In the fifth video in The Interventional Glaucoma Project series, Matt Jensen, of MJM / Marjen, speaks with Ben Seals, CEO of Thomas Eye Group, and Philip Garza, MD, a glaucoma specialist at the practice, about how they have utilized dashboards and level-setting education to move the needle on advancing interventional glaucoma approaches. The Thomas Eye Group team discusses the opportunity to move from a drops-first approach to a procedural intervention as early as after 1 patient visit. This can be accomplished with buy-in from optometrists and other team members, as well as the proper education for patients on why this management strategy will reduce their treatment burden and protect their vision.
Watch segment 1 of this series, featuring Dr. Mark Gallardo.
Hear from Charles and Dr. Blake Williamson about their practice assessment findings in segment 2 and segment 3.
Matt Jensen:
Hi everybody, and welcome to another episode of The Interventional Glaucoma Project. I’m your host and moderator, Matt Jensen, longtime administrator of Vance Thompson Vision in the upper-mid and mountain west, and for the last 3 years, a consultant on the topic of IG. Today, I’m joined by my friends from Thomas Eye, Dr. Philip Garza, and Ben Seals, CEO of Thomas Eye. Welcome, gentlemen. Thanks for joining the discussion.
Ben Seals:
Happy to be here.
Philip Garza, MD:
Pleasure to be here.
Matt Jensen:
Now, there’s a lot to talk about in the field of interventional glaucoma. Dr. Garza, you see things firsthand as a provider there. You’re a glaucoma specialist, correct?
Philip Garza, MD:
That is correct.
Matt Jensen:
Tell us about the transition that has taken place over the last 24 months in your program between typically seeing your patients and having a first-line offering of drops versus what it is now, being more procedure-based.
Philip Garza, MD:
Well, it’s been an absolute revolution in how we think about glaucoma care and how we are executing glaucoma care. It really all started with sort of embracing the procedure-first mentality and realizing that we had the technology to offer patients safe intervention that would minimize their need for perfect adherence to glaucoma drops. At the same time, we realized that asking for perfect adherence to glaucoma drops is not realistic for most patients. It has been an incredible change to experience, mainly because we’ve been able to unburden our patients, improve their quality of life, and, as a result, have so many more patients who are stable off of medications and very happy with their outcomes.
The majority of patients are having that same sort of Christmas morning experience that we have been used to for years with cataract surgery, sort of having significant reduction in not only the need to use the drops, but the anxiety centering around using those drops, and of course, improved vision from fewer topical agents and fewer preservatives on their eyes.
It has been a significant change in mindset and a significant change in execution, with more and more patients passing through a procedural pathway and fewer patients than ever on habitual drops.
Matt Jensen:
Well, and Ben, you’ve been at the helm of Thomas Eye for a long time and have become known really across the industry, but we got to know each other through ASOA and other organizations, but you’re kind of known as a data buff. You were starting to notice that Dr. Garza and others were spending their time differently than maybe they could in the clinic. Talk a little bit about what you noticed and how their time was allocated and what they were working on that you considered to be maybe not the best use of resources.
Ben Seals:
Yeah, I think that every surgeon goes through a significant amount of training and ultimately wants to and has spent a large portion of their life developing and honing a skillset that is specifically bent towards surgical intervention and surgical care. As we looked at our patient set within Thomas Eye Group, we very quickly began to notice that our doctors were spending multiple rounds with very similar or the same patient. Ultimately 4, 5, 6 appointments to get to a procedure or treatment that could ultimately create that Christmas morning experience for the patient that Dr. Garza described. Without that data, our 2 glaucoma specialists really otherwise might not have had the impetus to change or at least the baseline awareness of how often and how frequently their patients were having to come back and forth to clinic, between their appointments, between testing, for prescription refills, for medication updates.
It wasn’t until our team here at Thomas Eye Group really embraced the idea that we wanted to be procedure intervention first, that we started to see better treatments from patients, happier patients with better outcomes, better managed vision, and pressures within those patients. Then ultimately less necessary follow-ups or inconvenience to the patient to create that same clinical outcome.
Matt Jensen:
You mentioned 5 to 6 times a patient would perhaps visit before having some kind of intervention. What is the goal, Dr. Garza? How many times should they be able to visit you before having some kind of procedural intervention?
Philip Garza, MD:
Ideally, the answer is 1, and I think that we’re increasingly asking ourselves the question, “Is it possible to get to zero and go straight to intervention?” I think the safest answer for right now is 1. The way that we’ve done that is to really foster this idea of teamwork with what we’re calling our medical glaucoma specialists, our subspecialized ODs who have a specific interest in glaucoma co-management and who we work alongside very closely to hone their skills and to do quality control in their clinics, so we can have confidence that when they refer a patient to us and they ask us to consider intervention for a patient and give us an idea of what that patient might be qualified for, we have a good idea that that’s going to be accurate. That has been a key is sort of building that internal collaborative care with our internal ODs who have kind of self-identified as being interested in intensive glaucoma co-management with us. It gets us down to that 1 visit before a procedural recommendation.
Matt Jensen:
I like that. It reminds me of the days of LASIK where we used to have something called a see and do. It was all on the same day, see and do. You’d do a consultation in the morning, and then because they were traveling from so far away, we would likely do a procedure that same afternoon. I see something arising perhaps based on your commentary to have a similar approach to IG treatment. They’re seen for some kind of pre-op work and then they’re done same visit, knowing that maybe their glaucoma home was with a primary eye care provider within your organization, so you have that kind of foreknowledge of what they’re coming with or what failed treatments they’ve already had. But Ben, you also, because you deal with the reimbursement side of things, a lot of IG treatments now, you don’t have to fail a therapy.
Ben Seals:
There’s one comment I would make on that see and do opportunity. I think part of the challenge and part of the reality is patients don’t have unlimited access to providers that are delivering interventional services. Dr. Garza’s time is limited, and the access to his treatment and his surgical skillset is a limited resource within the medical community. That’s very similar throughout the country. If a patient had to wait 60 or 90 days to get onto a doctor’s calendar, why are we going to make them wait another 60 or 90 days to have a procedure done that can save their vision? Ultimately, our ability as organizations and administrators to engineer a process that reduces and eliminates the friction for patients to receive care creates better outcomes and happier patients and, as a result, happier doctors as well.
Matt Jensen:
We know from other things we’ve worked on together, Ben, that if a patient leaves and they’ve been assigned drops, their likelihood to actually follow through on this, and you keyed in on this, Dr. Garza, to actually take them consistently, fill the script to begin with, take them consistently, not miss, do it in conjunction with all the other drops that might be other times during the day, fight through adverse events such as redness or dry eye or what I call the dissipation of the lipid around the sunken eyelid look that might coincide with drop usage, all of that to make sure it’s therapeutically viable versus doing a procedure and knowing that an effort has been made to control that pressure, to control disease and preserve site. I guess where I was going with that, Ben, is if they’re just doing drops, they tend to also kind of flee the provider at a greater rate than if they were just lost to follow-up after surgery. Maybe say a little bit more about that, because I know you’ve tracked those kinds of things.
Ben Seals:
Yeah. The data in that specific scenario where a patient is put on a drop and ultimately tracking whether or not that patient is compliant to their follow-up, results in that next visit or attends that next visit, it’s actually the minority of those patients do that at the scheduled time. The result is often delayed care, a delayed secondary visit. Patients are not filling those drops that are prescribed at the recommended rate or utilization. There are all sorts of areas where patients just frankly aren’t compliant. The reality is an every day of the week drop regimen is not an easy administrative ask for a patient. There’s a whole lot of opportunity and space where patients get lost in the healthcare system because we’ve made care a burden that ultimately we now have the tools that can relieve that burden and make access to quality care and preserve vision attainable for our patient base.
Matt Jensen:
To summarize what you just said is patients leave with the drop and they have the best hopes and intentions, but the likelihood of them actually running that gauntlet that we both talked about and having that therapeutic viability is low. Plus their likelihood to not show back up for future appointments is higher than if we would have done a procedure on them. On one hand, the drops, while impressive from a compounding or chemical pharmaceutical standpoint are impressive so long as they’re used, patients kind of are out there thinking, maybe they’re overconfident because they think they’re under proper care when they don’t have the same viability therapeutically that the doctor prescribed, but they’re not the only ones. Because it’s been standard of care, Dr. Garza, a lot of your colleagues are out there thinking, yeah, I’m already doing the best thing for my patients because I’m giving them drops. I’m prescribing drops.
Philip Garza, MD:
That may have been the case not too long ago, that drops were the safest and best thing for patients to be using, but a lot has changed since iStent came out in 2012. We have a whole therapeutic pathway from initial diagnosis all the way through advanced disease that allows primary open-angle glaucoma patients, for the most part, to be controlled off of medications. We have to embrace the idea that these things are safe and effective, and we shouldn’t be timid about applying them. We are surgeons, and we are trained to do these things, and we are not only doing things that control disease, we’re unburdening patients and making their lives better and easier. I think that it’s important that we embrace that and accept the fact that our technology has changed in order to be able to treat patients with less risk.
We need to be lowering the barrier to safe care for our patients by making ourselves more available, focusing on the things that only we as proceduralists can do, which opens up more availability in our clinics. Then we need to lower the barrier to even doing procedural sign ups, for example. That’s where one of our most recent innovations is a parallel clinic structure where patients are seen by our medical glaucoma specialist optometrist, but might be able to, for example, have a same-day procedure with me after a brief evaluation and an order for procedure and an expedited off pathway. It’s all about making things easier for people and embracing the fact that we can make things easier for them safely.
Matt Jensen:
We’re going to go there in just a second. I want to kind of pin something to you, and we’ll see if you get the softball. I’m going to throw you a softball here. You mentioned how it makes life easier for the patient. Does it also make life easier for your team?
Philip Garza, MD:
Absolutely. I mean, one of the obvious ways that it does that is by reducing the overall number of medications that patients are on and reducing the number of patients who are on medications, period. Number 1, fewer prior authorizations. Number 2, less time spent on the phone afterwards or in clinic after the MD leaves the room explaining to patients what their complex eye drop regimen is and how they’re supposed to be using it. I mean, this is a major burden for our clinic staff to answer what can become repeated questions from the same patients who are honestly struggling to understand the complexities of the drop regimen and/or understand why there are barriers to them getting the medications that we recommend. It has the potential to streamline operations on a day-to-day basis in the clinic as well and increase the enjoyment of our staff members in interacting with patients and remove some of that drudgery, repetitious work of doing the [authorizations] and repeating drop regimens to people.
Matt Jensen:
Right. If it’s not complicated to do that with the patient, then it certainly is to do it with the pharmacy in which they’re trying to get their prescription filled.
Where we’re going next is just where you left off, Dr. Garza, is this whole idea of how do we make things operationally simple so we can help as many people as possible because we can’t possibly get to them all. Ben, he mentioned the kind of parallel clinic schedule. I think that’s very clever. What are some other ways that you’ve implemented IG strategies for your glaucoma patients? Because you’ve got a lot of them; you’re a big program.
Ben Seals:
I think one of the first and most successful things that we did was pre-appointment education. The reality is a lot of these patients have had glaucoma for a significant amount of time, and they’ve almost become numb to the fact that drops are the way that they treat their disease, and they’re not aware of any of the other alternatives. We began a process where every glaucoma patient that hasn’t received an IG procedure, about a week before they come into the clinic gets a video explaining to them that there are IG procedures available, and they should ask their doctor about those procedures at the time of their appointment. It creates some awareness, creates a little bit of a tease to the patient of there are other things besides drops that we could help you with, and then allows the doctor and the patient to have that conversation in a way that is already supported by the physicians and created…sort of teeing it up for the doctor to talk about that at the time of the encounter.
In clinic, drop adherence or compliance forms is another questionnaire that we’ve deployed in some of our clinics where our staff members are asking patients about their ability to comply with their drop regimen in order to initiate the conversation around, well, these drops are what’s controlling the pressure in your eye. If you’re not complying with your drop regimen, that leaves that pressure unchecked, and you really need to have a conversation with your doctor about other alternatives to help create a more compliant treatment alternative for you. Those 2 things are probably the most significant as we look at opportunities to create awareness within our patient base today.
Matt Jensen:
You’re pre-educating patients on their way into your clinic, maybe a week out. You can probably look out into the future and say, okay, we’ve got 4 or 5 weeks of patients scheduled out. We’ve got a plan for how we’re going to pre-educate them. But Dr. Garza, what about the patients 2 years ago who are still in your system, but they’re not scheduled or they’ve either been lost to follow-up or they’re within the practice of one of your primary eye care providers that work under the same brand? How will you reach out to them?
Philip Garza, MD:
Yeah. The key is really getting buy-in from all of our team members and basically leading. It takes the interventionalists, the surgeons, to set the tone and to lead and to lead by example in this way. A big factor for us reaching out and pulling those patients who are lost within our own system, for example, back into the interventional milieu has been stating as a company policy that we practice interventional glaucoma, that eye drops are the glaucoma treatment of the past, and that the preferred treatment for most patients is procedures. We rolled out a significant campaign at the beginning and middle of 2025 where we had a series of dinners that involved every single provider in our network. My partner and I, Dr. Dana Wallace, sort of laid out the rationale for this shift in mindset, and we made it clear that this was the standard of care at Thomas Eye Group.
I think that just simply taking a stand and explaining the why and leading by example and becoming more procedural and letting the team see the outcomes by taking a more procedural approach as an individual doctor has given us a lot of buy-in. From an operations standpoint, besides educating our network of doctors through these dinnertime education events, in addition to that, we’ve systematized this by having a consensus protocol that my partner and I developed alongside our operations team and that we’ve made the standard at TEG. It’s a document that you as a provider at TEG can look at to show what we expect to happen for each stage of disease. The second thing is to have clear referral triggers at each step of the way from diagnosis through severe stage disease that triggers those doctors to send patients. It all starts with initial diagnosis That should prompt the patient to be seen by an interventionist.
Matt Jensen:
Yeah, I like that. By the way, that protocol, so to speak, so valuable for getting everybody on the same page and that you’ve had your internal communications plan, dinners or otherwise, to get everybody on board is really, really important. Ben, you’ve got dashboards that you’ve set up where you can monitor how we’re doing. What’s included in those dashboards?
Ben Seals:
Yeah. The way that we created those dashboards was very similar to the way that we’ve as an industry structured cataract or refractive surgery dashboards. Is there a consult? If there was a consult, was it kept? If that consult was kept, did it convert to a surgery or some sort of interventional procedure? That ratio begins to inform, are the surgeons adhering to the protocol that they set? Is there some sort of qualification that needs to happen with the referrals that are coming in, hence the parallel path of clinics with a surgeon and a medical OD working side by side so that the qualified IG consults are of a higher yield and a better use of the doctor’s time. Because it’s not every glaucoma consult is qualified and ready for an intervention procedure. There’s an opportunity in those dashboards to really track and understand where are we succeeding?
Dr. Garza mentioned that as we did all of this training for our team internally and externally, we saw a surge of referrals. The interventional procedures that we saw actually lagged a little bit behind those referrals because 2 specific reasons that we found in the data; one was patients were referred, but they weren’t sure why. We were doing a good job communicating to them that they needed to see a surgeon, but they weren’t 100% sure of why they were getting referred, ie, that they were getting referred to talk to a doctor about a surgery or a procedure that they needed because of their glaucoma. The second was we were getting referrals from external ODs or other sources that were glaucoma suspects and not necessarily ready for an intervention. Those 2 referrals made up the preponderance of the patients that did not convert to a procedure as we initially stood up and looked at that dashboard.
We’ve made some corrective actions on how we address those to try to create a better yield for our surgeons in their clinic, to better use the patient’s time, to pre-educate those patients so that they’re aware of why they’re seeing Dr. Garza or Dr. Wallace in advance of their care and not surprised by a conversation related to a procedure when they get to our office.
Matt Jensen:
This whole conversation is about how you and your program went from belief to action. Dr. Garza, how do you think you’re doing?
Philip Garza, MD:
I think that if we say that we’ve arrived where we want to be, I think most of us would be kidding ourselves. This whole process really starts with taking a good, hard look at your own practice and asking yourself, who are you? What do you intend to be for your patients? What services do you really intend to provide, and are you really doing it? I think that’s how it all really began for us is realizing we weren’t as interventional as we knew we needed to be. I think there’s this ongoing striving that needs to happen and reevaluation. How are we doing with this? At the same time, you don’t want to beat yourself up. You want to educate as much as you can in your clinic lanes. You want to offer intervention to as many patients as you can every single day, but making that mindset switch is step 1.
Step 2 is saying you’re not going to be perfect about it. You just need to continually reevaluate. Every time you see a patient, try to identify the opportunities for intervention. I would say we’re not going to be where we want to be for a long time. I’m always kind of focused on the striving and trying to improve this. But I will say one thing that has been a key realization for me along this pathway is to realize that I have a team around me, especially my medical glaucoma specialist ODs, who are just as invested in this as I am. I used to think that I had to optimally interventionalize every single patient on my schedule, reorient them to the interventional glaucoma paradigm, and do everything I could to minimize their eye drop burden before sharing that patient’s care with our medical glaucoma specialist ODs.
I do try to do that as best I can, but here was a key realization for me, I have a great team. If I can’t achieve buy-in for a particular patient to take that next interventional step and reduce the medication burden, it’s okay for me to share their care with my medical glaucoma specialist for their next monitoring visit because they will give that additional chair time, an additional education, and perhaps a different perspective to that patient. So many times now, the patient returns to me ready for intervention and understanding why they need it, and roughly what they need. That has been a key strategy to continue to improve how we are operationalizing this and how many patients we’re reaching.
Matt Jensen:
That collaborative care is so important to be able to leverage everyone’s efforts in that way and really to help you focus doing what you mentioned before, things only you can do, staying in the OR. Ben, I want to give you an opportunity to give Dr. Garza a reality check because my guess is you understand exactly where you are from where you started. For example, today versus this time last year, are you doing more interventions? Give us a sense of with what little attention you’ve put on it, and you’ve put a lot on it over the last year, but Dr. Garza admits, it’s not as much as you could. Have you moved the needle?
Ben Seals:
Yeah, absolutely. I think the opportunity is to celebrate the fact that the intentional inertia that we’re creating is showing up and is making a meaningful difference in individual patient lives. Ultimately, as a practice, we measure the number of procedures that we do every single month and are scheduled. We’re seeing about a three-and-a-half-X increase in the number of procedures that we’re doing year over year. That’s substantial for our organization and is a huge improvement in that number of lives every single month. Are we moving the needle? Absolutely. But I think the more meaningful story and opportunity is for Dr. Garza and other doctors to experience that Christmas moment with their patients where they get to tell those patients, “You can stop taking that drop.”
Matt Jensen:
I want to stress, it’s not a numbers game. It’s not just to show percentage increases. However, that is 1 measure, just 1, but it’s 1 measure on the effectiveness of the belief set that you have, which is that there’s a better way to treat our patients with this progressive and debilitating disease. Congratulations, you guys, because I think it’s really hard to make change in practice and you’re really doing it, and you’re helping a lot of people.
I hope that as folks watch this session, they find ways to implement, take from past experiences like in the cataract realm or the refractive realm, and use it to apply to this category, which can be just as rewarding medically for your program if people just pay attention to it.
I want to thank you gentlemen for being a part of today’s conversation. Ben Seals, Dr. Garza, from Thomas Eye Group, thank you for dropping some knowledge on all of us on how to implement this new category and change from what used to be the status quo of drop management to truly intervening in this progressive disease. Thanks for joining us, everybody.
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).
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.
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.
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-3000
Matt Jensen, Ben Seals, and Dr. Philip Garza were compensated by Glaukos for their time.
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