Interventional Glaucoma and The Unmet Need of Stand Alone Patients
Blake Williamson, MD:
Hey everybody, it’s Dr. Blake Williamson from Williamson Eye in Baton Rouge. And I’m here hanging out with my really good friend, Dr. Deb Ristvedt tonight. And she’s going to be talking with me a little bit about interventional glaucoma, and the unmet need for standalone patients. Deb, what’s going on? You’re going to Florida tomorrow with the kids and the fam, right?
Deborah Ristvedt, DO:
Blake, I’m so excited, my friend. You and I both love to wake surf, but right now I’m looking at a frozen lake, and so we have to get away just for a week until that ice melts so that we can enjoy some sunshine and some water. But man, I am so honored to be with you today. You’ve been traveling all over as well and teaching, and I just always look to you as a mentor too and a friend.
Blake Williamson, MD:
I feel the same way. And I’m looking forward to our conversation tonight that’s really centered around something that I know that you and I are both passionate about. That’s the idea of standalone MIGS, the idea of interventional glaucoma. I’ve had a chance to spend time with you on the podium and at different symposia talking about this very topic, so no one better to speak to than you on this. So maybe getting started, are you hearing like I am, at different conferences and around your market that people are just getting more tired, surgeons are getting more tired of doing the drops first approach, the so-called wait and see paradigm, and more and more thinking about doing something for patients, especially standalone patients, who need something done for their glaucoma?
Deborah Ristvedt, DO:
Yeah, absolutely. Glaucoma is the second leading cause of blindness, and the first leading cause of permanent blindness worldwide. And I think we’re finally getting somewhere as doctors are saying, “Hey, we have all of these devices that have come to the market. Why are we delaying treatment? Why are we taking this reactive approach to glaucoma, instead of a proactive approach? And as you know Blake, most of our patients fortunately, have mild to moderate glaucoma, but I remember first joining and joining my dad in practice, and we had a string of glaucoma patients that he had been following for years and years and years. And it’s almost like you would react when the visual field changed, or when their vision changed, or when they were noticing changes.
And I finally feel like for the first time we actually have the opportunity to say, “Hey, let’s be honest with ourselves. We’re burned out with watching and waiting, and taking this reactive approach. Can we be more proactive?” And then lastly, we’re finally being honest with how patients are doing. What is their quality of life? How is their ocular surface? Are they really, really compliant? And for the first time we are looking at the data showing, no, actually our patients are not compliant. And so what can we do about that?
Blake Williamson, MD:
Yeah, why don’t you think … You mentioned the wait and see. And why do you think the current treatment paradigm isn’t working? What are some of the limitations that are obvious to you and I, but maybe not everybody’s thinking about it?
Deborah Ristvedt, DO:
Yeah, I think first and foremost, we as doctors, we feel like we try to give the best education possible to our patients. Nevertheless, they leave very confused. And so the higher complexity of the treatment and the drop regimen, the more difficult it is for patients to really understand what they’re supposed to do. And I have a majority of patients that say to me, “Doc, my vision’s not getting better with these drops, so I stopped them.” So that lack of understanding is real. And then you go into, you have one medication that works pretty well, but then you add a second or a third. Number one, we’re not getting as great of IOP reduction as we add more drops. We know that. And then lastly, we know that patients, the more drops we add or the more times a day we make them take drops, the less compliant they’re going to be.
And so again, we’re finally looking at this to be like, “Whoa, we’re causing ocular surface disease. Patients are getting fluctuation in vision and side effects from medications, and are they really doing the job 24/7? Are we really getting that IOP control that we need?” And so those are the big limitations of medications. And so not only that, but then we look at the economic burden. Once patients are starting therapy, they’re pretty much on it for life. And so we look at that burden to the patient, and we’re trusting that, that patient is doing what we think they’re doing. But we know that a majority of these patients will either stop their medication after a year, or they won’t take it correctly. And so those are the reasons why my passion and your passion to say, “Gosh, how can we help our patients?”
Blake Williamson, MD:
Yeah, I think that when you have the patients that come in who have glaucoma and they’ve had a recent procedure, whether it’s a SLT, or a YAG, or something, and they’re taking their steroid drops instead of their glaucoma drops. Or they say, “Oh yeah, I’m taking my drops. That’s the pink top, the milky white drop.” And I’m like, “No, that’s your steroid. That’s the complete opposite.” They’re just not doing it. And gosh, my own experience, I had LASIK surgery a few years ago. And even after a few days, I was supposed to take my post-op regimen of Cipro or Pred or whatever, for the full week. After about three days I stopped. And I’m an ophthalmologist. I’m a refractive surgeon for god’s sakes. The point is that I was doing great. I was having no problems, and after a few days I just stopped taking my drops a little early, so I was not totally compliant in my own eyes.
Well imagine that, stratify that towards sometimes an elderly patient who is seeing, okay, maybe they have mild to moderate glaucoma, no pain at all. It just doesn’t cross their mind. And especially if they have a thousand other things that they’re taking medications from. I don’t think that we appreciate enough that our patients, these glaucoma patients, have a lot of other things going on, and frankly, their eye drop is just not top of mind when they’re worrying about their ejection fraction of their heart. So at what point do you think clinicians just start to avoid drops at all and just go straight to an SLT or a Durysta, or iDoses coming out? What was that moment for you that, “Ah, the hell with it moment.”?
Deborah Ristvedt, DO:
I think it was really starting to educate our referring optometric network. We all work as a team, and we all have to be on the same page when it comes to treatments and therapy. And so when we look at the LiGHT trial, I think that’s when a lot of us were like, “Finally we have some really good data to show why we’re doing first line SLT in the first place.” And so when we look at glaucoma as a long-term disease, when we look at therapy when patients are starting maybe in their 50s or early 60s, hopefully they’ll have a great quality of life for a long time. And so when I started to ask the question of, how is this affecting this person’s life with having to take another medication or now they’re complaining of dry eye syndrome?
And I know it’s probably because of the preservative in this drop, I really started to shift towards, “You know what? We can do a laser as first line therapy. We know that it’s just as effective as starting a drop, it will last two to five years per data, and it’s just as effective. Would you like to maybe think about that?” And the way that you phrase it, is really the importance of how the patient responds. If you’re going to say, “Yeah, I’m going to burn some holes in your eye.” They’re not going to like that, but it really isn’t that way. And so I feel like the more knowledge optometrists had in the community of saying, “Okay, I have an option maybe to start a drop, or I can give my patient this option.” More patients came in educated saying, “I want option B, I want SLT.” And then you look at how medications are delivered. How exciting that we now have two different medications that take that burden off of the patient, side effects are less?
They work just as well. And we’re getting anywhere from 15 weeks to now three years with these types of drug-eluting products. And so it’s really exciting to see where we’re headed, because I don’t feel like drops or medications are bad. We know that drops can be really good, and we have the tried and true Prostaglandin say, and we have these new medications on the market, and we have preservative-free medications. But it’s depending on that patient to actually take the medication that can be the issue. And then the lack of understanding that this is a long-term disease, and that we have to work together as a team and referring clinics. So if you do a lot of MIGS and your ophthalmology partner doesn’t, or if there’s an optometrist that sends you their patients, that we’re all working together to say, “Let’s change our mindset here, and take more of an interventional approach.”
Blake Williamson, MD:
I love that. Yeah, especially, I just think that for me, my aha moment where I just said, “Enough.” Was, I thought to myself when I was talking to a patient, they were already on latanoprost, and I was about to put them on Combigan, or something like that. They had some progression. And in my heart of hearts, I asked myself, I was like, “Do I really think there’s a better than 50% chance they’re going to take these drops 50% of the time?” And if you’re being honest with yourself, more often than not, the answer’s no. And so then you have to really look yourself at the mirror and say, “Am I doing right by this patient, if I think that I’ve got a 50/50 shot that they’re going to take these drops even half the time?” And that’s when I said, “I don’t feel that way. I think that I’m better off, I feel more ethical, more moral, feel like I’m doing the right thing by doing SLT first.”
To your point, not that I’m saying drops are unethical. We’re not trying to … I’m sure the mixed companies would love that. No, they wouldn’t. But drops are great. You’re right. But if patients aren’t going to take them, they’re not going to take them. So anyway, that moves us on to the idea of success. I love talking about success with MIGS, especially in this whole interventional glaucoma paradigm that we’re talking about, standalone MIGS, patients who’ve already had cataract surgery, they’re pseudophakic, they’re having some progression, and you got to take them to the OR just to do a MIGS procedure. You’re not doing cataract with it. And so that’s been a big barrier, because honestly, I think one of the reasons, there’s many reasons, but one of them is I think there’s been a big question mark about what is success? Is it five or six point drop in IOP? Is it a greater than 30% reduction in pressure? Is it getting off one medication at two years, or is it just that you’ve not gone on to have another procedure, just delaying further surgery?
So I don’t know. It’s a hot topic and I think it’s sort of delaying some of the progression of this mindset of the interventional glaucoma paradigm. What do you think, Deb, how are you describing treatment success in this new MIGS era?
Deborah Ristvedt, DO:
Yeah, I look back just on my journey of MIGS. And I’ve been out now for 13 years, and we didn’t have MIGS in residency. And so here I am, a new doc. And I remember that the eye stent came out, and I was just like, “This is fascinating, that maybe we could do something at the time of cataract surgery to help these patients.” And I was just so curious about this space. And now look where we are, Blake. It’s just phenomenal to see how really MIGS has revolutionized, how we’re treating our glaucoma patients, whether it is with cataract surgery or if it’s standalone. And I think initially when we had that opportunity to say, “Hey, we’re just going to treat glaucoma, we’re not taking out the cataract.” I think that made a lot of docs nervous, because maybe they didn’t feel like there was enough data around going back to the angle, or maybe they felt unsure, or not confident that it would truly produce the IOP reduction that they wanted.
But now we know from multiple studies that standalone glaucoma is effective. And I describe it to patients as, “Do you remember cataract surgery? It’s kind of like that, where we go in, you’re slightly awake, but you’re really relaxed. And it’s our goal to really help to optimize your natural outflow pathway.” Because that’s what most of the MIGS devices do. And so I think my aha moment for standalone was to say, ‘Wow, if we can be proactive and not wait until their visual field is severe stage, or if we can lessen the medication burden, where maybe they’re taking two or three drops and they’re having side effects from those, or just not tolerating them. If we could say, “Okay, Mrs. Jones, you’re on two medications. We know that you’re having a difficult time. We know that our data suggests that we could get you off of a medication. Would you like that?” And they’re like, “Absolutely.”
And then to the point of being pseudophakic, they’ve been through cataract surgery, so they have experienced what that’s like, and so they can relate to that. And then the last thing is, when we look at the safety profile, my goodness, to know that this is just as safe, when you look at say, cataract surgery with MIGS, as cataract surgery alone, that is such a win. And so what are we going after? Are we going after a complete drop reduction? Not necessarily, but it is nice. Are we going after IOP in the eight to 10 range? Not always. We know now that putting pressure in the mid-teens, say 14 instead of having pressure at 17, is a success. Every millimeter in reduction in pressure, gives us about 10% less progression over time.
And so we’re not going after trab like effects a lot of times with minimally invasive glaucoma surgery, but a lot of our patients, do they really need that eight to 10 range? And that’s a question that we have to ask. And then the last thing is, what we have seen with some of these MIGS devices is, when you look and you compare visual fields over time, we see less progression. And I think that truly is because we’re optimizing that outflow pathway. We’re creating less IOP fluctuation, so better 24/7 IOP control. And patients are able to be a little bit more compliant, if we can reduce medications.
Blake Williamson, MD:
Yeah. I think that it’s really important that we can overall just improve their quality of life. And the patient conversation really hasn’t been difficult for me. In terms of success, I just simply tell them, “Success is just simply delaying further more invasive surgery, even if it means that we don’t get you off that drop, even if it means that we don’t have a certain amount of pressure lowering drops on board, even if it means that we have to add a drop for God’s sakes, a year down the line. If it prevents you from having an incisional surgery that’s got a lot more side effects, that’s still a success.”
And so if you set the bar that low, which is nice as a refractive surgeon, because the bar’s set so high, but you can put your glaucoma hat on and say, “Listen, my whole goal is to do no harm, but not make you any worse. And in fact prevent you from having more surgery.” That is a worthy idea of success in my mind. So it makes the adoption of standalone procedures much easier, especially when we know they do a lot better than that low bar. But what about your patient criteria? Is there a certain type of standalone patient that you think is perfect for MIGS? Who might you choose for a standalone procedure? And maybe talk about some of the procedures that you are doing, whether it be stripping procedures or stenting, or the new drug alluded devices?
Deborah Ristvedt, DO:
So I really look at patient criteria in a broader spectrum of, what is that individual struggling with, or how can we help that patient more effectively? And like you said, Blake, we just want to do the right thing for our patients. That’s why we push ourselves to learn new techniques, to learn more. You’re a refractive cataract surgeon and I’m a comprehensive surgeon. And why is it our passion? It’s because it truly is changing our patients’ lives. And how can you not almost tear up from that, when you can reduce that medication burden or prevent them from having bigger procedure that could actually cause vision loss, even though effective in IOP lowering? And so there’s a lot of different patients that are candidates for standalone procedures. I’ve had patients who did great with SLT for a while, but after the second SLT and the pressure starts to go up, and being really not tolerant of a lot of medication, and trying different biodegradable implants, I finally said, “Your pressure is not controlled. You already have visual field loss and you’re only 50 years old. I really think that we need to optimize the outflow pathway.”
And so at that time, he had no cataract, and I went in and we did a canaloplasty with goniotomy at the time, and he did beautifully. And so I really think that getting in and being proactive, really restores this natural outflow pathway. So when we talk about standalone procedures, there’s a lot of them now. We have SLT, which is not going to the operating room. We have a biodegradable implant bimatoprost, which you can do in the clinic that lasts anywhere from 15 weeks to two years in about a third of patients. And now we have our new eye dose drug eluting membrane, which is like a larger stent that you implant in the trabecular meshwork, that lasts over three years. So that’s pretty incredible to have a medication that patients don’t have to take and don’t have to worry about.
Now, when we go into optimizing the angle, we can do so by passing the trabecular meshwork, which is where the most resistance lies, about 70% of resistance. And then we have canaloplasty, which can open up Schlemm’s canal, helping with maybe a little bit of adhesions that have formed, or collapse of the Schlemm’s canal, or herniations of the aqueous collector channels that can all be optimized to restore that natural outflow pathway. And then we have cutting procedures, where you remove some of that trabecular meshwork. And so that’s just the angle. But we also have inflow procedures where you can do ECP or MicroPulse to delay or to decrease the amount of aqueous production.
And then we have our minimally invasive web surgery through XEN® Gel stents, that can also be standalone. So we have a lot of opportunity, a lot of chances in standalone procedures. Our newest standalone procedure in my hands has been iStent infinite. So one stent was less than two, so two was better than one. Now we know that three is better than two. So you can go back after you’ve done prior mixed procedures. And so we’ve seen just great data come out with standalone technology.
Blake Williamson, MD:
And so obviously the results have been fantastic in your clinic. I know we’ve talked about all the different devices that we use, and routinely patients are having success with it. And I think everybody should get on board with this. Any last thoughts as we finish up about, maybe that surgeon that has been on the fence thinking about standalone MIGS and maybe what needs to be told to he or she to push them forward and jump in?
Deborah Ristvedt, DO:
Yeah I, just in closing, encourage doctors to really look at glaucoma now as a proactive approach to what we’re doing with treatments, and not a reactive approach. We have now enough devices, enough technology, to be able to treat patients earlier in a safer manner and be effective doing so. And so when you look at the quality of life and quality of care, I really feel like these are right up our alley when it comes to having the technique and having the hands, to be able to address glaucoma in a standalone way. And don’t be afraid to be able to learn these devices.
And if you are a little leery about standalone, start with your cataract patients and get really good at a couple different devices, whether it’s bypass or cutting, and then move on to those standalone cases. Because what you’ll find, is that your confidence rises as you see medication reduction, as you see stable visual fields over time in many of your patients, and a happier patient as well. And so I really get my happiness from seeing patient’s journey, and to be able to add value to their life and improve their quality of life. And these little things do help. And so if you’re on board, or if you’re just starting, or if you’re on the fence, this has been a journey of a lifetime in my career.
Blake Williamson, MD:
Yeah, I love that. I think that I always tell colleagues who are on the fence, “If you’re doing SLT when someone’s pseudophakic, you’re already doing standalone MIGS in a way. Technically, you’re already doing it. So that means that you believe in it. So that means that there’s these other procedures, whose learning curve is every bit as approachable as SLT, if not better, why not jump in?” And to your point, patients are so happy, they’re just as happy to get off drops as they are getting out of glasses, which blew my mind as a LASIK and refractive dude. So anyway, it’s been a great conversation. I hope that some folks out there have benefited from it. Deb, I love talking to you about this. I hope you have a great time in Florida, and get out of the snow.
Deborah Ristvedt, DO:
Thank you so much, Blake. You are a pleasure to work with and to be friends, and to just watch you grow is an honor. So I appreciate you, buddy.
Blake Williamson, MD:
All right, man. See you soon. Bye.
