Dr. Ehsan Sadri, MD, FACS, Minimally Invasive Glaucoma Surgery - Episode 4

Impressions and take away points from Patient Case #2

Ehsan Sadri, MD FACS, A minimally invasive glaucoma surgery specialist discusses impressions and key take away points from patient case.

Ehsan Sadri, MD FACS: The main impression I get is that this is an unhappy patient. This patient is on polymedication and has a lot of adverse effects, and the intraocular pressure [IOP] is still way high. Because remember, this patient essentially has presumed normal tension glaucoma. When I see a patient like this, I sit down with them, show them their visual field, show them the optic nerve disc photographs and the OCT [optical coherence tomography], and really build my case, because I want to get buy-in from them. The other thing I tell them is that I want to know their concerns. A lot of patients in this social media or information age, if you will, they have done their due diligence, they know their options, have done their homework, and they’ll come with questions. They will want a certain device placed. It’s important to sit down with them and individualize their therapies.

For this patient, what we decided to do is explain the advantages of the trabeculotomy or goniotomy using the OMNI device, and help them understand what we’re doing. The way I articulated it is that the patient is doing a great job taking the medications, but the eye needs some support, some structural sort of support to be able to dilate the drainage areas that feed into the…. The way I do this is by drawing on the photograph or having it on screen, and I play videos and show them the diagram. I feel like a picture’s worth a thousand words. The patient sits in the chair and really begins to understand and gives the buy-in. Because remember, unlike cataract surgery, they are not seeing better right after surgery, they are typically feeling OK, maybe they’ll complain about drops, maybe they’ll have some complaints about the adverse effects of the drops and costs, and whatnot. But you’re really not reversing the disease and you’re not improving their eyesight.

So, it’s a separate conversation, and they need to understand the importance of, if they don’t do anything, they’re going to have loss of vision, especially if they are what we call fast progressors. The initial conversation with this patient is, “Look, we’re going to use a device that’s minimally invasive with pretty rapid recovery, you’ll be able to drive the next day, you use your drops.” Obviously, I tell them about the risks and benefits. But I feel like the patient who understands has better buy-in. And so, in my hands, I think the response of the MIGS [minimally invasive glaucoma surgery] procedures, namely the OMNI in this case, has been remarkable.

We talked about this slide earlier. We want to do a procedure that’s quick with rapid recovery for this patient, that’s not too long for the surgeon, and is pretty user-friendly. Ideally, we’d be able to redo the procedure if you needed to do SLT [selective laser trabeculoplasty], and you want a nice, large reduction of pressure. And that’s what happened with this patient using the OMNI system. The average IOP reduction in my hands is right around 30% to 40%, which is remarkable. And while I tell the patients, “We can’t look at you and tell you what kind of medication reduction you’ll have, we know that most patients respond nicely.” When I say it like that, I’m telling them our initial impression and clinical experience in a high volume setting, but also explaining to them the advantages of being able to reduce the pressure and get them off the drops. I think that’s the era we’re going to be entering. We’re going to be entering an era where we’re going to be focusing away from using drops, but obviously, drops are going to always be around.

But I think anytime you have a patient with a blinding disease, participating in their own care, and if they don’t perform their end of the bargain, their end of the partnership, and they have loss of vision, they never really appreciate that, and it becomes your problem. We see this all the time. In other words, we really want to take the clinical therapeutic aspects of the intervention away from the patient and put it back in the surgeon’s hands. And I think the OMNI system is a great example of this. There are obviously other MIGS procedures out there as well, but you can see the nice IOP reduction in this patient.This patient went down to 1 eye drop.

The takeaways here are, as discussed, that we really want to have buy-in, No. 1, from the patient on the procedure. No. 2, we want them to understand this is not a reversible disease, because if you don’t tell them that, sometimes patients complain about, “Wait a minute, I still can’t see out of my visual field,” and you have to make sure they understand that the disease process is not going to be reversed. I’m excited because we didn’t have any of these options. I think, for surgeons, and for patients, it’s been a really nice change. I do hope that we are going to be able to preserve the professional fees for surgeons in the future because of the fact that these procedures are benefiting patients, and costs to the system. There are a lot of studies that show that for the health payers, all the stakeholders, it’s creating a nice cost-effective manner for patient outcomes, but also patient care, because we are seeing a reduction of patients’ needs for drops, and also doctor visits.

The other thing I would tell you here is that we’re entering a modern era of remote- monitored care. There are several groups right now that are looking at, studying the utilization of visual field perimetries done from home. We’re working with several companies that are looking at intraocular pressure measurements from home, so the patient has fewer visits. This OMNI system fits nicely with that, it stabilizes the ocular pressure reduction. I’m just excited. I’ve got to tell you, we have so many therapeutic options. I do think we’re in a renaissance in ophthalmology, not just in MIGS, but also in eye surgery in general. And I think our patients benefit from that.

It’s been an absolute honor and a pleasure to be here with you watching this Ophthalmology Times® presentation, and if you have any questions, please don’t hesitate to reach out to me. We hope you enjoyed this presentation.

Transcript Edited for Clarity