Insights and Considerations for Interventional Glaucoma, MIGS, and Collaborative Care

Eva Liang, MD:

I am Eva Liang from Center for Sight in Las Vegas. I’m a comprehensive ophthalmologist that specializes in complex anterior segment disease, including glaucoma and cornea disease.

Question:

What advantages and disadvantages do you see in treating patients in the interventional glaucoma paradigm? Is interventional glaucoma the right answer in treating glaucoma in the future?

Eva Liang, MD:

So what’s been interesting about glaucoma since the advent of iStent and the other MIGS devices is that the paradigm shift towards treating earlier is definitely here to stay. The patients embrace it. Most of the patients that are being offered a device or procedure to help lower their eye pressure really love the idea of having the opportunity to get away from the drop. So I think that in the beginning, patients like the idea of a drop because it doesn’t sound that bad.

So I think a lot of people start off with SLT and then drops. I think in our practice, patients tend to gravitate more towards drops than SLT if given that option because the drops don’t sound that bad. But after they’ve been on the drops for a while, they definitely want some freedom from the drops, as it is a daily routine that they’re not always the best [inaudible 00:01:29] plus the expense and so forth. The other problem is the ocular surface disease that they ultimately get if they don’t already have when they’ve been using glaucoma medications for a long time. So being able to offer them a device or procedure to help reduce their dependence on drops is very appealing to the patient.

Question:

What advantages does MIGS combined with cataract surgery present to both the surgeon and the patient? Is the combined procedure right for all patients?

Eva Liang, MD:

I think the combined procedure is great for everyone involved because they’re already in surgery, we’re already there. Yes, cataract surgery alone has been shown to lower pressures, but most of the studies show that in combination with the device or with the procedure, they do have lower pressures or lower medication burden. So I think for the patient, it’s very appealing because they already there for cataract surgery.

Question:

In your viewpoint, does the patient have better chance of success for a quieter eye following an invasive-filtering procedure?

Eva Liang, MD:

Having the patient undergo a combined procedure with some mixed type of procedure with cataract surgery definitely lends to a quieter eye in the long run if we can get the patients off of drops. Some of the procedures are quite successful at getting patients medication free. So I definitely think that in the long run, the combined procedure is definitely the way to go.

Question:

With a rapidly aging population, the number of glaucoma specialists to treat those patients is in decline. Should glaucoma specialists endorse refractive and comprehensive ophthalmic surgeons to perform MIGS? Would glaucoma specialists be receptive to having other subspecialties intervene and perform MIGS?

Eva Liang, MD:

I think they absolutely are. I would say it was a glaucoma surgeon that encouraged me because I’m really a comprehensive ophthalmologist and it was a glaucoma surgeon that highly recommended that I embrace MIGS. This was probably back in 2013. It was Dr. Crandall, Alan Crandall, and he encouraged me to take it on, and I think it was actually quite straightforward once you set your mind to it. I mean, as cataract surgeons or anterior segment surgeons or even corneal surgeons, we all have a skillset to perform microsurgery. So we all have the skillsets. You might change things up a little bit, tilting this or tilting that and getting used to some of the actual techniques that are necessary to provide this surgical service. But they’re all within our wheelhouse. And once you start doing it, I think you’ll find that it’s something you’ll find that you’re very confident and competent and confident in performing.

I was lucky in that I started probably in 2013, maybe early 2014, and I started with the iStent and it was the first generation iStent, and I felt like that was actually a great way to start because of the technique, you have to hook it into the canal. I think the second generation iStent, yes, it’s nice in that it’s these two shots basically or two tacks that you’re putting into the trabecular meshwork that connects into the canal, but there is a little bit more finesse because the patient has to be very still and you can’t really anchor into the canal like you do with the G1. So that device I think is still around. So if you wanted to start that way, you could. But once you start working in the angle, I think adapting to new or other procedures is pretty straightforward.

Question:

How could glaucoma specialists bridge the gap between the subspecialties and encourage more eye surgeons to perform MIGS?

Eva Liang, MD:

Well, I think it’s going to get forced upon us because you go to refer a patient to a glaucoma specialist, and it could be three or four months before you even get them in, and you can only call them so many times for this other patient that really needs it. So you really have to prioritize what goes through the glaucoma specialist and what you can manage. And I think that it’s perfectly reasonable and it is within the standard of care for comprehensive or general ophthalmologists to be doing MIGS and managing glaucoma, managing mild to moderate glaucoma and perhaps even more advanced glaucoma depending on how comfortable that doctor is.

The patients want it. I mean, for the most part, patients really value their relationship with their eye surgeon or their primary eye surgeon, and they will want to be with you if you give them that opportunity. I mean, I’ve had many patients in my career where I’ve wanted to refer them out and they really reinforce, “Gosh, I feel so much more comfortable with you. Isn’t this something you could do?” And I think that’s a very common phrase that you’ll hear from patients once you engage in that conversation.

Question:

What knowledge and techniques are required for a refractive and comprehensive surgeons to become a competent MIGS surgeon? How much training is required? How much of a learning curve is there for surgeons?

Eva Liang, MD:

Well, with anything, I think it’s better to be prepared for the worst and be pleasantly surprised when you’re not having to go through all of that. I think starting by looking in the office with gonioscopy more frequently, so you’re identifying the structures and getting more comfortable with the anatomy first. And then once you’re in the OR at the end of the case, perhaps tilt the scope, tilt the patient’s head, use a gonioscopy just to take a look so you get comfortable getting into that position. And then once you’re ready to dive in, obviously there’ll be support from whichever device manufacturer you are choosing to begin with will definitely send support to help get you going, and they will be there step by step and give you advice to help you have a successful case. And they’ll provide that support for really as long as you need until you are comfortable.

Question:

What advice would you provide for refractive and comprehensive surgeons who may be interested in adding MIGS in their practices?

Eva Liang, MD:

First, just try to take in as much information as you can. There’s so many different ways to get information now, whether it’s throwaways or in journals or podcasts or meetings. YouTube, YouTube’s a fabulous thing. I mean, we joke around in life. Whenever you need to fix something, it’s like you go on YouTube. Quite frankly, you can go on YouTube and see plenty of videos about these types of medical procedures. I mean, I do that myself if I’m learning a new technique.

I learned to DSEK that way. I mean, I did take a course, but then before you go in the OR, you just refresh yourself with a video and run through the technique. And like I said, those first few cases, you’ll have some support. I think all of these devices have slightly different mechanisms of delivery. The handles might be a little different and how you deploy them may be different. So I always think it’s a good idea before you walk into the OR if you do have that support to ask to play with the device, make sure you know how it all operates before you get into the eye. And then once that’s nice and fresh, you’ll be ready to go once you’re in the OR in the eye.

I have been tossing around a concept with some surgical colleagues about surgical coaching where people could hire a surgical coach to come in and help the new surgeon who’s trying a new procedure and be in the OR with that surgeon and giving them tips along the way. It’s not something that I think is currently available, but hopefully in the coming years, it’s something that can be developed where there’s a group of coaches that can be accessed, whether it’s directly or through industry, where an industry vendor that wants to support the rollout of a device may hire some surgical coaches that are there with the surgeon to do new procedures.

So that’s something that we’ve talked about. And I think, I know personally when I was just starting to do DSEK or DMEK, I would’ve loved to have had a surgical coach that I could have hired or bring in to walk me through it and be in the OR with me to help anticipate any of those problems. We just don’t have a proper system for that now. Certainly, I think if you’re in a group and there are other colleagues within the group that could be helpful and you can tap some of your subspecialists that might join you for a case or two, I think that’s great. Or if you have some mentors that are in your community that wouldn’t be that much of a burden for you to have that person join you in the OR, having a surgical mentor I think is always the best way to go.