Christine Funke, MD; Brian Shafer, MD; and J. Morgan Micheletti, MD, talk about optimal first-line treatment for glaucoma and how to introduce a more interventional approach in this engaging podcast episode.
Christine Funke, MD:
Hey everybody. Christine Funke here talking to you guys for Ophthalmology 360, and I have 2 of my favorite people with me, Brian Shafer, as well as Morgan Micheletti. We’re going to get into some information about glaucoma and how we see it and how we like to treat people. With that being said, everybody want to say hi?
Brian Shafer, MD:
What’s up everybody? Good to see you Christine. Good to see you, Morgan. Can’t wait to talk to you guys about my favorite topic: glaucoma.
J. Morgan Micheletti, MD:
Hello Brian and Christine, it’s a pleasure to be with you here right now. Excited to get into this.
Christine Funke, MD:
Awesome. Today, I think really what we’re trying to focus on is first-line therapy and how we’re starting to kind of morph, how we’re treating patients when they first come into the office and are getting diagnosed with glaucoma. That being said, I’m going to kind of push it over to Brian first and talk about when you are starting to look at that first patient walking into the office, what are you looking at for first-line intervention at this point?
Brian Shafer, MD:
Before deciding exactly which intervention I’m going to do, the first thing I think that’s critically important that we’re all realizing is how necessary a really solid and efficient workup is for these patients. All of us on this call and a lot of our viewers spent a lot of time with patients who are glaucoma suspects or are recently diagnosed with glaucoma, and it’s our responsibility to quickly evaluate: A, Do they have glaucoma? B, What is their subtype of glaucoma? C, Have they been treated previously? D, What is their target IOP? It’s a lot for us to figure out in a single visit.
For you, Christine, I’m excited to hear how you deal with this because you’re really a true not co-manager in a formalized sense with the 54, 55 modifier, you’re a true glaucoma co-manager. For those who are not quite as co-managing, we have to do all of the testing right out of the gate, decide if they have glaucoma, and if the answer is yes, then ultimately decide how much do we need to lower their pressure and therefore by which method are we going to do that?
For me, at this point in time, I would say that 90% of my patients who come in with new diagnosis POAG are going to have first-line DSLT.
Christine Funke, MD:
Awesome. Morgan, what about you? How are you seeing first line and especially also with SLT, and are you using DSLT?
J. Morgan Micheletti, MD:
Yes, DSLT has made my life easier, not just from a throughput and the number of patients we can move through that sort of a treatment kind of in a day, but also like Brian said, I mean from a comfort standpoint. We purchased 2 of them and put them in 2 of our ASCs, which are connected to clinics. There’s some benefits to putting it in the ASC, but for me personally, I was in the same boat, Brian. I’d see a bunch of YAGs on the schedule and it’s like, “Cool, no problem. YAGs all day, no problem.”
But you start seeing 5, 10, 15 SLTs and between your arm and your neck, it’s a workout, it’s a marathon almost. I think just from a comfort and ergonomic standpoint, it’s been a huge benefit. Then obviously just the throughput. We’ve really been able, because it is just such an efficient procedure with similar results to SLT, we’re really able to get a lot of the optometrists on board. It’s really helped to just improve the number of patients that are getting treated.
It’s a more efficient way of going about that first line of treatment. I think it’s important to note that, even this, I mean just SLT in general in 2019 with the LiGHT study, which has what really pushed it to the forefront. Yet, when we look at what people are doing in their own practices with SLT versus drops, it’s still amazing to me that drops still make up the majority of first-line therapy for most people. I think more recently, people are willing to flip the script on that. Many of us on this podcast have already done that.
For me, when I see a patient that comes in, I agree with Brian. All of my patients, for the most part, if it’s a newly-diagnosed patient, mild, moderate, it’s SLT first line. I will typically start some sort of medication to show the patient how important it’s to have a treatment, something to help lower the pressure. Because it can take a little bit of time to get onto the schedule and get it all taken care of, but it’s a bridge.
It’s a means to getting them to the next treatment that is going to sustain them and not something that they’re going to forever be on while experiencing all of the unpleasant side effects of topical medications.
Christine Funke, MD:
We know even a single med, people just aren’t filling them compared to coming in, having laser, and then not having to be concerned when it comes to if they are or aren’t taking treatment, which is awesome. That being said, we’ll start with Morgan on this one, but how did you start to adapt to this model, because all of us trained in the world where dogma of glaucoma treatment was drops, then drops, and then maybe a filtering procedure.
This is a big switch, and I think it’s something that’s probably scary for a lot of people. How did you get there? How did you get to the place where you thought intervention is best first?
J. Morgan Micheletti, MD:
I mean I think we bridged kind of our own mind gap, if you will, with MIGS being associated with cataract surgery. Once you’ve kind of bridged that in your own mind that, wow, this is actually a really safe procedure and you can start to decouple MIGS as we have now from cataract and turn it into a standalone procedure even in phakic patients, all of a sudden it unlocks so many doors. It used to be like you said, start drop 1, start drop 2, 3. “Now let’s intervene. Maybe we’re doing some of this.”
I mean, I remember in residency that was even what we were taught. We sometimes wouldn’t even consider SLT until they were on 3 medications. It’s been a whole change in the mindset and how we approach things because we’re now looking to intervene. It does change the discussion with patients a little bit because they’re used to, “You have a problem, start a medication.”
But I think it’s easy to draw parallels between what we do and a cardiologist per se. They start medications to help lower blood pressure, help control heart rate, things like that. But at a certain point you got to go in and do a Roto-Rooter and place some stents and it’s very similar. That’s kind of how I’ve been able to discuss this with my patients and really get them on board because that’s kind of the next step. Once you get on board and you’re comfortable, then it’s getting your patients on board.
To be honest with you, it has been significantly easier to do that than I would’ve thought. You believing in an interventional mindset and adopting that really translates to your patients a lot quicker than many people think.
Christine Funke, MD:
I agree. I think it translates also to all the support staff around you because if they’re in and the optometrists who work with you are in, then again, I think the ball of IG gets rolling. Then, Brian, what do you think with adopting this mindset, have you noticed a change in your tube and trab volume? Have you been seeing a change there?
Brian Shafer, MD:
Absolutely. I can think of a very recent patient who is near and dear to me because I’ve seen him so much lately who came to see me. His eye was beet red from his eye drops, and he is pseudoexfoliation, very asymmetric. Left eye was the only one truly affected, and he did not tolerate any medications. He was still phakic and we talked about the different options and for him, I ultimately decided to do a cataract plus canaloplasty plus a stent to see if we could get him low enough off of drops that we could at least freshen up his eye.
Ultimately, he was one of those patients. Christine, I actually texted you about him. He was the one I said to you, I was like, “Do you ever feel like some people’s angles are just dead?” Because despite perfect surgery where… I use the iTrack™ Advance, so I watched that beacon light go all the way around. I watched that Hydrus® go right straight through and his pressure was still 40s afterwards. That’s the person I’m still reserving filtering procedures for.
Christine Funke, MD:
I think that’s great.
Brian Shafer, MD:
Aside from that, ideally we’re avoiding a lot of that and we know that the LiGHT trial even showed us that SLT could prevent us from going on to filtering procedures and secondary interventions. I thought of something while Morgan was just talking about the shift into interventional glaucoma as a practitioner. I almost feel like the 3 of us were kind of like the classic millennial where we remember the times before IG, we were there for when IG happened, and then we grew with IG kind of like we did with the internet and cell phones.
We remember what it was like before then and we remember that there were some beautiful parts of that, but things are a lot better now that we have access to these sorts of things.
Christine Funke, MD:
I think, too, being in private practice myself, you hang on to patients. The longer you’re sitting in practice, the first year or 2, you’re not really realizing what you’re kind of marrying into with patients. But as you get to see them longer and longer and create these relationships is when I think the IG mindset might change too. Of saying, “I want to leave this disease early.” I think that’s another really important point that we all, I think, are kind of glommed onto at this point, which is if I can keep this disease young and early, all these interventions work better, 1, and 2, we don’t have this potential terrible outcome of somebody losing a lot of vision and also losing a lot of function.
I mean, that’s great because it used to not be that way. But I do think private practice changes your mindset a little bit, especially when you’re doing high volume too, because you get to see that change quicker.
Where do you guys think procedural pharmaceuticals are coming into this picture? Because that’s also, I consider to be very early intervention. I love procedural pharmaceuticals. I personally think it’s those doors are going to continue to get wider and are going to have more and more options. I use them probably more often than not after SLT for most patients because I do think SLT… I like using it first line. I do think it has maybe a slightly less risk profile, but what do you two think?
J. Morgan Micheletti, MD:
For me, it really depends on where the patient is in their journey as it does for all of these patients, but in terms of their cataract status. For me, if a patient is, let’s say they come in, they’re newly-diagnosed with a glaucoma, and they have a cataract, I’m probably going to go take the lens and combine it with something else.
In some patients who have been on a lot of drops and they come in, is it nice to throw a Durysta® in right away because they’ve been on these drops and you give them a little drop holiday and kind of tide them over while you get them squared up for SLT or whatever the next step may be. As the gates continue to open and it becomes more and more available to more people, I think it’s something that’s going to continue to be adopted earlier in the course.
In a perfect world, I mean assuming this is… coverage for everyone. I think if a patient came in and right away you could give them Durysta® and then get them scheduled for SLT and then at some point do some other intraocular procedure like MIGS or a procedural pharmaceutical like iDose (travoprost intracameral implant) 75 mcg that’s more inside the eye and you can clean out whatever was left over from the Durysta® at that time. I mean, to me that’s kind like the ideal in someone who’s continuing to progress or at least looking at it over the years.
Unfortunately, that’s not exactly the world we live in, but I think we’re hopefully getting closer as we continue to push along this pathway and show how efficacious these procedures and procedural pharmaceuticals are.
Christine Funke, MD:
I totally agree. Mechanistically too, it makes sense, which makes me happy. The scientific part of me always wants to understand what we’re doing and that it makes sense. Again, if we do this stuff early, I think we see a lot more success. I think doing SLT and then also doing an intracameral prostaglandin, they each are having their own mechanism of action. My hope is that I’m fixing multiple things with very small intervention.
J. Morgan Micheletti, MD:
I think another important thing to add to that is we’re not saying we would do these things because it’s covered by insurance. I think all of us believe that if this were us in the patient chair, it is what we would want for ourselves.
Brian Shafer, MD:
Agreed.
Christine Funke, MD:
Absolutely. It’s what I would do for anybody. It’s not even just blindness. That used to be the only thing we talked about. Now it’s just losing anything in terms of vision, which could alter somebody’s lifestyle because decibels of loss can mean a lot of change to people. All these things hopefully will keep anyone from having something that keeps them housebound or feeling uncomfortable with taking care of themselves. It’s a really good step in the right direction for this disease state.
Also, when I think about the risk factors associated with these minimally invasive, whether it’s MIGS, whether it’s injectables or drug deliverables or SLT, I think about the risk associated with all those. Then I think about the risks I see with eye drops every day, and I’m starting to change my tune about… drops are not a risk-free decision. We know just looking at the LiGHT trial, if you just look at the risk profile or the adverse effects profile of drops versus the SLT, even that the list was super long for drops and super short for the SLT.
It’s another nice discussion that I like to have with patients when they’re like, “I just want to do a drop.” It’s like but you’ve got to understand the risks actually of the drop in a lot of patients are higher than the things that we’re talking about otherwise. Do you guys feel the same?
Brian Shafer, MD:
I definitely feel the same. It’s so obvious when a patient walks in on chronic prostaglandin, they’ve got the prostaglandin look. Aside from just the cosmesis associated with it, the chronic lid disease, the chronic irritation on the surface of the eye, these are way more symptomatic aspects of glaucoma than glaucoma itself and… for at least the early disease patients and avoiding that is definitely something I would want to do.
J. Morgan Micheletti, MD:
I think we’ve transcended the point in glaucoma care where we solely look and judge a patient’s wellbeing or status in terms of just their vision. We’re looking at their entire quality of life. When you do that, it’s the drops, it’s the side effects, it’s the cost of the medications and keeping up with them. Then you have obviously the vision loss and decibels and all of these other things that create this big picture of that person’s life.
We have shown now with numerous publications how much better procedural intervention can be compared to just throwing more drops at a patient.
Christine Funke, MD:
With all this, because I think if anybody listens to this, I hope those who aren’t as procedurally forward or interventionally forward as the 3 of us are, feel more motivated, but then here comes the question of, how do they get over the barrier to get there and what are the barriers you guys think that are keeping people from the interventional mindset? Morgan’s got his hand up, so you’re first.
J. Morgan Micheletti, MD:
I mean I think some of the barriers we’ve already discussed. I mean one of those is clinician inertia, and so most of us were trained with drops first, and it’s like you said, Brian, we’re the millennial generation. We’ve seen both sides of this coin, and so it’s easy for us to move on and hopefully the younger generation, same thing. But still, you have to take those first steps and I think that at least from a getting inside the eye and being more procedural, the easy step is just to start considering MIGS in all of your patients who have glaucoma at the time of cataract surgery and then SLT is first-line treatment.
If you can start with that, I think that’s a great way to get over it. Then you can start talking about access, which we talked about, or even the training and feeling comfortable with the procedures, and that’s just being in private practice a lot of times don’t have that red tape and can move quickly, but plenty of academic centers can move very quickly and want to to train residents, and so I think there is that as well. We talked about the reimbursement issues and I think that’s certainly a barrier for some things but not all and is improving.
Then there’s the patient fear or misconception about surgery and interventions, and that one’s actually easier honestly of most of the… because I was thinking in my mind, what are all these barriers? I think that’s actually the easiest one to get over. Then really the last one is do surgeons believe in it? Is there proven efficacy for SLT and MIGS? We have numerous studies that are repeatable and with long-term data that have just shown that all of these things work and they work well.
I think that we also have so many more tools nowadays than we used to in terms of eye models and skills labs, and there are I think 4 MIGS skills labs both provided by the Young Eye Surgeons and just the ASCRS skills lab that if you’re new and want to get into MIGS, that’s a great way to do it. The Academy provides some wet labs as well, and then obviously there’s just getting some kits yourself. Plenty of artificial eyes exist and getting comfortable with the surgical microscope and a surgical gonioprism aside from just an in-clinic gonioscopy like Brian said, which is such a great point.
I completely skipped that step, but it’s so true. It’s a great way to, if you have those fears, you’ve had those anecdotes and you’re concerned about it, get in there and practice. That’s how we all learned cataract surgery, and I don’t think we should expect MIGS to just be something you do once and you master. It’s something that most intraocular surgeons can become comfortable with pretty quickly with the right mindset, but there’s no reason that we shouldn’t all be practicing these things kind of on our own before doing them anyways.
Christine Funke, MD:
I was just going to say to piggyback off for a bit of both of you guys and what you’ve said, which is kind of tiptoeing in, don’t be overwhelmed. I mean, because one thing that’s hard. If you look at the list that we now have available for interventionally forward individual surgery, I mean it can get overwhelming. There’s a lot out there. I just say take it 1 step at a time, get comfortable with 1 procedure and then move on to the next. Don’t try and overwhelm yourself and learn 6 different things.
It never goes well that way. Just be gentle and patient. I think all 3 of us were just lucky enough that we kind of grew into this world of IG and one thing was kind of presented 1 at a time. But if you’re coming into it now, it can feel again overwhelming. Also to remember too that get comfortable with the things we’ve been talking about as first line. Those are really usually gentle approaches to glaucoma and glaucoma treatment.
As you start to realize what effect you’re having on your patients, I think then you’ll move into wanting to do more and more interventionally forward work because you just see the effect that it has on the patients and also on a lot of the referring providers. I can’t tell you the number of ODs I have just amazing conversations with them how different their style of treatment is for glaucoma now that I have changed my style of treatment.
Brian Shafer, MD:
Morgan, you mentioned the wet labs that are different at the various meetings, and that’s a great point. That is a great way to access this. The other place that is now available for people to learn more and more about this is the IG Masterclass series, which we’re going to get ready to do the second iteration of. I know Christine and I are both faculty for that one coming up in just a couple of months.
That was great the first time around. I think we changed a lot of people’s perspectives and added a lot of confidence to their ability to really engage in IG, and it’s a really well-structured class where there’s a bunch of different modules going over all the didactic information and then an in-person where there’s wet labs as well as didactics and just good conversation.
Christine Funke, MD:
I agree. I think that’s a really great way. If you really want to get more interventional, it’s an awesome way and you feel super supported, and we have a group that you actually have a chat with, including somebody who’s more forward-thinking like all 3 of us are, and then you can actually talk to them even after Masterclass is done so that you can have just a touchstone in case you feel lonely ever about it. Awesome.
Well, I thank you guys. I think that’s all the time we’ve got tonight, but I wanted to thank all of you for an awesome conversation. Hopefully this is going to help a lot of people with what they want to think about when they see a first newly-diagnosed glaucoma patient walk into the door, and hopefully we’re just going to keep moving the needle of IG forward.
J. Morgan Micheletti, MD:
Thanks, Christine and Brian, thank you as well. I absolutely love listening to both of you talk. I learned so much from you both, so thank you.
Brian Shafer, MD:
Right back at you.
Christine Funke, MD:
Me too. Thanks you guys, and thanks for Ophthalmology 360 for having us together tonight. Have a good one.
Brian Shafer, MD:
Thanks everyone.
IMPORTANT SAFETY INFORMATION for iDose® TR (travoprost intracameral implant) 75 mcg
Dosage and Administration
For ophthalmic intracameral administration. The intracameral administration should be carried out under standard aseptic conditions.
Contraindications
iDose TR is contraindicated in patients with active or suspected ocular or periocular infections, patients with corneal endothelial cell dystrophy (e.g., Fuch’s Dystrophy, corneal guttatae), patients with prior corneal transplantation, or endothelial cell transplants (e.g., Descemet’s Stripping Automated Endothelial Keratoplasty [DSAEK]), patients with hypersensitivity to travoprost or to any other components of the product.
Warnings and Precautions
iDose TR should be used with caution in patients with narrow angles or other angle abnormalities. Monitor patients routinely to confirm the location of the iDose TR at the site of administration. Increased pigmentation of the iris can occur. Iris pigmentation is likely to be permanent.
Adverse Reactions
In controlled studies, the most common ocular adverse reactions reported in 2% to 6% of patients were increases in intraocular pressure, iritis, dry eye, visual field defects, eye pain, ocular hyperaemia, and reduced visual acuity.
INDICATIONS AND USAGE
iDose TR (travoprost intracameral implant) is indicated for the reduction of intraocular pressure (IOP) in patients with open angle glaucoma (OAG) or ocular hypertension (OHT).
Please see full Prescribing Information.
You are encouraged to report all side effects to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. You may also call Glaukos at 1-888-404-1644.
Risk Information
The most common side effect of iDose TR was increased eye pressure. Other common side effects were inflammation of the iris, dry eye, a loss of part of the usual field of vision, eye pain, eye redness, and reduced clearness of vision.
IMPORTANT SAFETY INFORMATION for iStent infinite®
INDICATION FOR USE. The iStent infinite® Trabecular Micro-Bypass System Model iS3 is an implantable device intended to reduce the intraocular pressure (IOP) of the eye. It is indicated for use in adult patients with primary open-angle glaucoma in whom previous medical and surgical treatment has failed. CONTRAINDICATIONS. The iStent infinite is contraindicated in eyes with angle-closure glaucoma where the angle has not been surgically opened, acute traumatic, malignant, active uveitic, or active neovascular glaucoma, discernible congenital anomalies of the anterior chamber (AC) angle, retrobulbar tumor, thyroid eye disease, or Sturge-Weber Syndrome or any other type of condition that may cause elevated episcleral venous pressure. WARNINGS. Gonioscopy should be performed prior to surgery to exclude congenital anomalies of the angle, PAS, rubeosis, or conditions that would prohibit adequate visualization that could lead to improper placement of the stent and pose a hazard. MRI INFORMATION. The iStent infinite is MR-Conditional, i.e., the device is safe for use in a specified MR environment under specified conditions; please see Directions for Use (DFU) label for details. PRECAUTIONS. The surgeon should monitor the patient postoperatively for proper maintenance of IOP. Three out of 61 participants (4.9%) in the pivotal clinical trial were phakic. Therefore, there is insufficient evidence to determine whether the clinical performance of the device may be different in those who are phakic versus in those who are pseudophakic. ADVERSE EVENTS. The most common postoperative adverse events reported in the iStent infinite pivotal trial included IOP increase ≥ 10 mmHg vs. baseline IOP (8.2%), loss of BSCVA ≥ 2 lines (11.5%), ocular surface disease (11.5%), perioperative inflammation (6.6%) and visual field loss ≥ 2.5 dB (6.6%). CAUTION: Federal law restricts this device to sale by, or on the order of, a physician. Please see DFU for a complete list of contraindications, warnings, precautions, and adverse events.
PM-US-2712
The doctors were compensated by Glaukos for their time.
Third-party marks are property of their respective owners.
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