There is a growing sense that “glaucoma is a surgical disease.” It’s a sentiment that has been percolating within the management of glaucoma for quite some time, especially since the dawning of the MIGS era. The safety profile associated with microinvasive devices has pushed their use to earlier in the treatment paradigm, and the efficacy of the MIGS class of procedures often allows patients to reduce their dependence on drop instillation. Fundamentally, what this new era heralds is a subtle yet profound shift in glaucoma management, away from dependence on pharmaceutical options as the default option for treatment-naïve eyes and as add-on therapy for uncontrolled pressure, and toward a preference for procedural management (inclusive of laser, surgical procedures, and devices) early in the natural history of glaucoma.

Yet, procedural management of glaucoma has important ramifications for how practitioners assess and follow patients over time, especially those who have either not developed frank glaucoma and those who are struggling for any number of myriad reasons with taking ocular medications. What this new era of glaucoma management needs, experts agree, is a new mindset, one in which ophthalmologists treating glaucoma begin to think about when and how they can intervene using the wide array of procedural options at their disposal to address the anatomic structures within the aqueous drainage pathway, rather than targeting uncontrolled pressure as a risk factor for glaucomatous progression.

So what is the interventional mindset and why should ophthalmologists at every phase of their career be paying close attention to the changing tides in glaucoma management?

To answer these questions, Young MD Connect gathered a renowned panel of experts, including Lauren S. Blieden, MD; Bac T. Nguyen, MD; and Steven R. Sarkisian Jr, MD, to share their perspectives on what this mindset really means, how to adapt it into practice, and how to use it to elevate patient care in the management of glaucoma.

What is the “Interventional Mindset”?

Steven R. Sarkisian Jr, MD

• The interventional mindset is …
  • being proactive.
  • individualizing care by talking with the patient about their needs.
  • acting in the best interest of the patient by reviewing surgical options from the beginning of the doctor-patient relationship, or before by mentoring your referral sources in the interventional mindset.
• The beauty of MIGS is that the array of options allows us to individualize treatment for the patient.
  • “I’ve been saying my whole career that glaucoma is a surgical disease. Now it’s perhaps more accurate to say that it is best treated as an interventional disease.”

Bac T. Nguyen, MD

• The interventional mindset …
  • should represent a shift in our thinking away from medication first toward a mindset of addressing the suspected area of outflow resistance.
  • is how we can think about factors that are important for the patient.
    • IOP response is still crucial, but we also need to think about factors like quality of life.

Lauren S. Blieden, MD

• The interventional mindset is ...
  • about asking questions.
    • Treating pediatric patients is very much oriented to a procedure-first mentality—why don’t we think that same way for adults?
  • intervening for the patient.
    • To intervene implies an action that alters a course of events.
    • Surgery may be performed on a patient, but it is really done because the outcome has potential to change their life, such as reducing medication use or reducing the potential for vision loss.

Getting Started With the Interventional Mindset

Bac T. Nguyen, MD

“You never stop training; you’re always learning.”

• Adopting new technology is in our blood as younger surgeons.
• You learn from your mentors, but also your peers.
  • Exposure to amazing mentors challenges us to break existing thought patterns, but our peers are often the ones introducing us to new ideas.
    • It’s a good reminder to stay curious and to stay receptive to new ways of thinking.
• The Interventional Mindset is growing, especially in private practice.
  • In many settings, practices are looking to younger surgeons to be the leaders because they have the most recent experience (through training) to new devices and technology.
    • To the surgeon just getting out of training, it can feel a little unsettling to think you may be the expert; but it may also be true, so embrace it!

Imaging and the Interventional Mindset

Lauren S. Blieden, MD

“To truly master angle-based procedures, you need to master looking at the angle,” and that means gonioscopy.

• Imaging the anterior segment has come a long way; you are far more likely to notice early signs on OCT and other advanced imaging well before visual fields.
  • In fact, visual field loss is a sign that some permanent damage has already occurred.
• Intraoperative OCT is a newer technology that may soon become very important, for example for visualizing stent placement.
• Still, with all advancements, gonioscopy is still a crucial skill to learn and practice:
  • Practice in the clinic; learn what “normal” looks like; it will pay dividends when you use it in the OR.
• Two examples of why gonioscopy is vital:
  • During TM-based procedures—visualization of an episcleral fluid wave may predict response.
  • Information from gonioscopy can provide clues about the most likely area of outflow obstruction, such as in pigmentary glaucoma.
    • Lack of treatment response to certain interventions can also be telling: for example, SLT targets the TM; if that doesn’t work, it may be time to target another part of the outflow pathway.

Getting Creative & Innovating With the Interventional Mindset

Steven R. Sarkisian Jr, MD

“You can put a dent in the universe if you refuse to be limited by conventional wisdom.”

• We really need to think about MIGS in terms of where we are having effect in the outflow pathway.
  • It is a good idea to have a “go to” procedure for each part of the pathway.
• Why should we think about mixing MIGS procedures?
  • We already mix medical therapy with fixed combination medications. Why? Because each drug in the combination has a diferent mechanism of action. The same thinking can apply to mixing MIGS that address different points of the pathway.
  • We already have experience “mixing MIGS.”
    • Some of the earliest efforts with iStent were in combination with ECP.
  • Mixing MIGS can allow for lower IOP.
• When you try new procedures, be “all in.”
  • Dipping your toe in the water is a common mistake.
  • Half-in leads to failure; bad results lead you to drop something from your repertoire.