The contents of this article are informational only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment recommendations. This editorial presents the views and experiences of the author and does not reflect the opinions or recommendations of the publisher of Ophthalmology 360.
By Peter Marzano
Having spent over 20 years working in the spine field, I have gained diverse experience leading market development, global sales training, and surgeon education departments, as well as commercial teams in the United States, Europe, the Middle East, and Africa. A highlight of this period was introducing a new minimally invasive surgical procedure, educating surgeons about the advantages for patients, and ultimately seeing widespread adoption that became a ~$500 million market segment. Working with ophthalmologists over the past year at Sight Sciences, I’ve seen multiple commonalities from my previous experience. The patient benefits of minimally invasive glaucoma surgery (MIGS) are clear: reducing burdensome self-care with drops, obtaining predictably lower intraocular pressure, maintaining visual field and quality of life, and often getting a 2-for-1 benefit with combination cataract/MIGS surgery.
With so many advantages, I wonder why MIGS adoption isn’t more widespread.
Of the 4.9 million cataract procedures done in the United States last year, about 500,000 eyes had primary open-angle glaucoma (POAG), yet a MIGS procedure was only done in about half of cases.1 The percentage of MIGS interventions was much lower for pseudophakic patients. Here’s what I’ve learned about the gap in MIGS adoption and how we might bridge that gap to ensure patients get the treatment they need to maintain their vision.
Why Has MIGS Use Plateaued?
At conferences and in the pages of ophthalmology journals, leaders in the field have long discussed the shift from conventional to interventional glaucoma treatment. The benefits of safe, minimally invasive procedures make them the standard for treating patients with glaucoma, essential for early intervention that slows progression of the disease.2
Yet, with only half of POAG/cataract patients receiving MIGS, the numbers clearly tell us that not everyone is on board. Far from growing year after year until MIGS are embraced across the surgical community, their growth has plateaued,1 and I’ve seen several challenges hindering adoption.
It’s challenging to operationalize a “new” surgery. Industry partners have supported training and education in MIGS technologies to reduce the barrier of entry into angle-based procedures, providing a pathway for everyone from residents to the most tenured surgeons to embrace MIGS. However, adding a procedure requires an algorithm for making decisions—whether to use MIGS and which procedure to choose. Daily workflows need to evolve, including preoperative testing and follow-up, patient education, interaction with the referring doctor, surgical planning, supplies, and billing. Practices need processes to identify MIGS candidates among in-house glaucoma patients, those referred for cataract surgery, and pseudophakic patients as well. The more step-by-step guidance we can provide surgeons to efficiently align their practices for MIGS, the more readily they will adopt these procedures.
Education across the continuum of patient care needs to grow. Beginning with the initial diagnosis, patients experience a series of ups and downs along their personal journeys with glaucoma. While therapeutic interventions like selective laser trabeculoplasty and MIGS have grown in popularity, not all patients are offered these options. Many patients diagnosed by an eye care provider outside of a surgeon’s practice are offered traditional medications as frontline treatment. It’s becoming increasingly clear that broad educational efforts focused on the glaucoma patient’s journey is necessary to drive change. In addition, both industry and professional societies can help bridge the gap between the ophthalmic and optometric communities to elevate the level of communication and sharing of interventional options to ensure all patients have access to well-established, safe MIGS procedures.
Industry and eye care providers need to tell patients’ stories. What perplexes me most about plateaued MIGS adoption is the fact that patients are denied something safe and minimally invasive that can make such a significant impact on their lives. Perhaps a problem is we’re not telling those patients’ stories. Instead of talking about outcomes, we could show the eye care community a 62-year-old man explaining that he sometimes skips his glaucoma drops because the copay is too high. Or a 70-year-old woman wincing as she puts stinging eye drops on her red, inflamed eyes multiple times a day, and explaining that she’ll need to do this every day for the rest of her life. It would be memorable to share an 85-year-old couple’s struggle as the pressure-lowering effect of his cataract surgery having worn off, she now needs to put drops in his eyes because he can’t do it himself. Eye care providers who are face-to-face with patients like these everyday care about their struggles at home; their stories might go a long way in motivating others to make a change.
How Can We Change the Status Quo?
What will it take for all MIGS candidates to be offered the option of surgery? As I talk to surgeons in their practices and ambulatory surgery centers every day, I see roles for all of us.
From an industry perspective, we’re invested in building relationships with surgeons and the broader eye care community to understand their needs. But we need to get better at understanding the dynamics within the patient care pathway and working together to accelerate change for the benefit of patients. From experience, I know changing an established behavior is the most difficult thing we are asked to do. It requires a foundational level of trust and a compelling message that makes everyone involved in the patient’s journey (optometrist, ophthalmologist, technician, scheduler, administrator, etc.) acknowledge and embrace that change, while uncomfortable, is better than continuing to do the same.
MIGS devices are such exciting, life-changing technologies. They empower surgeons to treat glaucoma at any time—early, during cataract surgery, and post-cataract (pseudophakic)—and literally change patients’ lives. When MIGS becomes a routinely utilized, integrated part of everyone’s practice, patients will be the greatest beneficiaries.
References
- Ophthalmic Market Trends: US Cataract Edition: Q4 – 2023 | Market Scope.
- Heijl A, Peters D, Bengtsson B. Long-term impact of immediate versus delayed treatment of early glaucoma: results from the Early Manifest Glaucoma Trial. Am J Ophthalmol. 2023;252:286-294. doi:10.1016/j.ajo.2023.04.010
Peter Marzano is Vice President and Business Leader of Surgical Glaucoma at Sight Sciences.
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