Explaining MIGS to Patients

How would you explain microinvasive glaucoma surgery (MIGS) procedures to patients? Valerie Trubnik, MD; Savak "Sev" Teymoorian, MD, MBA; and Carlos Buznego, MD; speak with Marguerite McDonald, MD, to share advice for educating patients about their options when it comes to MIGS and cataract surgery.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.

MARGUERITE: Welcome listeners. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island, in Lynbrook, New York and this is Informed Consent: Getting to Yes. In this podcast, leading eye surgeons share the fair and balanced words they use to get their patients to say yes to the treatments they recommend.

In this edition we’ll be talking about MIGS—minimally invasive glaucoma surgery.

My guests are glaucoma specialist Dr. Valerie Trubnik, my associate at Ophthalmic Consultants of Long Island.

VALERIE: Thank you, Marguerite. It's a pleasure being here.

MARGUERITE: It’s great to have you. Also offering his MIGS expertise is Dr. Sev Teymoorian, who is a glaucoma and cataract specialist with Harvard Eye Associates in Laguna Hills, California. He also happens to be both an MD and an MBA.

SEV: Thank you, Marguerite. Appreciate it.

MARGUERITE: And finally, let me introduce Dr. Carlos Buznego, a founding partner of the Center for Excellence in Eye Care in Miami, Florida, where he has a special interest in cataract surgery and MIGS.

CARLOS: Thank you very much for the invitation, Marguerite.

MARGUERITE: Carlos, how do you decide which patients should have standard cataract surgery and which get cataract plus MIGS?

CARLOS: Well, I think from my point of view, the clinical trial results from the FDA trial for the Glaukos iStent were really, really important. In that trial, what was determined is, when we compared control patients who had cataract surgery alone and cataract surgery plus iStent, the complication rate or the adverse event were basically equivalent.

So this is kind of a neat opportunity to provide an additional service to a patient without increasing the risk required of the surgery. So from my point of view, any patient who is on medication for glaucoma and has open angle, so it's open angle glaucoma, which is the majority of my patients. Any patient who has cataract with coexistent glaucoma and is on medications at all, I will present the option of incorporating a MIGS procedure along with their surgery.

VALERIE: I think now, more than ever, that there are different varieties of MIGS available, including the XEN and the CyPass, and they're FDA approved. Not always available through insurance, but they are available in the United States. Having the variety to treat different types of glaucoma, anything from severe to mild, really makes things safer for the patient, and easier for me.

MARGUERITE: As cataract surgery lowers pressure anyway, how do you decide who gets just standard phaco, or femto-phaco, versus phaco with MIGS?

VALERIE: Typically, because I get mostly referred patients with glaucoma, if they are at least on one drug, then they're probably going to get phaco with MIGS.

MARGUERITE: Great. Do you use pretty much all of them? Do you rely more on one than the other?

VALERIE: I certainly have more experience with the iStent, because that's been available for a longer period of time, as well as the ECT. We don't have the Trabectome in our surgery center, so I unfortunately don't have access to that, but I've been trained in it in residency. Now, because the CyPass and the Xen are coming out, I'm getting involved in that as well.

MARGUERITE: There are different types and different approaches. Let's pretend that I'm Mrs. Smith and you've decided that I need cataract surgery with MIGS. How would you explain it to me?

SEV: Before I decide which of my approaches that I would use for Mrs. Smith, MIGS actually is divided up into a couple of different categories, and the reason why it's important to differentiate between them is because the risks and benefits are different, and this becomes a very important thing when you're talking about consenting for a patient.

Just briefly, you can divide MIGS up into three bins. That's the way I think about them. There are canal-based procedures, which will simply bypass the trabecular meshwork. There are suprachoroidal or supraciliary procedures that shunt the aqueous to the suprachoroidal space, and there are subconjunctival procedures that divert the aqueous to sub-con space that would sort of look like a trabeculectomy.

Now depending on which of these bins we're talking about, the discussion's a little bit different. That's one thing to consider. The other consideration is what are our goals for the patient. In certain cases, the goal is to just minimize eye drops, because the patient is doing well. They're stable. It's just they're having cataract surgery, so we're going to do an additional procedure like a MIGS to decrease medication load. In other cases, the glaucoma is not controlled and we're actually doing the procedure to control the glaucoma, and that generally goes along with more invasive procedures.

The way I would approach it is for the first bin, the canal-based procedures ... this is the one where an iStent procedure would fall into ... we're not so much trying to control the glaucoma because it's mild to moderate. The patient's generally doing well with medications or a laser. Really we're just trying to decrease the amount of medications that they're on.

The way I would approach that is, Mrs. Smith, we're going to go ahead and proceed with our cataract surgery. I'm going to say one important thing to remember is you also have glaucoma. And in the long scheme of things, what's going to affect your vision the most is how your glaucoma does. Not so much how your cataract does, because we can take care of that. If we don't manage their glaucoma well, we're going to run into issues later.

Now we have an opportunity here, when we're doing your cataract surgery, to implant a stent that will help better control your glaucoma. The benefit of this procedure is it's one additional step to your cataract surgery. I'm already in the space working, taking your cataract out and putting a new lens in, but since I'm already in that space, we look to see if that area's opened up and we implant a stent in. The goal of this is to help minimize some of the medications you're on, but ultimately give you really good glaucoma care in the future.

MARGUERITE: So, Carlos, pretend I'm Mrs. Smith and I'm sitting in your chair and you've made the decision. How do you explain it to me?

CARLOS: Okay, I practice in Miami. Can you be Mrs. Garcia?

Alright, you'll be Mrs. Smith. So, Mrs. Smith, I notice from your exam today that your vision has decreased and, as we discussed a minute ago, you're having difficulty driving at night and you're visual function's not where it ought to be. So I think it's time for your cataract surgery.

So, Cataract surgery nowadays is painless and you're going to see a whole lot better after cataract surgery. The important thing is that we have a new development in ophthalmology where, over the last several years, we have been able to kill two birds with one stone. So while we're doing cataract surgery, we can insert a tiny device in the eye that helps your eye drain fluid better. And that gives us a high rate of getting you off of medications. And the nice part, it really doesn't increase the risk of your surgery. It really only takes a few moments more, or, a few minutes more than the cataract surgery alone will, and the nice part is insurance covers the procedure. So there's really no additional cost for trying to address both issues in one sitting.

MARGUERITE: As Mrs. Smith, I would then ask, is the recovery longer? Is it more difficult? Is it different?

VALERIE: I think the recovery is the same. It's certainly not more difficult for you, as the patient, and for me, as the physician. At this point, once you've done quite a bit under your belt, it is not difficult in the least. I shouldn't have any difficulty implanting it, and the recovery should be the same as standard cataract surgery. Your vision will be excellent the next day.

MARGUERITE: Great. The surgery is just a little bit longer than normal cataract surgery?

VALERIE: Not by much. Probably, at this point, for me, maybe just a few minutes. I think, with something like an iStent, as well as the CyPass, the insertion is pretty quick and easy once you've gotten a few under your belt. I don't think it's going to take much longer than a regular procedure of cataract surgery.

MARGUERITE: That sounds reasonable. I think the conversion rate has to be super high once they hear that they're likely to get off drugs.

VALERIE: Pretty high. The only times that I've had patients kind of hesitant, they say "Well I've read about this stent. You're going to put this stent in my eye. Does it come out? Does it fall out?" No, it stays in place. It's nonferromagnetic, you can go through metal detectors; it's not going to fly out of your eye if you go through an MRI. Often times I get phone calls from MRI techs concerned about patients. That's not an issue at all.

The other question that I often get is whether the stent will clog up over time. In fact, I've noticed that, if anything, the iStent tends to work better over time. With CyPass, sometimes the fenestrations do tend to kind of close up, and pressure can climb up with time. That's something that we can address with drops, if need be. It does give you the potential to come off the drugs, you don't have to spend hundreds of dollars every month, and also kind of tolerate the side effects that are associated with drops.

CARLOS: Some people say, well wait, that device, I mean I might feel something in my eye and I'd sort of know. It's tiny. I don't usually go off on these tracks but if I do, I say it's the smallest implant, regarding the eye it's the smallest implant in medicine. It's half a millimeter by one millimeter, so I reassure the patient, there's no sensation, there's no maintenance to it. We don't ever have to take it out. It works most of the time and if it doesn't, we're back where we are right now which is back on medication.

SEV: The canal-based procedures really rejuvenate the natural pathway to the aqueous, so whenever we shift over to this next bin, we're diverting aqueous to an unnatural space, into the suprachoroidal space. When I bring this up with Mrs. Smith, she's generally someone who's doing worse than the first bin, in the sense that their glaucoma's getting worse or they feel like they really need much better control.

In this discussion with the patient, I would say, Mrs. Smith, after we're done with your cataract surgery, we have an opportunity to better take care of your glaucoma. And we know this is going to be a major issue for us moving forward. We have a chance here, when we're doing the glaucoma procedure, to place a stent to help divert the fluid inside of your eye to a different compartment. We've already attempted to restore your natural pathway of where the fluid goes, but we're going to resort back to this other option to help further bring your pressure down. I think this would work well for you, because it'll help us decrease the amount of medications you're on and better control your glaucoma.

The next big bin of MIGS procedures would be your subconjunctival procedures. These are the ones that almost look like a trabeculectomy. These would be like a XEN procedure. This discussion is more focused towards mitigating the risk part of the discussion. In this case, I would say, Mrs. Smith, in this procedure, what we're trying to do here is bring your eye pressure down, but we want to do it in a safe way. Now it used to be we had these older procedures, which we could rely on, but we ideally would prefer not to do them just because there was inherent risk involved.

Now, what's exciting to us and for you is that there've been many new innovations recently with better ways of doing these procedures that allow us to bring your eye pressure down, but also decrease the risks that are involved. Some of these risks that will help decrease would be issues of bleeding in the eye or low eye pressure. What these new stents do is mitigate the risk in doing that, and I think you would do well with it.

MARGUERITE: That sounds great. Basically, it's mild, moderate, severe.

SEV: That’s correct.

MARGUERITE: The more aggressive the procedure and the more unnatural the space into which the aqueous is being shunted, the greater the risk. Would you say so?

SEV: That’s correct.

VALERIE: Typically, I would do the iStent or the Kahook Goniotomy for mild glaucoma, CyPass, probably for something moderate, with someone who's on several glaucoma drugs, and then the Xen for advanced glaucoma, instead of a trabeculectomy. Often times they approach me and say "Hey, I read about the Xen. What do you think about it?" I think the patients almost self-select. They read about it, they often know it's out of pocket, but they're willing to pay out of pocket for something that they understand will give them significantly less side effects, less risk of infection, over their lifetime.

MARGUERITE: When do you say, "Oh, I think I'm going to refer you to my glaucoma specialist," for a trab or a tube or whatever?

CARLOS: So, a patient who is on maximal medical therapy and still has pressures, you know, high 20s or above 30 for sure. Those patients, I'll say, "Hey, I'm not sure that I can really fix your glaucoma problem with a cataract surgery." However, at times, I think it doesn't hurt. One of the interesting parts of MIGS surgery, if we're doing ab interno MIGS surgery, we're not involving the conjunctiva in the square and therefore we are not interfering with it for future trabeculectomy or tube.

So at times, even for patients who have ... I'm not sure that I can take them all the way home, off the meds with a MIGS procedure, I will offer that, but obviously you want to tell a patient who's got a high pressure and is on maximum meds that we may not get you all the way off meds but if we can get you on less medications, that'll be better.

MARGUERITE: Right now, how does the insurance coverage look? Pretty good?

VALERIE: iStent, pretty good coverage. Medicaid plans, not so great. Fidelis and other plans don't really have great coverage for the iStent. In that case, I would use a Kahook Goniotomy, which is another mixed procedure that I've found to be successful. The risks to benefit ratio, the risks are significantly lower than any other standard glaucoma procedure.

As far as the CyPass, I think they're still trying to get coverage from insurance companies, but some do cover. The XEN, if my patients are getting it, they're currently paying out of pocket.

MARGUERITE: Well, this has been extremely informative. I’d like to ask each of you for a closing thought.

SEV: It's important for the physician providing MIGS procedures to realize that although we have an idea of what we want to say, you do have to tailor it based upon the patient need and what the patient is expecting. I wouldn't use exactly the same approach if I'm talking about an iStent procedure in two patients. It's really important to realize that each of our patients are different. They're unique puzzles that we're trying to put together, and sometimes certain approaches are better than others. This is where understanding and knowing the patient and using words really well become very critical.

VALERIE: The other thing that I would say to my patient that seems to increase the conversion rate, is to say "if I was doing this on my family members", and they really stop and listen when you start saying that. "I would do this mixed procedure, because I think that would be in their best benefit." Often, they'll say "What would you do on your mother?" Then, they kind of listen a little bit differently.

MARGUERITE: I love that, that's a pearl we can use no matter what we're discussing. I would do it on my mother.

CARLOS: I think the MIGS procedure is relatively straightforward. So, in my hands, it's been a real boon to my patients, it's been a boon to my practice, and really, I get patients coming in specifically, who said, "Hey, I used to se Dr. So and So and you operated on my neighbor and I heard that when I get my cataract done I can also get off some medication." So it's really been a big "C" Change in treating our geriatric patients who have coexistent cataract and glaucoma.

MARGUERITE: ThankyouCarlos, thank you Valerie, and thank you Sev. And THANK YOU LISTENERS! Please join us again next time.

Speaker 1: Informed Consent: Getting to Yes, is editorially independent content supported with advertising by Alcon.