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Glaucoma
Podcast

Why Glaucoma Specialists Should Endorse Cornea & Comprehensive Doctors to do MIGS

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Introduction:

This podcast is brought to you by Ophthalmology 360.

Nathan Radcliffe, MD:

Well, hello and welcome to the Ophthalmology 360 Podcast. This is Nate Radcliffe and I’m thrilled to be here today with Brandon Baartman of Vance Thompson Vision. Dr. Baartman is an anterior segment surgeon. Welcome.

Brandon Baartman, MD:

Thanks, Nate. I’m happy to be here and excited to talk about some MIGS.

Nathan Radcliffe, MD:

Yeah. So we have a topic I’m fairly passionate about today and one that I think is really important to the future of glaucoma to the future of ophthalmology, and it’s the topic of why glaucoma specialists really should endorse cornea and comprehensive doctors to perform MIGS or microinvasive glaucoma surgery. I know that both of us wear a number of different hats. You yourself were trained in a true anterior segment, cataract refractive glaucoma setting. Tell me just a little bit about your training and where MIGS was at the time that you were being trained.

Brandon Baartman, MD:

Yeah. That’s a great intro to this discussion I think. I did my fellowship at Vance Thompson Vision in Sioux Falls under John Berdahl, and this was in 2017, 2018. So it was a few years after iStent launched the first generation of the product, and it was really in full swing as far as utilization of that technology for mild to moderate glaucoma in conjunction with cataract surgery. And I had some exposure to a variety of other MIGS at the time. OMNI was actually just forming from Trab 360 and Visco 360, KDB, Kahook Dual Blade, was being performed as well. So it felt like what now feels like, I guess the infancy of what continues to really explode in our field as far as a category of surgeries for the anterior segment surgeon.

Nathan Radcliffe, MD:

Yeah, absolutely. And it’s funny to think back to when I did my training because I was trained as a glaucoma specialist right before MIGS really came about. I finished my fellowship in 2007 and of course the iStent didn’t arrive until 2012. So I’ve had to do a lot of my training after the fact, which puts me in the category that a lot of comprehensive cornea other ophthalmologists are in. And I think you can get really comfortable with MIGS training yourself. So we’ll talk about that a little bit. I’d like to start by recalling one of our major thought leaders in the field of glaucoma himself also, a fantastic cataract refractive surgeon, Ike Ahmed, who at the ASCRS meeting this spring gave the Steven Ops Baum honored lecture and he’s been focusing a lot on interventional glaucoma.

And Ike had this quote, he said, “Glaucoma is only young once and as it gets older it gets harder to treat.” And he really made a strong argument for how the earlier we treat glaucoma the more we enhance our opportunities for success and reframed our thinking by addressing us towards initial stepwise interventional glaucoma therapy in mild to moderate glaucoma rather than just piling on drops and moving in that direction. And give me your thoughts on this approach and its meaning in the world in which we practice today.

Brandon Baartman, MD:

Yeah. I think it’s really well said by Ike. I love the framing it as only young once because it is so true. And we think about specifically in terms of an interventional mindset in glaucoma. Historically, you’re thinking about MIGS being more plentiful the earlier you treat or start in that interventional process until the recent iStent infinite approval, trabecular bypass was really only indicated for mild to moderate glaucoma at the time of cataract surgery. So it was a narrower window and we know that lowering pressure using laser or surgical therapy earlier in the disease also keeps some options open for pharmacologic therapy down the road, which was one of the philosophies that John Berdahl my mentor and fellowship instilled in me too. So I’ve carried that into my practice. We also know the burden of disease to these patients will be lower to those folks that can be treated without drops or in drop sparing therapy, which is why we’re seeing a lot of drug delivery options show up these days too.

And I think when you’re thinking about an interventional approach, the most important part is you’re taking the treatment out of the patient’s hands. It’s important because in my mind those earlier stages, it’s those stages where patients often underestimate the severity of their disease or the importance of treatment and they might be less motivated to put in eyedrops. So all of those things combined has to me suggested the earlier we’re able to do something that doesn’t involve patients putting a drop in their eye is going to be beneficial for any number of those reasons.

Nathan Radcliffe, MD:

I spent a lot of time thinking about this. I mean, we probably do not consent patients appropriately to talk about the long-term effects of eyedrops and their preservatives. And we frame it as this easy decision like, “You could have a drop,” and no one says, “Hey, you have a 60% chance of having dry eye in 10 years on our typical therapy.” And getting back to some of the points Ike made, and I think leading us in this direction is Ike really was arguing that SLT is our first line therapy for interventional glaucoma and then we can move forward with drug delivery, these micro incisional MIGS, standalone MIGS, and then eventually MIGS cataract and then MIGS with blebs. Is that how you see the algorithm? What would you say would be a reasonable algorithm as we look at this in the most thoughtful way moving stepwise?

Brandon Baartman, MD:

Yeah. I agree again with Ike, SLT is my first line therapy, and when I think about what I would want if I were diagnosed with glaucoma today, it would be SLT. And the rationale is simple. It’s a one-time or we know repeatable if need be, and you’re not worried about missing doses, pressure fluctuations from that, and it’s extremely low risk. I know that there’s great data from the light trial and others that suggests that this is a really powerful tool that we have. And it had been around for a while, even before then during my residency, and this was the time of transition from argon laser trabeculoplasty to SLT. I mean it wasn’t widely adopted as a first line therapy then, and that was coming up on 10 years ago. So that’s come a long way probably thanks to some of those trials that have shown its benefit.

And I think it’s utility in a scenario where you’re delaying the need for drops. As we’ve talked about earlier in this podcast and many have talked about before, I think there is hard to quantify, but a significant benefit I think to delaying starting a drop on a patient because think of how many times you actually take a patient off of a drop without doing something else. If you put them on that drop, you’re basically signing them up for years of treatment with that medication. And sometimes it can be mindless, “Well, they use timolol.” And that’s just part of their life now. And if that’s something that we can delay, boy, I think that’s significant.

Nathan Radcliffe, MD:

Yeah, absolutely significant. And the biggest hit to a patient’s quality of life with glaucoma is typically the day they start the drop. One thing that strikes me as I look at my career and how my SLT use has evolved is I know I used to use it, I would say a little inappropriately. I mean I wait until people almost needed surgery and then laser, and this was at the very beginning of my career and it often didn’t work in that setting. So I actually had a bad impression of SLT because I was using it in the wrong place. What we now know from the light study is that SLT works its best as a therapy prior to any topical drops and it will work well, but less well the later in the disease you use it. That’s probably not the case with eyedrops. So you have this really unique opportunity there to use it first and get the most out of it.

And we know it can prevent future glaucoma surgery. We know it can prevent visual field progression compared to drops, probably due to its sustained nature. And one of the lessons from the light study, and we’ve seen similar data with the meshwork stents are that anytime eyedrops have been compared to a therapy like laser or stents that are sustained, the sustained therapy tends to do better in terms of visual field progression even when the pressures look the same in the studies. So I think that speaks a lot towards the fluctuation that we don’t see that’s happening all the time with drops.

Brandon Baartman, MD:

Yeah. That’s a really good point. And one of the reasons why I tend towards surgery more frequently now that we have safe things like laser therapy and MIGS devices, we know they’re working in the background, they’re not subject to the pharmacokinetics of a drug in the eye and its effect on aqueous production or outflow. So I think there’s a significant benefit to that. I also think that as drug delivery continues to evolve and we’ve got a good option on the market right now, that’s something that we can sometimes use in a stage fashion with SLT. I’ll often start with SLT and plan for a pressure check and perhaps employ the use of a drug delivery implant at that time if we feel like we need a little extra control. So you’ve got this little bit of burgeoning mix and match titrable effect of these different minimally invasive tools, which is exciting to see where that’s going to go too.

Nathan Radcliffe, MD:

Yeah, absolutely. I mean the options are really getting pretty exciting here. And I want to bring us back just to MIGS with cataract surgery. And I guess for here, since we want to talk about drawing people in, I mean we haven’t covered this, but I know we both feel that there are enough patients with glaucoma. Many of the mild glaucoma patients aren’t being cared for by specialists. They are being cared for by comprehensive ophthalmologists, cataract, cornea, anterior segment surgeons that we want these procedures being offered by those cataract surgeons. And in my case, even knowing that that might be a case I lose from my practice because my colleague does it. I want that because I want what’s best for the patients and I know this is the way to do it. But talking to me like I am a comprehensive ophthalmologist who hasn’t done that much MIGS, can you paint for me some of the advantages and your thoughts on just the approach to combine cataract with a MIGS, let’s say a MIG stent?

Brandon Baartman, MD:

Yeah. I mean, I’m with you on the opinion of that. So when I’m talking to the colleagues in my community that maybe are saying, “Hey, what’s the first MIGS? If I wanted to dive in, what do I do? How do I get started?” First we step back and say, “Okay. Why are you interested in that?” One of the things that I hear frequently is they want to hold onto these patients too. They don’t necessarily want to have to send to a glaucoma colleague just to have the patient sent back. And that’s most significant when you’re talking about comprehensive cataract surgeons bread and butter continuing to be cataract surgery. So with the increase in the recognition diagnostic tools of glaucoma, the availability of different MIGS devices, that’s squarely in the cross hairs of one of their primary procedures. So I think it makes sense from a practice standpoint to continually push your surgical abilities to the top level.

And I believe that an angle based surgery is well within the wheelhouse of a comprehensive ophthalmologist. So I also believe that it’s also a nice practice supporter. You’re adding additional surgical procedures and while we don’t do surgery to support our practice, we all know what we’re facing in terms of reimbursement and that will continue to be a problem moving forward. So taking an easy, I would say, almost lateral step to include an additional procedure while you’re doing your bread and butter cataract surgery makes a lot of sense from the surgeon’s perspective too.

I think that it makes sense from a patient’s perspective, they’re doing the right thing by their patients knowing, “Hey, I’m going to do a cataract surgery on you anyway.” We’re going to use the same incision and add an additional anywhere from one to say five minutes of time to that surgery with minimal overall additional risk. So I think if you’ve got a mild to moderate glaucoma patient having cataract surgery already on a drop, boy, I have a hard time thinking that they shouldn’t have a MIGS procedure. So that’s the rationale that’s being translated to the comprehensive guys and girls. And I think that we’re starting to see an uptick of adoption of that technology too for those reasons.

Nathan Radcliffe, MD:

Yeah. And I agree with all those points. And I think the one that you made there is that the risk profile comparing the cataract with the stent or whatever to the cataract alone are nearly identical. I think I throw out the number of you have a one in 100 risk of bleeding interfering with the healing a little bit with the MIGS that you don’t really see typically with the cataract and even far more rare to actually have to do anything about that blood. Usually you can just wait a little bit and watch it go away. But really delivering those excellent cataract outcomes, but possibly enhancing them by helping the ocular surface and getting the patients off the drops as well. All right. And then we even have evidence that stent placement can help patients avoid tubes and trabeculectomies down the line and also a visual field progression. Any thoughts about how having a stent with a cataract can change the glaucoma patients disease trajectory over time?

Brandon Baartman, MD:

Yeah. I think you basically put them on a different track, in my opinion. If they’re a patient that’s headed towards, they’ve got a family history of blindness or trabeculectomy, that’s a common thing. My grandmother, one of my parents had a major glaucoma surgery. I remember a big event when I was a child of them having this surgery. This is a way to help divert them from that, what seems like sometimes an inescapable future for all the reasons that we’ve talked about reducing their pressure and delaying the need for those surgeries. Now, it’s not to say that they’ll never need it. I think one of the biggest risks of vision loss from glaucoma as a family member that has lost a significant amount of vision from glaucoma. So it’s not a hard cell to talk to these patients about potentially intervening earlier in the process to try to avoid that.

Because I know that you do a lot of incisional glaucoma yourself, Nate and I also would be willing to venture that you’d like to avoid one of those surgeries if you had glaucoma yourself. So I think it’s really a meaningful thing. And as a cornea specialist, and maybe this is a stretch, but let’s see how it plays. I think that I liken it to the treatment of keratoconus. Traditionally, you wait and you wait and you wait, and then you do a corneal transplant. But I also tell my patients nowadays, you don’t want to have a corneal transplant, and that’s why we’re going to go through this cross-linking procedure to help divert you from the course that you might be headed towards. So I think MIGS can play a similar role in the field of glaucoma.

Nathan Radcliffe, MD:

It’s funny you say that. I agree completely with the analogy between keratoconus and look, I’m a glaucoma specialist, but if I had keratoconus, I would not want to wait for more progression. I would want to get cross-linked right away. And I know you have your own guidelines and all those things, but that’s how I feel about it because I already treat a progressive disease that just by virtue of having the disease does mean you progressed at some point in time. You aren’t born with glaucoma. So if you have glaucoma, you’ve progressed. And that to me is one of the reasons.

There was an argument against doing stents with cataract surgery that went something like, “You know Nate, most glaucoma is mild. It’s a benign disease. Most people can just be on one drop and everything’s fine.” And what we saw in the light trial with ocular hypertension and newly diagnosed glaucoma was 3% of people in the first three years going on to a tube or Trab with newly diagnosed glaucoma if they had drops. And that number was 0% with laser. Similar numbers looking at the hydra stent for MIGS where you’re cutting the number of surgeries in half. So I don’t agree that most glaucoma is benign. I think most glaucoma progresses over time. I think with longevity in everyone’s future, the disease is more of a threat to quality of life than ever.

And that point that you made, when I meet a new glaucoma patient, I basically say, “There are two things I want to help you avoid. Number one is blindness, and number two is incisional glaucoma surgery.” We have tools to do that. And you’re right, it changes someone’s year. If they don’t have to get a tube that year, it’s a better year in a meaningful way because the tube is going to be one of the most negative things that happens for that given year.

So now let’s going to ask you, we all have our own challenges with getting into the interventional mindset with patients. Maybe we know we should offer more patients laser, maybe we know we should do more standalone. And I think we have the arrival now of our first standalone FDA approved iStent infinite. We’ll have iDose soon, which is also depending how you look at it’s a sustained therapy, but it’s one that’ll be delivered in an OR setting in much as a similar standalone interventional glaucoma paradigm. How do you get into the mindset and how do you recommend for maybe someone who isn’t as deep into MIGS as you’ve been, how are they going to get into the mindset and practice of providing these options for their mild, moderate glaucoma patients?

Brandon Baartman, MD:

Yeah. I mean, I think that the first step is to start doing the homework on understanding the rationale. Because I think if you start with why, why is this significant? And for all the reasons that we’ve talked about already today and probably more, it’s worth people understanding the rationale behind early intervention for their patients. We believe, I bet the two of us together on this call, that early intervention is meaningful and can make a difference for a patient. So if I’m a comprehensive ophthalmologist with a panel of patients I’ve been following for years, I think adopting technology and venturing into the literature a little bit and attending a course, that’s the easiest way to do it I think, is you go to one of our national meetings and you sit in on a course by the likes of Nate Radcliffe or John Berdahl, you’re going to start to understand the significance of incorporating technology like that into your practice.

But it’s probably a little bit intimidating when you’re thinking about, “I’m a cataract surgeon, I’ve been doing cataract surgery the same way for 20 years now. I don’t know that I want to turn the patient’s head 35 degrees and tilt the scope and have to muck around with a prism. And how do you get comfortable with that?” And I bet you could probably explain that a little easier than I could having gone through MIGS training after you’re out of training yourself. But I think the first step is understanding the rationale. And that I hope would help motivate people to see that it’s something relatively simple to incorporate. You just have to take the leap. And I think the biggest hurdle of resistance is that first exploration into doing a wet lab or contacting a local rep and say, “Hey, I want to take a look at one of those devices. Do you have any simulated eyes that I can practice with?” And I think that’s probably one of the biggest hurdles that those face, don’t you agree?

Nathan Radcliffe, MD:

I do. And it’s funny you’re setting off all sorts of thoughts for how I adopted MIGS. And part of it for me was it was out of training. So I learned the role that industry can play in getting you things you need. And that can be how do I work my scope? How do I set up my OR? What equipment do I need? Can we do a dry run on a day? I’m not going to put any stents and just make sure we have everything we need. Maybe that would’ve been my answer like 10 years ago, and I was just thinking of… Last night I was doing a sustained delivery talk and I realized that my femtosecond rep, so the rep who taught me how to talk to patients about the femtosecond cataract surgery had given me a lot of pearls on how to talk to patients about MIGS and about sustained delivery.

And there’s just some simple principles like telling a patient good news, you’re a candidate for this procedure. Good news, your insurance is going to cover this procedure. That’s a benefit that your insurance provides you that you can take advantage of. People love to know that they can take advantage of things they’ve already paid for. And the more and more I get into it now, I realize that the industry helps us cross pollinate. They meet with you one week, they hear you say something to a patient that resonates and they can tell me about it, and then I can use it for free. And it really is reaching out. And of course you reach out through your videos, you reach out through your colleagues, and you have these conversations like we’re having, but you also have officials channels of help. You have the academy courses, ASCRS courses, and those are great places as well, but lots of people excited to see us succeed in these venues and more than willing to give us the tools we need. And I think that’s a really a neat part of all of this.

Brandon Baartman, MD:

That’s a good point. Really good points.

Nathan Radcliffe, MD:

I think we’re doing great here, and I think we’ve made a strong argument here for why everyone should be involved in this. And maybe for this last little part, I’ll just pick your brain on what things are going to look like in a few years when we have iDose, three years of at least sustained prostaglandin therapy. We have infinite with improving insurance coverage. I’m sure. What are we going to be, what’s the new algorithm going to look like? I think we’ve got some new things here to plug in between that first SLT laser and the cataract surgery with MIGS, which may be coming further down the road.

Brandon Baartman, MD:

Yeah. I mean that question alone is probably your pitch to a comprehensive ophthalmologist on why they should make the leap now. Because unlocking the ability to work in the angle is going to increase comfort level with putting a small pellet in the angle, probably like a Durysta, or of course putting an eye dose in the angle in the OR. So you’re unlocking a number of surgical procedures at their fingertips. And with the brilliant minds in the field of glaucoma, we’re going to start seeing people rapidly come out with studies on, “Hey, I combined these two procedures and these were my results on IOP lowering at six, 12 months, three years down the road.” If you’re looking at iDose, it’s really exciting to think about what it’s going to look like. And I bet for a while MIGS, it felt like maybe MIGS increased how the latency to cataract surgery.

So maybe you would’ve sat on cataract a little longer, but you say, “Boy, you’ve got a mild cataract in glaucoma. Here’s what we can do for you now. We can treat both things, so we should just take care of your cataract first.” Now, I wonder if we got a bunch of other things approved that we could potentially do before cataract surgery and save that, maybe it shifts it back a little bit. I’m not willing to wager that, but it wouldn’t be unreasonable to think, the primary problem is glaucoma progression right now. Let’s exhaust some of these other things. And then we come to cataract, or maybe you leapfrog it and do some of this stuff on the back end of cataract and MIGS.

So we’ve got all these things that are going to shuffle around on the glaucoma timescale in a patient’s journey. And the data that’s going to come out is probably going to be plentiful and exciting to see. So I’m not exactly sure what it’s going to look like, but I know that drug delivery is going to probably fit squarely in the realm of the phakic patient and pseudophakic patient alike.

Nathan Radcliffe, MD:

No, I agree. It is exciting for all those reasons. I think when MIGS came, it helped us diagnose more glaucoma because we now had to think a little bit more about whether it was there or not when we took the cataract out. And maybe we’ll be doing an even better job diagnosing early glaucoma now that we have these earlier treatments. And I totally agree, this is huge opportunity that’s only growing, and now’s the time for everyone to get in the space, plenty of patients to take care of, great safe technology. It’s been well studied, FDA approved. We’re in a really good place with these options. Well, I’d like to thank you for letting me pick your brain and sharing with our audience here today, Dr. Baartman.

Brandon Baartman, MD:

Yeah. Thanks, Nate. It was honestly an honor to get to talk to you about it. I know how involved in the MIGS space you’ve been and to have you asking me questions is surreal, but hopefully they were all in line with what you were thinking too. And yeah, I had love to see more comprehensive surgeons adopt this, and I think training programs are eyeing that too, and putting out surgeons that have that capability now. So we should see a big expansion.

Nathan Radcliffe, MD:

That’s great. Well, all right. I’d like to thank everybody for listening to us today on the Ophthalmology 360 Podcast and have a great rest of your day.

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