In the fourth video in a series assessing trends in interventional glaucoma care, Matt Jensen, of MJM / Marjen and host of The Interventional Glaucoma Project, speaks with Deborah Ristvedt, DO, and Mathew Walker, OD, both of Vance Thompson Vision. Drs. Ristvedt and Walker talk about how they transformed their practice in Minnesota to take a co-management approach with local optometrists. The collaborative model they created allows the practice to provide more interventional glaucoma care and optimize patient outcomes.
Watch segment 1 of this series where Matt interviews Dr. Mark Gallardo about his practice.
Matt Jensen:
Well, hello, everybody, and welcome to episode 4 of The Interventional Glaucoma Project. Now this is a series that’s been brought to you by Glaukos, and I’m glad today to introduce my friends from Vance Thompson Vision, Dr. Deborah Ristvedt and Dr. Mathew Walker. This series has been put together to help practices understand how to implement new technologies when it comes to interventional glaucoma, and you can look forward to this and many other programs within this series that do just that.
Now, I’m your host, Matt Jensen, former administrator and consultant. Like I mentioned before, I’m here with my friend, Dr. Deborah Ristvedt, she goes by Dr. Deb, and Dr. Mathew Walker. Team, it’s good to see you again. We were all at Vance Thompson Vision together. This is going to be a nice little walk down memory lane.
Deborah Ristvedt, DO:
Yes, it is. It’s always good to see you, Matt. We couldn’t have our own screen because we really collaborate together here at Vance Thompson Vision.
Matt Jensen:
That’s great.
Deborah Ristvedt, DO:
We need to be on screen together.
Matt Jensen:
Yeah, it’s great to see you both and I love that what we’re talking about today is the structure of your practice, Dr. Ristvedt, and how you built it to be truly collaborative because you really had to go from zero to one. You went from a program that was comprehensive, non-co-managed, and a great familial story, but then to almost completely collaborative care model, brought in Dr. Walker. We have a lot that we can go into on both topics and I almost consider them 2 topics. One is how did you restructure your practice, and then the other is how have you become truly interventional as a natural output of that?
I think our listeners are going to want to know more about both, and so I want to stay on this, “How did you restructure it?” point for just a second. Frankly, it could probably be its own show at some point, but it’s extremely gutsy, Dr. Ristvedt, that 10 years into your career, third generation, you’re going to completely change the fabric of how you practice. There’s people interested in doing this. How did you do it? I mean, structurally, how did you change course?
Deborah Ristvedt, DO:
That’s a great question because it was a risk, right? You have a name in the community that’s been established and now you’re going to tell patients, “Well, this isn’t your home anymore.” That’s personal. I care so much about this community. A lot of these patients saw me grow up, and so they were personal to me. Your heart just breaks when you say, “Hey, I don’t need to see you anymore.” But when Matt got here, it was more of a celebration like, wait a minute, we don’t have to see you here anymore. That’s a good thing. It’s a good thing that you just need routine eye care and remember what our goal is. Our goal is to really help people see, to change the surgical landscape as that’s growing in Alexandria, Minnesota.
The need is growing so much, and so I really need to be focusing my talents on helping people more surgically. I think a lot of people got that. We got a little bit of pushback and people would call my dad and say, “Well, what is your daughter doing?” Unfortunately, Matt had to be part of that finding another home, but what it did, it turned the entire relationship of eye care around in our community. That’s what’s been such a fun journey is we have cell phone numbers of people really wanting to help their patients. We’re talking all the time from Alexandria within 100 miles of us now to really improve eye care everywhere in rural Minnesota and beyond.
Matt Jensen:
Yeah. One of the keys that I remember you saying, and it’s strange in some ways to be moderating this conversation because I was also riding shotgun in the conversations, and so we can offer each other’s perspectives in this conversation. One of the things that I thought you were really astute about is the over-communication required. I remember you writing letters to patients saying, “Hey, just so you know, over the last 50 years, it’s been going one way and now it’s going to go this way. That’s so I can be doing what only I can do, which is surgery, surgical interventions.”
It was very similar to the letters you wrote to optometrists, and there was at least 6 that I remember that would go out every other month or so for a year saying, “Hey, if you’re not interested in receiving these patients, let me know because we’re trying to get them back out in the community so long as everyone is trained to manage their care. That way, I can keep my deck cleared for surgery. That way, you can be doing the ongoing care that you’ve trained especially for and have invested in diagnostics for.”
I just think it was a great rhythm that you had on how to communicate with the community. I think for the listeners who are asking the question, “But how did you do it?” I think that there’s little morsels in there that helped you do it right. You said it was a risk, but it was less risky because you let everybody know what the goal was in mind, more surgery, more people intervened upon.
Mathew Walker, OD:
Sorry. I was going to say it wasn’t more surgery to do more surgery. It was because the need was here in our little rural community. There’s so much, especially pseudoexfoliation glaucoma that these were being left to drops and at risk of progression where we were actually able to intervene.
Matt Jensen:
You did an assessment of your glaucoma work, and I just want you to talk about that. What were you looking for and what did you find with your own internal assessment?
Deborah Ristvedt, DO:
When we do some of these talks, it’s so easy to be like, “Well, you’re making it look so easy.” It was not easy, Matt. I mean, we had to go through a lot of learnings, but one thing that I would be very encouraging of is really looking at your data and that’s exactly what we did. We see a lot of glaucoma here. A lot of patients are co-managed as well. We don’t have every patient that’s with us for long-term anymore, but again, it’s all about collaboration, making sure that we’re all operating at the highest level of care.
One thing that we wanted to look at over the last 2 years, how many patients came in and had a procedure and what did we think that rate would be? How many patients do we treat that are mild, that are moderate, that are severe? How many patients, as we’ve learned with other practices doing these assessments, have actually not come to our practice when they should have or have not followed up when they should have? Because one of the key pieces that we’ve learned with our colleagues is that patients that have procedural intervention actually will stick with you more than those that are on a drop.
You can say, “Well, those are the ones that are just going back to their primary doc.” But we’ve actually looked at bigger data pools and we’ve found that these patients actually don’t find a home anywhere. It’s more likely that patients will stick with an eye care provider if they’ve had an interventional procedure. That’s what sparked this. Well, where are we at? How are we doing with our intervention? Because we claim that we are interventional glaucoma docs. We are looking for things such as first-line SLT. We’re looking for patients that could benefit from procedural pharmaceuticals or from combined cataract plus MIG surgery or standalone surgery. We have all of that going on during the day. It was fun to actually see the data.
Mathew Walker, OD:
To me, it seems like we would be 100% in all of it because as I joined, well, this is how we’re going to do it. You need to think like a surgeon, take care of your patient, but then also find them a new home. It was surprising those that wanted intervention that did it and then left or those that did but then they decided, “No, I want to wait.” It’s opened up an idea of let’s look through those, see where the gaps are to fill that.
Deborah Ristvedt, DO:
Just starting from what we’ve learned, we learned number one that 70% of our patients have mild to moderate disease and 30% have severe primary open-angle glaucoma. What that showed was that’s pretty similar to what we’re seeing nationwide with we have patients in the United States coming in before they have severe vision loss. Why aren’t we doing intervention? That’s where I get so passionate about we have the perfect opportunity with these patients before they lose vision to be able to say, “Hey, what’s happening anatomically? What’s happening at the level of the trabecular meshwork? How can we do a safe and effective procedure that’s going to diminish the risk for vision loss over time?”
Just this whole algorithm has changed in our practice to really only using medication as bridge therapy. That was one of the key things is where are we at with who’s coming into our practice? Because some people say, “Well, yeah, I just get all the bad disease.” It’s not true. We see primarily mild to moderate. It’s our opportunity to start then instead of waiting until they’ve progressed to the point where they need more invasive surgery.
Matt Jensen:
Yeah. I think that early intervention helps stabilize and not allow the disease to progress. I do think it’s worth us talking about what role drops play right now, because I think that as the IG conversation has been happening over the last decade but has really gained traction in the last few years, people have been slow to downplay drops. Because they’re impressive, and for a long time, it was our best first-line treatment. But what you said, Deb, I think is a real indictment that patients, when left to their own devices, if they’ve only been prescribed a drop, their lapse rate is higher than a patient who has had a procedural intervention.
That patient will stick around with their surgeon, their doctor relationship. It’s interesting and it makes sense I guess. The patients almost view themselves as being under management now that they’ve had a procedure, but that loss to follow-up is a real dangerous thing when it comes to a progressive disease that’s the silent thief, right? It’s progressing without us knowing.
Deborah Ristvedt, DO:
Just bringing it further, what we learned in our assessment, it was really interesting because of the practice structure that we have. Again, we’re a primary referred practice now, and so our lapse rate in patients that had a procedure was extremely high, Matt. It was 73%, but Dr. Walker here is giving a thumbs up because what that means is that we’re co-managing effectively and that patients have gone back to their primary eye care doctor and are doing well.
They know, we’re very specific about, “Hey, if there’s any change, if their pressure is not at goal, we need to see those patients back.” We’re very, very strategic about that because again, what did we say? We’re all raising each other up to be excellent. If ODs aren’t comfortable with managing glaucoma, we see them here. But if they are, that’s awesome. Technology has changed so much, so dramatically as well as what optometrists are learning in practice. It’s just so fun to be able to collaborate in that way.
Matt Jensen:
I think it’s really important the way you said that, both you and Dr. Walker, because you got smiley when she talked about the lapse rate because you have to not only have the data, which most people don’t do that work, but then you also have to understand the story that the data tells because it’s not just comparing lapse rate to lapse rate. It’s the way you’ve restructured. You intend to have a high lapse rate. You want those patients coming in for intervention and then going out for their aftercare and ongoing primary eye care.
You can keep that spot open for the next patient who needs intervention. So long as that regional and local provider has all the skills and tools necessary to see that patient and see those needs and then so long as you’ve also done what I know you do, you’ve had communications that are almost like, “Hey, doctor, if you see something, say something, right?” If you see it, send it.
Mathew Walker, OD:
Usually, what I do is when we see a patient for a consultation, I set up, here is our target with OCT, visual field, and almost guard rails for the primary OD. If they fall outside of those guard rails, it’s not good luck. It’s you better let us know. Text me, call me, send the referral back if they fall outside those guard rails. Some ODs, again, they choose that they don’t have the equipment. They’re in a more retail setting, but does that mean that we keep that patient? No, we still co-manage. They see them once a year for their routine care. The doc can do what they want and then I still see them back once a year for visual fields, OCTs, all the above.
Matt Jensen:
Yeah, I think that’s really good. I like the way that you said that too, that you want those patients to be out back with their doctor under their management, but you’re also communicating very clearly what the target is. That sounds like a term that I like to use in this category. It sounds collaborative. You’re both contributing.
Deborah Ristvedt, DO:
It’s so true. One thing I wanted to point out too in the lapse rate that we found, so there were 4% of our patients that lapsed before they had a procedure, and I want to bring that up because what did it make us do, Matt?
Mathew Walker, OD:
Yeah, 4%, it was like 38 patients who I said or we said, there’s an intervention that’s going to help and they fell off. Those to me is probably the most concerning where we actually looked through the 38. We had some patients who they ended up being a terrible diabetic when they went in for their pre-op physical, and so it’s been delayed, some of them only a month or so where we’re still in communication. Others, it’s been 6 months to a year and they slipped through both their primary OD’s schedule and ours. We need to work on trying to close the loop or if something like that were to happen that the patient’s not just stuck on their own. Actually, because of this collaboration and because of this survey, we’re able to call some of our patients back and say, “Whoa, what happened?” They’re just like, “Yeah, no one ever got back to us.”
Matt Jensen:
I love how seriously you guys are taking this. That’s a real program.
Deborah Ristvedt, DO:
It’s a program because guess what? Now we can educate our surgical counselors on, okay, if this happens where a patient says, “I need to think about this.” Some things that we do are more non-urgent. Cataract surgery can wait for the most part, but glaucoma can’t wait.
Matt Jensen:
I want to transition us to something that we may have glossed over that I want to make sure we hit home because you mentioned how we might do SLT that day or other things. There’s first-line therapies where you don’t have to fail another therapy in order to have it. Laser is one, procedural pharmaceuticals are another. How often are you recommending patients have some kind of intervention the day of the consult or to give it more color, how often are they pushing back on your recommendation?
Mathew Walker, OD:
Good question. Since I’m the seeing a majority of the glaucoma evaluations, I really don’t get any pushback. Again, you’re in there so you think, “Well, everybody’s going to do it.” I asked my scribe, Diana, “Hey, what do you think of the amount of patients who I suggest laser, MIGS, anything, procedural pharmaceuticals, XEN, whatever? How many say no or how many change their mind because they don’t want to say that in front of me?” She responded back on an email, “Probably less than 5%.” That was not from me. That’s from Diana. I was thinking, “Well, why?” Well, it’s because I don’t have to be refracting and doing contacts at this time. Deb doesn’t have to be having this discussion while she’s late for OR.
I get the time to sit down with the patients and say, “Here’s where you are. Here’s maybe what has failed. Here are your choices. Let’s work together as a team to figure out what’s right for you.” I’ll give my recommendation because this is what I would do if you were my family member. Managing risk and reward, yes, we could do something easy, but it could progress. For a little bit more risk, we could get longevity for a long time. I get the time to do that, and I feel like that’s where when I recommend something, it’s maybe 95% good. I appreciate the time to get to do that versus trying to hustle.
Deborah Ristvedt, DO:
It’s all the expectation too. We just celebrated at an educational conference last year about how the ODs that are referring patients are talking to them about what they need. They’re like, “Oh, my goodness. I’m so grateful that there’s another opportunity to lower pressure other than a drop.” I’ve had patients tell me that. We celebrate that together because we’re seeing this paradigm shift where the patients are maybe even aware of it before they even come into our 4 walls. That’s one thing that’s so neat about it. Then the number 2 thing is, Dr. Walker, you mentioned, I recommend.
We were just getting going with this and learning about MIGS. Maybe when I wasn’t confident doing say a standalone OMNI case or a standalone procedure, I was more confident doing cataract plus MIGS because I was already in the eye. I’m like, “Well, we can do this or we can do this.” But now it’s like I recommend this absolutely wholeheartedly from the last decade of experience. Interventional glaucoma is here and it’s here to stay. We’ve just seen beautiful outcomes and just stable pressures and less vision loss. Wow, I can’t even imagine if we keep going at this rate catching these mild to moderate patients at an earlier stage, how that’s going to totally transform what we’re having to manage when it comes to a glaucoma-heavy practice.
Mathew Walker, OD:
Yeah, that’s the goal, dream. Yeah.
Matt Jensen:
I wanted to circle back about what drops do to the flow of your practice because we know that there are a nuisance to patients, adverse events or they forget to take them, or sometimes they don’t want to fill the prescription. Certainly, maybe they don’t refill the prescription, but what kind of burden is it to your practice?
Mathew Walker, OD:
Yeah, I’ll take that. Not only is it a discussion on all of the side effects that are going to happen. I am so glad I don’t have to have that discussion. Now I have the discussion, “This is what has happened to you because of what you have taken.” Anyway, but not only that, but oh, this one burned, this one caused discomfort, this one made it so that I was dizzy. What else you got? Okay, so then that’s more chair time for me or managing all the ocular surface side effects that come with it.
But then our poor team that has to run all these prior authorizations. Julie, who runs a majority of it here in Alexandria, she has to come to me in between every other patient to say, “This isn’t covered. What else do you want to do? This isn’t covered. What other ideas do you have?” I said, “I already told them they need SLT or they need standalone iStent infinite.” Whatever it is. I would say even in an IG practice, it takes up way too much of our time.
Matt Jensen:
Julie, who is doing some of those pre-authorizations and chasing you down for clarifications, how much of her time and your time or your scribe’s time do you think is spent just on the topic of drops?
Deborah Ristvedt, DO:
Yeah, we actually did a time analysis of that because we wanted to know where techs were spending the majority of their time, if they were spending it in front of patients, so patient facing versus doing things behind the scenes like calling patients back, communications, drop refills. We found that the majority of our techs doing this type of work were spending 3 to 4 hours a week doing this. It’s incredible.
Matt Jensen:
Is that each, Dr. Deb?
Deborah Ristvedt, DO:
Yes.
Matt Jensen:
That’s an FTE equivalent.
Mathew Walker, OD:
It’s a full-time job…
Deborah Ristvedt, DO:
It’s a full-time job.
Mathew Walker, OD:
…just for drops, in an IG practice.
Deborah Ristvedt, DO:
That’s what I don’t understand with a lot of these market scope analysis graphs that we see. I think it can be as high as 80% are still prescribing drops as first-line. Again, medication is awesome. It works, we know that, but there’s better ways to prescribe that medication now via through drug delivery. What we’ve seen over time is that, like Matt said, we’re managing ocular surface disease. Are we going to put in a premium IOL in a patient that has poor surface? No, we don’t want to.
The BAK in these drops can actually cause change in the trabecular meshwork that actually worsens that whole disease process. That’s the outflow pathway that we’re managing with IG. We’re going directly to the source, instead of prescribing something that does work, but number 1, you have to take it. Number 2, over time, it can actually lead to worsening of the disease state through stiffening of the trabecular meshwork. I just nerded out a little bit because drops aren’t benign either, but there’s better ways to control glaucoma. There’s better ways to manage without putting something topically on the eye, and we’ve seen that.
Matt Jensen:
How would you two suggest, to a practice or a provider who’s listening to this, how would you suggest they do that assessment? What questions should they be asking?
Deborah Ristvedt, DO:
Number 1, look at your new patients that are coming in. Do they have mild, do they have moderate, do they have severe disease? Get an idea for your patient population. Because I think as doctors, the bad ones stick out in our minds, the really difficult to manage, and we were chuckling that we know those 63 patients that have had 20+ visits with us in the last year. They’re tough patients, but we care so much and we’re seeing them often to make sure that they don’t worsen. You get to know these patients so well that you forget about all those successes that you’ve had with patients that had early intervention and still to this day are stable.
That’s what’s so cool to see, Matt, is by doing this survey or this assessment, we were really able to see what our journey has been like thus far was starting interventional glaucoma in 2012. Those patients that maybe didn’t have a procedure in the 2-year analysis that we looked at had had a procedure way back when and are still doing great. They had an SLT 5 years ago, they had a G1 iStent in 2013, and their pressures are still kicking butt. I think the big questions are what’s your patient population? Who are you seeing? Number 2, when you see that patient, how many patients, what percentage, are getting a procedure or what percentage of those patients are you recommending surgical or a procedural intervention?
Because that really truly will shock you into are we still just taking the easy route as doctors and saying, “Well, just take this latanoprost and you’ll be okay.” It was interesting talking to my colleagues who did this assessment. They were shocked at the amount of procedural interventions they thought they were doing to actually what the data showed. That just really keeps them in check to say every patient that comes through my door, I’m going to make sure even if they’re stable on 1 drop, that they know about SLT, that they know about drug delivery. Oh, they have a cataract.
We’re talking about what’s going to happen down the road as an algorithm, as a patient journey because glaucoma doesn’t have a cure. Now we’re talking about a journey and not about what we’re doing in that moment. That’s what’s neat. That would be the second thing is to see how much percent of the time you’re recommending some form of a procedure. Then lastly, looking at those patients that haven’t come back, because that was a real awakening to us to say, “Where are they? Are they getting the care that they really need and making sure that these patients have a home?”
Mathew Walker, OD:
The way that we do it because a lot of docs will ask, “Well, where did they go?” If you send the severe glaucoma patient away, are you really letting them go for the rest of their life just being managed by their OD? No. If I was in a practice by myself, I wouldn’t feel comfortable doing it. This was actually John Berdahl’s idea, they a lot of times will do an oversight exam. Okay, we have done MIGS, you are in a great place. We’re going to let you go back to your OD, but we would like to maybe see you back in a year just to make sure. The co-managing optometrist will send notes back in the meantime as they’re being seen every 3 to 6 months, visual fields, OCTs, that we can review. Then the second question is, well, okay, do you guys actually review all those visual fields, OCTs?
No, but our techs do. If they see something that isn’t quite right, pressures above goal, well, the OD should actually be referring that back as well, saying, “We gave you these guardrails. If you fall outside of it, it’s time to come back.” Then, at that 1-year oversight exam, if it’s still in good range, well, let’s go 2. I feel like that has done well where it’ll say that the patient has lapsed, but they’re not because they’re coming back in a year or coming back in 2 years.
I was just going to mention too, so for a doc that wants to do this for their own practice, I would want to know, almost have them do a survey before. Here’s where I think I am and then show the data. Okay, here’s where I am. Maybe I’m not so great, but maybe then a survey afterwards of here’s all the patients that should have had something. What should be my new goal and how should I get there? Also, how do I do it in maybe the least amount of visits possible? I guess that’s being goal-directed change, I think, would be really powerful.
Matt Jensen:
It’s been so impressive to hear how your progress has been coming on the interventional glaucoma world, but also how you’ve just totally changed the form and fabric of your program to be extremely collaborative. You can stay in the OR and do specifically what you do that no one else can do, which is excellent surgery and get patients back out to the community where they can be cared for by primary eye care. That’s the name of the game, especially in rural America.
I want to thank you both for being a part of this discussion. Everybody, this has been 4 of The Interventional Glaucoma Project. Thanks for joining us, and we look forward to seeing you on episode 5. I’m Matt Jensen, your moderator. Thanks for listening.
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-2992
Matt Jensen and Drs. Deborah Ristvedt and Mathew Walker were compensated by Glaukos for their time.
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