself.
My Le Shaw, MD:
My Le Shaw. I am a glaucoma specialist in Michigan, about an hour north of Ann Arbor. I have been in solo practice since 2020. It’s a great time to start a solo practice. I did my training at the University of Washington for medical school, and then I did residency in Kansas and my glaucoma fellowship at Cincinnati Eye before going to Michigan.
Nick Bruns, OD:
Dr. Shaw and I have a lot of history working with glaucoma, seeing the mild to the moderate, to the severe, to the ultra severe. So we’ve seen everything, a lot of it, the two of us together, which was always really fun. So today’s talk is really about managing glaucoma between optometrists and ophthalmologists and the importance of co-managing. So first talking point, Dr. Shaw. The ultimate goal of glaucoma management is to really maintain vision, especially in those patients who have already lost visions. How important is it to co-manage and how important is co-management in meeting that goal of retaining vision?
My Le Shaw, MD:
I think working as a team is important. During my training in the hospital, it was always a team effort. There would be residents, attendings, nurses, because one person can’t do it all. And I think that team approach is important because there’s only so much time in a day. And I think, Nick, you saw this as well in my clinic. As it gradually got busier, I just couldn’t physically see all the patients. And I feel like once I felt like the patient had gotten to a stable point, they could be watched carefully by somebody who I worked closely with and somebody who I trusted. Having that team approach to patient care, I think has always been a good model to follow.
Nick Bruns, OD:
Yeah, I think we’ve gotten so much better at diagnosing glaucoma. So you see the overall quantity of glaucoma patients just increasing year after year, and really the team approach, like you said, is just so important. It’s not just one thing and it’s a continuum of treatment. It’s not just a one treatment, you’re cured. These patients require constant monitoring.
My Le Shaw, MD:
Even patients who are glaucoma suspect that we follow for a while, and they’ve been stable for a while, and then one year they come in and you see changes. But these patients, I don’t necessarily feel need to be followed by a glaucoma specialist because they’re not needing that surgical management right away. So again, having somebody who you trust that you work closely with to say, “Hey, you’ve been looking good for a while, but something’s different. Something’s up. Do they need a closer look?”
Nick Bruns, OD:
Yeah, we always had such an open dialogue and an open line of communication if there was ever something. Either you were in the room next door or I could just send you [inaudible 00:03:32].
My Le Shaw, MD:
Exactly.
Nick Bruns, OD:
Always nice to have that in my pocket. What are the clinic roles for both optometrists and ophthalmologists in meeting the desired goals in therapeutic co-management? I think you already touched on that, a lot of surgical versus non-surgical and that gray area in between. How do we define those roles and where’s the roles for both specialists?
My Le Shaw, MD:
Yeah, I don’t necessarily see it as this is your role, this is my role. Even that word co-management, it doesn’t really define the team effort that it really takes. And I don’t think it’s one of those things where if it’s surgical, then the ophthalmologist sees it and if it’s non-surgical, the optometrist sees it, because I think some of this stuff is very nuanced. And I think you’re going to agree you can’t treat all mild patients the same. You can’t treat all moderate patients the same. So I think knowing when to pull the trigger to refer, I think it’s earlier better than later. And if there’s ever a question, I think I’d prefer to see a referral sooner if there’s any question at all, rather than have it come much later and then have that case then need urgent care.
So I don’t think it’s a black and white split. I think, again, being in a team environment where you have somebody that you know, somebody that you trust to really say, “I don’t know.” And I’m very quick to say that, especially for things that I don’t see very often, like the retina, the cornea. I’m very quick to say, “Hey, this isn’t looking right. I need you to go see somebody who’s done this more, who can sniff things out a little bit better for you.”
But really it’s a team approach because even now I don’t have the same environment that you and I are in. We’re really just down the hall from each other. But I still feel like communication is such an integral part of managing these patients and taking good care of them. And so I always try to keep that line of communication open and I always say, “Hey, right now they’re looking pretty stable, but anytime at all you feel like things aren’t looking right, send them back.”
Nick Bruns, OD:
Yeah, glaucoma is a true spectrum. Just because we try to define it as mild, moderate, or severe, you cannot call it black and white. Every patient does require a different level of care. And I think from the optometry side, there is a really true balance between confidence and then humility. You need to have confidence that you know what you’re doing and that you aren’t letting these patients get to a point that it’s beyond repair, and the humility to know when it’s becoming out of your control. I always prefer to at least have somebody bless a patient. Yes, does this need surgery or no? And feel free to say yes or no. And if it doesn’t, just send them on back. If it does, great, then they’re in the position where they need to be. And so again, open dialogue is just so important.
My Le Shaw, MD:
Yeah, agreed.
Nick Bruns, OD:
Which brings me into my next point. Interventional glaucoma is the latest paradigm in the treatment for the disease, and this new clinical approach is really more proactive rather than reactive, more patient focused. It entails an early predictive diagnostics, active and advanced monitoring and early procedural intervention. So how does interventional glaucoma after the treatment of glaucoma patients in general? How has the treatment paradigm shifted in your experience? Have you seen a lot of treatment shifts?
My Le Shaw, MD:
In terms of interventional glaucoma, it really has taken off. The things that we’ve were able to offer now versus even when I was in fellowship has really changed what we’re able to offer patients now. Whereas before you’re like, “Okay, we do the cataract surgery. If that doesn’t work, there’s a trab, there’s a tube, we’re cutting on the eye, we’re making a bleb, and the pressure’s too high, the pressure’s too low. It really took a lot to get to the point where you would want to do a trab or a tube just because of the risk benefit ratio.
But nowadays, with more MIGS-based surgery, if somebody’s going in for cataract surgery, you can also do another procedure that adds not a lot of time, not a lot of risk, and be able to get that patient potentially, if not off drops, at least decrease their drop burden. And so I think it’s really changed the way that we treat glaucoma in terms of what we’re able to offer the patient. So surgically, it’s been a really nice change because I can now offer something that doesn’t necessarily beat up the eye quite so much as a traditional trab or tube.
Nick Bruns, OD:
Yeah, those are pretty invasive surgeries. Those surgeries are a lot for the eye to handle and you can do a beautiful surgery. I’ve seen your post-ops before. They’re wonderful and they’re beautiful, but they still are kind of rough on the eye, and so the ability to do something that’s minimally invasive and still really get some bang for your buck is pretty great, and it’s cool to be a part of that now with the MIGS space.
My Le Shaw, MD:
Yeah, I will say that it’s being able to do cataract surgery and then throw in a MIGS surgery on top of that and get their pressures down and get them off drops, they’re super happy. So it’s been a nice change.
Nick Bruns, OD:
Yeah, I think preserving the corneal, pure chemistry I think is just so important too. We see dry eye more often than we ever did in our practice.
My Le Shaw, MD:
Oh, for sure. Yeah.
Nick Bruns, OD:
Part of that is because of what we’re doing right now, we’re on Zoom and we’re staring at a screen and you’re just not blinking very much. So preserving the tear film is just so important. And we know that putting any sort of drop, especially one that’s preserved or generic sometimes is even rougher on the corneas. If we can help our patients by doing anything to get them off at least one drop or even multiple drops, I think we should be taking advantage of it.
And there’s also the financial aspect. Drops are expensive, and this is something that’s a one-time thing. It’s billed to the insurance and this is just a single cost, it’s not a recurring cost. You don’t have to pay for drops every single year or every single month. But I think an important key point to make is that I have patients all the time, “Well, you did this MIGS surgery to me, so I’m cured.” That’s not the case.
My Le Shaw, MD:
Exactly.
Nick Bruns, OD:
They still need monitoring.
My Le Shaw, MD:
Exactly. Yeah.
Nick Bruns, OD:
They still need monitoring, and I bang my head against the wall so many times when patients just disappear and “Oh, you said I was cured, so we’re good. I don’t have glaucoma anymore.” No, no, you definitely do. You’re controlled, but you still need to be monitored because you don’t know as a patient, if your pressure went above its target, you don’t feel that unless it’s obviously out of control and they’re not going to have any symptoms. So where’s the optometrist’s role in the MIGS space? I mean, what is something that you would recommend for an optometrist to be comfortable with? How do you know if a MIGS surgery is done well, when it needs more intervention, or where’s the optometrist’s role there?
My Le Shaw, MD:
I think it’s very similar. It’s similar, but it’s more, right? It’s early referral. It’s knowing that instead of putting that patient on their fourth or fifth drop or whatever it is, and they’re coming back to see you and their eyes are red and they’re miserable and they have medicamentosa, I think recognizing that and sending them earlier for a MIGS eval is important. I think knowing what options are available to patients.
We often talk about combination surgery like cat MIGS surgery, but even if they’re pseudophakic, you can still do a MIGS type procedure and get them off their drops. So I think in terms of keeping the patient and putting them on drop after drop after drop after drop, I think even then an earlier referral to an ophthalmologist for a MIGS-based procedure could possibly make sense for these patients.
Nick Bruns, OD:
What about on the backend? What about after surgery? I see patients sometimes or I’ve talked to optometrists who will do a MIGS procedure and they’ll be off the drops at day one, which is, don’t do that, right? You want to wait, sometimes these devices take some time to really see the effect, so just because their pressure is at a certain point on day one or on week one doesn’t mean it’s going to stay there. What would you recommend as an optometrist postoperatively, and how to monitor their … When would you consider-
My Le Shaw, MD:
Anytime I do a MIGS-based surgery and actually surgery in general, I always see them day one, week one, and then if they look pretty stable at that week one time period and again, if I have somebody that I know and I trust, like if you were my clinic for example, I’d be like, “Hey, this eye looks pretty good. You look fantastic. I’m going to have Dr. Bruns keep an eye on you, make sure that you continue to do well.” But the way I have done postoperative drops has changed based on my experience with MIGS. The more I do it, the more comfortable I am, depending on their level of glaucoma, to pull the drops day one.
So sometimes I’ll do the surgery and they just do their post-op drops and they can stay off their glaucoma drops. I see them day one and see how their pressure does, but it’s surprising how you can do the same surgery, have it turn out the same way in the OR, and have the eyes react completely differently in the post-operative period. And as much as you try to predict, the one thing I’ve learned is you can’t. Every eye’s just a little bit different.
Nick Bruns, OD:
Yeah. I think you hit it right. I think the only, at least lesson I could teach about managing postoperative MIGS or glaucoma surgical patients is just the only consistency is you need to see them often. You’re seeing them at day one, week one, and then maybe again at week two, maybe again at week three, depending on what things will look like. Almost always day one, week one. Maybe day two, it depends. It depends on what-
My Le Shaw, MD:
It totally depends, yeah. Absolutely. It depends on the eye. Some of them look fantastic, and I’m like, “Yeah, I’ll see you in a month or whatever.” Otherwise, I don’t know. I always talked about how this smells funny, right? I’m like, “This doesn’t smell right.” So it’s always better to, especially the ones that when their nerve just doesn’t have a lot of reserve, those are the ones that absolutely you got to keep a close eye on.
Nick Bruns, OD:
Yeah, you look at the nerve too, right? Don’t forget about what space we’re in. We’re in the glaucoma space. Take a look at the nerve, reminds yourself what it looks like. If it barely has a couple neurons hanging on there, be a lot more aggressive with how often you’re going to see these patients, how closely you’re going to watch them. If the nerve looks robust, if it’s healthy, if it’s well perfused, you may be able to extend it. I think that’s a part of the hydration too. Well, the first FDA-approved makes device for use in standalone procedures was the iStent Infinite, which is a trabecular micro bypass system by Glaukos. What do ophthalmologists and optometrists need to know about this device and other standalone devices moving forward?
My Le Shaw, MD:
If I think in terms of the iStent Infinite for ophthalmologists who have been familiar with the iStent and have done well with the iStent, this is an easy transition, and it’s nice to be able to offer it outside of cataract surgery because what if they already had cataract surgery and you want to offer something in the angle and you’re not quite familiar with the other devices. If you don’t have access to a trabectome, which is hard to have access to, then this just adds another layer of options for patients and for ophthalmologists to potentially get patients on fewer drops.
I would probably say that for me, the iStent infinite would probably be for somebody who was controlled on drops, but just for whatever reason, didn’t like it or couldn’t take it or couldn’t remember to take it. I think it offers a good role in that space, but I think it has a good role in the right patient in the circumstance where they’re probably able to be controlled under drops, but they just, for whatever reason, they’re allergic to it, they can’t take it, they can’t remember to take it. I think it’s a good option in those cases.
Nick Bruns, OD:
Just like the disease as a spectrum, I think the MIGS space is an entire spectrum too. So I think each device, each standalone device in particular has a spot depending on, again, comfort level. I think iStent is a well known device. I think there’s a lot of surgeons out there that are very comfortable with the iStent in conjunction with cataract surgery, and so the iStent infinite probably would be a relatively easy transition. Speaking as a non-surgeon, but it seems like that would be the case.
My Le Shaw, MD:
Yeah, it is similar to the second generation iStent. I think when I was in training, the first generation iStent came out, and so when I was in fellowship, that was the new thing. And fast-forward, what, 10 years and all of a sudden instead of one device, now you have many devices to choose from, which is really nice.
Nick Bruns, OD:
That’s great. Yeah, having choices is a wonderful thing. It’s not a burden. It’s a great thing. So to have that area where you can find your niche and find your comfort spot and the iStent Infinite is, I’m sure, a good place for a lot of surgeons. How has your use of more invasive trabs or tubes, how has that changed over your career since you graduated from school?
My Le Shaw, MD:
It’s gone down significantly. I still do them. I just did a tube today, in fact, but it’s the number of trabs that I’ve done has gone down dramatically.
Nick Bruns, OD:
Any surgical co-management pearls that you can share for both ophthalmologists and optometrists as we move into the new era, this new paradigm shift of glaucoma care?
My Le Shaw, MD:
Having people that you work well with and that you trust and are open with, and that’s one of the things that I really liked about working with you, is I knew that if you saw somebody and there was any question at all as to whether or not they were stable, I always appreciated that you got me. You know what I mean?
Nick Bruns, OD:
Yeah.
My Le Shaw, MD:
Was really nice because I could trust that the patient was being well taken care of. I do a lot too, is, I don’t know, I say that a lot in clinic because I would rather them see somebody, cornea, retina, whatever it is. I would rather them see somebody that can take care of them and have them catch it early rather than futz around.
Nick Bruns, OD:
Yeah, that’s the hardest thing to say.
My Le Shaw, MD:
[inaudible 00:19:43] is that problem.
Nick Bruns, OD:
Yeah. Yeah. I don’t know is a phrase that … We’re in science, right? There’s a lot of things we still don’t know as an entire community, so saying those three words, I don’t know, is tough, I think naturally, but it’s important to say. I think being fully transparent with patients is how you earn their trust and how we all collectively do the right thing. I do a lot of lecturing to optometrists in the area here locally, and one of the big things I preach is that it really does have to be team. When you deal with surgical eye care, whether it be MIGS or not, it’s a team approach. When you schedule surgery, it’s not just patient doctor, it’s patient, patient’s family, insurance companies, surgical center, optometrists, optometrists clinic. There is dozens of people behind the scenes that are involved in surgical procedures.
So having that team approach and understanding and educating the patient that, “Hey, you’re not alone here with just the surgeon, it’s a lot of people involved, you’re going to get to know a lot of people.” I think that’s just so important, and I think it’s almost comforting too for patients to know that there is dozens of people behind them that are really involved with this. Well, Dr. Shaw, thanks so much for doing this. This is a lot of fun. Any final words or anything?
My Le Shaw, MD:
No, just really miss working with you.
Nick Bruns, OD:
Miss you too.
