There are a variety of avenues to proactively seek out information on minimally invasive glaucoma surgery (MIGS) and to make it part of your glaucoma treatment armamentarium. Here, editor in chief Nate Radcliffe, MD, talks with Blake K. Williamson, MD, MPH, MS, of Williamson Eye and Michael Patterson, DO, of Eye Centers of Tennessee, 2 self-taught MIGS surgeons who didn’t pursue a glaucoma fellowship but are passionate about this emerging field. We learn how and why they joined the MIGS revolution.
Dr. Radcliffe: I’d love to hear your input on how a physician who is thinking about MIGS might become more comfortable trying it. Dr. Williamson, could you tell us a little bit about your background and share some advice for those looking to incorporate MIGS?
Dr. Williamson: I got started in residency when I realized that the majority of my patients just were not taking their glaucoma medications. I felt like I was doing them a disservice by writing them a script for a second or third bottle of drops. I knew I needed to do something different, and this was around the time that the iStent (Glaukos) came out. It just made perfect sense to me. I talked to colleagues outside the United States who were having good results with it, and I thought this was something I can do at the end of my cataract surgery that won’t compromise safety and will allow me to better serve my patients battling glaucoma. At worst, their pressure stays the same, at best I get them off a drop or two. It was a no brainer. So, I set out trying to get it done. At first, I was flatly told no, that “residents are not allowed to do MIGS.” Our residency director said absolutely not. But I was a pretty aggressive resident when it came to the OR. While I respected the faculty’s initial response, I was persistent and demonstrated that I was focused and committed to learning iStent by practicing surgical gonioscopy and reading all the literature on this emerging field. When I started my rotation at the VA, I finally had convinced my attendings to let me give it a shot. They were probably just trying to shut me up! He called the representative from Glaukos, and the next week I placed 4 iStents, becoming the first “resident” physician in the South to perform the procedure. I saw it as the future. I thought of it as something that was inevitable, something that I would need to bring to my private practice one day. So, I wanted to learn it before I got out of training.
Dr. Radcliffe: I think that’s one pearl there. Don’t be afraid to be the first to bring something to your residency if you’re a resident or to your hospital if you’re practicing already. I did the first toric lens at my VA during my residency, which makes me sound old. How did you get the idea to do the iStent in the first place? Was it just reading about it in journals? Was it listening to lectures?
Dr. Williamson: Before residency, I was working on my MPH and doing ophthalmology research at Johns Hopkins University when I met a classmate who was also going into ophthalmology, Hady Saheb, MD. He became one of the first fellows under Ike Ahmed, MD, and coauthored the original paper defining microinvasive glaucoma surgery with Dr. Ahmed. Dr. Saheb and I kept in touch and he told me about the device. I got in on the ground floor by being pals with Dr. Saheb.
Dr. Radcliffe: Dr. Patterson, did your adoption of MIGS begin in residency or did it begin your first year in practice?
Dr. Patterson: My story is very similar to Dr. Williamson’s. No one had done MIGS at our veterans’ hospital. I knew I was coming to my father’s practice in rural America, and I knew that he was having to do some glaucoma surgery. One piece of advice he gave me before I even started residency was, no matter what you do, learn how to be a glaucoma surgeon, because that was the biggest thing he had to deal with. I started with the iStent as well, and then when I got out into practice, it changed rapidly for me. The iStent was being utilized in our ASC by my father, but not much, and so I started doing that. At the same time, I started doing ECP. We already had that technology in our facility. Within 3 months of being there, I used the Cypass (Alcon) and within 1 month of being there I started using the Kahook Dual Blade (New World Medical). And so, I had used 4 MIGS devices within a very short period of time. And quite frankly, the reason was that we just had so many glaucoma patients. I agree with Dr. Williamson that patients can’t take drops. I don’t even think they can take latanoprost accurately. They call me within 3 days and say they ran out of their bottle.
Dr. Radcliffe: The literature definitely agrees with you, Dr. Patterson.
Dr. Patterson: Yes. Patients would call and tell me they were out of their drops within a week. The pharmacy won’t just refill that. So, they don’t have any drops. So, for me, the decision was very simple. I’m already doing cataract surgery, I don’t feel MIGS is much riskier. I know some people would disagree with that, but I think overall, it’s not much. And that’s when I started doing it regularly.
Dr. Radcliffe: Dr. Patterson, you did iStent and then quickly grabbed on to at least 3 other MIGS procedures in your first year of practice. Dr. Williamson, was your experience similar?
Dr. Williamson: Yes, very similar. I tried to change the mindset of my practice and let them know surgical glaucoma was something we can do as refractive cataract surgeons. MIGS put it right in our wheelhouse. When I started at my family’s practice, the situation was unique because I took over the surgical practice of an uncle who had been practicing for 40 years and retired from surgery just before I started. I was doing 20 phaco procedures out the gate on my first surgery days, which is a heavy caseload for a young doctor coming out of residency. It turned out that one-third of those people had glaucoma, so the volume alone made me a “MIGS guy” overnight. I welcomed this challenge and started intervening surgically from the jump.
While I started with iStent, there were conflicts with insurance coverage for a lot of my patients, so I couldn’t use the implant. I had to learn other procedures so that I could offer MIGS technologies to a wide range of patients on different insurance plans. This led me to the Kahook Dual Blade and then later to Cypass, XEN (Allergan), Omni (Sight Sciences), and so on. I branched out in a similar way to Dr. Patterson. I had no choice but to adopt these procedures in my practice, and I had to learn on the fly or else the case was sent to the glaucoma specialist for “trabs and tubes.” While there’s still a place for these filtering surgeries, I didn’t believe they were the best “second-line” alternative following SLT for a lot of the patients I was seeing.
I also learned many surgeons in Louisiana weren’t embracing MIGS back then. Several had started and then abandoned these procedures. I ended up launching some of the new devices in our state whereas you would think it would be a glaucoma surgeon. I’ve spent the past 3 years trying to bring this mentality to my home state. I’m often talking to other doctors in my state about new MIGS devices, even “competitors” in my own market, although I don’t think of them that way. I truly consider them colleagues who are doing what they can to improve people’s quality of life with MIGS. I believe this message is resonating as I’m hearing more and more of my friends and colleagues getting started with MIGS in Louisiana. It is a growth market right now; we’re all in this together. The real competition is surgeons who ignore glaucoma at the time of phaco and don’t at least let the patient know they have options that may help lower their medication burden. I’m trying to spread the word that this is a safe procedure that’s not going to take you much additional time, helps you better serve your patients, and you are well reimbursed for your efforts. It’s a win-win.
Dr. Radcliffe: So, you have both said something that I thought resonated with me and that makes a lot of sense is that you both came into a practice that had some mature patients, meaning they’ve been within the practice for many years, and you were able to transform the practice by bringing MIGS into that mix. And so, maybe some doctors who have been practicing for a long time might be able to translate that type of thing into their own practice.
Dr. Patterson: Performing MIGS is not easy. It is not good when people say that, for a lot of reasons. Number one is every one of us that do a few hundred of these a year has had someone with a choroidal effusion or an eight-ball hyphema or something that doesn’t go away for a long time. So, “easy” is not a good term. But they are trainable and teachable procedures. The first thing to do is talk to colleagues. Blake and I bounce ideas off each other all the time on surgery. But you’ve got to find someone that has done it and can give you some sound advice for simple first patients.
You also have to see your patients. Some surgeons aren’t even seeing patients preoperatively at all. That is difficult with MIGS, because you have to know what the angle looks like. If someone has a completely white trabecular meshwork, the iStent is probably not your best go-to. It’s just hard. And certainly not on your first case.
But more importantly, you’ve got to study. You’ve got to watch videos. You’ve got to read the literature, you’ve got to know the product that you’re handling, and you’ve got to mentally practice. I’m all about mental preparation, even though Allen Iverson didn’t agree with practice. You’ve got to practice it mentally. Then, when you go in there, it becomes easy.
Dr. Williamson: I’ll add to something Dr. Patterson touched on about expectations. We talk about expectations all the time for our patients, but we don’t talk about it enough for each other as surgeons. People try to put in a couple of iStents, they struggle, and then what do they do? They blame the technology and they say it’s taking too long and they aren’t going to learn it. But if you have a colleague who tells you that it’s going to be difficult at first and that it gets easier after a number of procedures, then you know what to expect. You improve, just like with anything you do repeatedly. Surgery is a performance art, like playing the electric guitar or hitting a baseball. I struggled in the beginning, but I’m glad that I did it because now I’m much more comfortable in the angle.
So, setting expectations with colleagues for MIGS is important. This way they don’t feel like a failure if they don’t knock it out of the park their first time through. Confidence is critical when getting started with MIGS, especially for the busier cataract surgeons who are experts at phaco and are uncomfortable being humbled by the challenges of doing MIGS.
Dr. Radcliffe: To your point, I’ve taken to showing my first video of the procedure during lectures just to disarm people. I was giving a talk and someone said, “I’ve seen some of your videos and they’re not that great.” That was a compliment, because we all know where we can go for the perfect video of a new MIGS, and my goal is to draw people in. I’m happy to share some of my humble moments because I feel that I am a good surgeon and also, even though some of my videos aren’t perfect, the patients did perfectly. So, maybe there was a little blood and we had to do a few extra steps here and there or maybe the procedure took 10 minutes instead of less. But we’re not trying to present MIGS as perfection from case one. We should let people know that you’re going to have a learning curve and that either way, your patients will do well, and eventually, you’ll get on top of that curve.
I also want to ask, did you ever struggle to get MIGS into your ASC? Do you operate at a hospital? I think one of the concerns that people may have when they’re trying to bring something new to their area is that no one else is doing it and they don’t want to be the first to bring it up. Is it difficult? Are you ultimately met with gratitude when you bring a new technology in?
Dr. Patterson: During my residency, I operated in an ASC owned by a hospital and there was a lot of red tape, and several committees had to review your request for a new device. I understand the frustration there. But in my practice, it’s not hard for me to do a new device at all. I can just say I’m going to do it. What I focus on is the adoption of a new procedure by the staff. In my practice, the staff are very proud of their work. They like to feel like they’re doing a great job as nurses and scrub technicians, so they get very anxious every time I bring in something new. I make sure that I communicate with them why I want to bring in a new device. That’s extremely important for the staff’s job satisfaction.
Dr. Williamson: I agree. I will come back from a meeting ready to start something new immediately. But often for our scrub technicians and nurses, change is a big deal. I have the industry reps bring information and presentations to the office to show the staff. I want to make sure they are fired up about launching a new procedure. I want to motivate them. Our saying is, “If you don’t excite, it won’t ignite.”
As for red tape, we have our own in house ASC at Williamson Eye that was actually one of the very first private ASCs dedicated to ophthalmic surgery in the United States. While it’s an older ASC, our staff runs those 2 rooms as efficiently as any ORs I’ve ever seen. We are lean and mean, and we look at cost/profit analysis for any new technology we’re thinking of adding. If we’ve green lighted a new machine or device, an analysis has already been done that came back favorable and we’ve already negotiated price with the company, likely multiple times. The biggest thing that the industry has to understand is that to mainstream glaucoma surgery, they must do it through cataract surgeons. Busy surgeons in private practice don’t want to spend tens of thousands of dollars on bulk orders to do these procedures. Industry needs to make it easy for us to do. So, the way they can get through the red tape is to get rid of bulk orders and offer more a la carte sales, like they do in the refractive space with consignment.
Dr. Radcliffe: Dr. Williamson, do you have a reimbursement expert?
Dr. Williamson: Revenue cycle management is a full-time job at Williamson Eye because of our volume, so we have a billing floor. We have several employees dedicated to billing, so I ask them to investigate reimbursements when considering a new MIGS procedure.
Dr. Radcliffe: Blake, do you ever pick a procedure for a patient and then you’re told that that’s not covered and then you have to go back and change it?
Dr. Williamson: It happens all the time. When we were launching Cypass and Xen, the companies were up front. They told us no one was reimbursing it (at the time), and that there was not even a code. So, we had to work that out. We did some Advance Beneficiary Notice of Noncoverage cash-pay procedures for these devices when they launched.
Dr. Radcliffe: And, Dr. Patterson?
Dr. Patterson: I don't do billing on my own, but I choose my own codes. In our state, reimbursement is dependent on the MIGS procedure. In 2017, the Centers for Medicare & Medicaid Services (CMS) awarded Palmetto GBA as the administrator of Medicare Part A and Part B claims in Tennessee, and reimbursements fell. I have altered my practice because of that. We have to be dynamic in the landscape of changing reimbursement. I’m definitely cautious about even the cost of a device. I agree with Dr. Williamson; having to buy in bulk is too expensive.
Dr. Radcliffe: So, it’s worth learning about the reimbursement landscape before you launch into a new MIGS so that you can make sure not to create a situation where you’ve got accounts receivable skyrocketing.
Dr. Patterson: Yes. I think you owe it to not just your staff, but yourself too. Whether you work in a hospital or not, you shouldn’t be out there doing things that aren’t being paid at all.
Dr. Radcliffe: This is all very valuable information; thank you both for joining us. GP
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