MIGS Comanagement for the Modern Optometrist

Sir William Osler’s assertion that “the good physician treats the disease; the great physician treats the patient who has the disease”¹ resonates daily in our clinical practices, particularly in the management of glaucoma. Today, optometrists in all 50 states actively diagnose glaucoma and are charged with identifying strategies for managing this disease without over-burdening patients. Although the therapeutic drugs we initiate may mitigate field loss, they can also negatively affect the patient’s quality of life. Thus, effective long-term management of glaucoma is challenging at best and recalcitrant at worst. This article reviews the various options for treating glaucoma and then delves into three main professional relationships involved in the comanagement of the disease.

GLAUCOMA THERAPEUTIC OPTIONS

Minimally invasive glaucoma surgery (MIGS) is the term used to describe a suite of interventions that involve minimal tissue disruption. MIGS procedures are typically performed ab interno and are followed by a swift recovery from surgery.² Although they may vary in appearance and mechanism of action, MIGS procedures, as a collective, are safe and effective. These tiny yet powerful tools are slowly moving toward the forefront of the glaucoma treatment paradigm.³

Before the advent of modern MIGS procedures, the primary care optometrist played a nominal role in the management of patients undergoing glaucoma surgery. However, in modern day glaucoma comanagement, we are often responsible for initiating the discussion with patients on surgical options, including the benefits and risks of MIGS procedures. Our role as optometrists, in many cases, is to set the stage for the “why” behind MIGS procedures, which doesn’t necessarily require us to recommend a specific technique. Although some MIGS procedures are FDA-cleared to be performed as standalone procedures, the most common situation in which an OD would comanage a MIGS procedure with a surgeon is when such procedures are performed concurrently with cataract surgery. Comanagement of these MIGS procedures is not much different from comanagement of cataract surgery, as their ultimate success is heavily influenced by the fundamental quality of the OD’s relationship with three key individuals or groups: the surgeon, the staff, and the patient. The next section explores each of these relationships in detail as they pertain to enhancing the success of MIGS procedures.

KEY COMANAGEMENT RELATIONSHIPS

The Surgeon

The primary relationship in MIGS comanagement is the one you maintain with the surgeon. Knowing which MIGS procedures are within the surgeon’s armamentarium will guide you in identifying patients who are appropriate candidates. In addition to familiarizing yourself with the mechanism of action and the clinical appearance of various MIGS procedures, it would behoove you to meet personally with your comanaging surgeon to establish clear expectations for the whole process, from pre-referral patient discussions to postoperative clinical care.

Understand the postoperative timeline for each MIGS procedure and what it entails, including the surgeon’s preferred postoperative drop regimen and whether they would prefer formal or informal progress notes. (On a related note, be sure you are accurately documenting and coding throughout the process.) Clinical practice patterns are always evolving, so it is important to periodically check in with your surgeon to see if anything has changed in their technique or postoperative preferences.

Being aware of potential complications, and recognizing them when they arise, is a critical part of successful MIGS comanagement. Examples of potential adverse effects include hyphema, uveitis, IOP spikes, hypotony, and stent obstruction. It is imperative to know not only when to refer the patient back to the surgeon, but also how to manage immediate complications. With regard to contacting the surgeon, some may be fine with a simple phone call or text message, while others may prefer more formal clinic-to-clinic communication. Define communication protocols with the surgeon early, so they are readily available if and when they are needed.

The Staff

Another important relationship that augments MIGS comanagement is the one you nurture with your staff. Regardless of practice modality, the attitudes and attributes of our clinical staff directly influence the quality of care we can provide our patients. When your team recognizes the value of MIGS procedures, their active participation in the comanagement process becomes invaluable.

My technicians assist in the identification of patients who may be good candidates for a MIGS procedure concurrent with cataract surgery. For example, they may notice gross dexterity issues as a patient holds a pen to complete their intake paperwork, which may indicate the patient is having or will have issues putting in their eye drops. Or the patient may disclose barriers to good compliance with drops to the technicians, such as rising medication copays or unreliable transportation. Each additional piece of information we glean from our clinical encounters allows us, as doctors, to create the most appropriate and individualized management plan.

Moreover, clinical staff members are aware of each surgical team’s expectations, and they can assist in answering questions regarding postoperative drops and follow-up appointments. Clear, concise communication with your clinical team and supporting staff members enhances the collaborative nature of comanagement and contributes to improving the patient experience.

The Patient

The most important relationship that directly affects glaucoma management and, ultimately, long-term disease stability or instability is the one you cultivate with the patient. Indeed, the strength of your relationship with each patient may help to ameliorate any stress or hesitation they may feel regarding the need for surgery. From the moment you greet the patient at their first examination, your verbal and nonverbal communication builds a fundamental level of trust that benefits both you and them over time.

Education is key to ensuring patients thoroughly understand their condition and why it is important to continue with the prescribed regimen. Explaining the natural history of glaucoma can drive compliance and affect their ultimate clinical outcome.⁴ Non-native English speakers and patients with low health care literacy tend to have worse outcomes with glaucoma, so it is imperative that translation services are used at every examination when treating individuals with such barriers.⁵

Just as we do with any surgical referral, always set appropriate expectations for the postoperative period and explain to patients that the goal of the recommended MIGS procedure is to stabilize their disease by maximizing IOP control and potentially minimize drop burden. Have an honest discussion with them about the risks and benefits, and be willing to answer questions in a manner that the patient understands. Assure patients that you have a direct line of communication with the surgeon and that they will have your professional support throughout the postoperative process and beyond.

CULTIVATE AN INTERVENTIONAL MINDSET

The burden of glaucoma within our communities is ever-increasing. As diagnostic capabilities and access to care increase, so too will the number of patients who require our competent and compassionate care. Many factors affect patient outcomes, and although some of these are within a patient’s control, many are not. Maintaining an interventional mindset toward managing this disease can enhance the patient’s quality of life, maximize the benefits of collaborate care, and may even prove critical to preventing vision loss.