Adopting the Interventional Mindset: MIGS in a Comprehensive Practice

This is editorially independent content
6 min read

Drs. Radcliffe and Ristvedt review methods for implementing minimally invasive glaucoma surgery (MIGS) procedures in your ophthalmology practice.

In this installment of Interventional Mindset, Nathan Radcliffe, MD, speaks with Deborah Ristvedt, MD, a comprehensive ophthalmologist practicing at Vance Thompson Vision in Alexandria, Minnesota, about integrating minimally invasive glaucoma surgery (MIGS) into a comprehensive ophthalmology practice.

Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.

Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.

Intervening earlier in glaucoma treatment with MIGS

Dr. Radcliffe explains that ophthalmologists are used to providing cataract surgery with MIGS added as a quick, bonus procedure with lasting benefits; however, it’s often more challenging to recommend MIGS procedures as standalone treatments for glaucoma patients.
Dr. Ristvedt started as a comprehensive ophthalmologist at her family’s third-generation practice in a smaller town where they were expected to do everything. During this time, Dr. Ristvedt noticed a need for glaucoma care. She was introduced to MIGS as she was taking patients over from her father, and she was very excited about the potential it offered to help glaucoma patients.
MIGS provides the opportunity to intervene earlier in the disease process, where it can bring the intraocular pressure (IOP) to a more stable level so that the subsequent treatment can be less invasive.

The evolution of MIGS technology

Dr. Ristvedt started with MIGS procedures using the iStent, and her interest grew from there. Approaching the procedure with a similar mindset to cataract surgery and breaking it down into steps gave her the confidence to continue to grow and develop the technique with practice. The various MIGS devices offer a high level of customizability, and with practice, clinicians can build on top of each procedure to tailor the treatment to the patient’s needs.
To develop confidence in performing MIGS procedures, Dr. Ristvedt points to the following foundational skills:
  • Establish the correct angle
  • Identify the trabecular meshwork
  • Know where you are going with the device
  • Be able to do two-handed surgery, where one hand holds the gonioscopy lens, and the other holds the instrument itself
On top of the customizability of MIGS procedures, patients recover quickly, making it a minimally disruptive technology to their lives. The development of the Omni expanded access to MIGS as a standalone procedure. From the clinician's perspective, it can sometimes feel like the boat has already passed to treat many pseudophakic patients’ glaucoma; however, with MIGS technology, clinicians can revitalize the outflow pathway even after the patient has had cataract surgery.

Setting MIGS treatment expectations for patients

Over time, Dr. Ristvedt gained confidence in the procedure's efficacy and realized that recommending the procedure was a simple conversation with patients. One method for communicating how MIGS procedures work to patients is to outline the basics of cataract surgery and compare the two.
Once the patients understood the basics of cataract surgery, she compared cataract surgery to the Omni device. She explained to patients that surgery with the Omni device takes about the same amount of time as cataract surgery, surgeons use the same sedation as cataract surgery, and the recovery time is about the same.
Incorporating ocular surface disease treatment in glaucoma treatment is another recent evolution. Mentioning this and the benefits of MIGS procedures on symptoms can help with patient communication. With the Omni, informing the patient that they can get off a drop or two will likely excite them. These patients frequently have fluctuating vision, and surgeons can use these innovative technologies synergistically to provide comfort, better vision, and stable eye pressure.

The evolving role of comprehensive ophthalmologists

Dr. Radcliffe noted an ongoing renaissance of the “old-school” comprehensive ophthalmologist. Around 20 or 30 years ago, comprehensive ophthalmologists did everything from buckles to penetrating keratoplasties (PKs) and, of course, cataract and strabismus surgeries. Now in the present moment, comprehensive ophthalmologists can combine the eyecare fields of dry eye, advanced cataract surgery, and glaucoma into this effective interventional approach that wasn’t available a generation ago.
He also noted that clinicians see so many pseudophakic patients crying out for help because they are on three drops and have red eyes. These patients would benefit from many interventions to combat these symptoms, particularly the Omni, Xen, Durysta, and even selective laser trabeculoplasty (SLT).
Dr. Radcliffe highlighted that pseudophakic patients are the golden population clinicians can help using MIGS procedures to alleviate their topical drop load.


MIGS procedures offer patients direct improvements through a reduction in intraocular pressure and increased outflow facility, as well as indirect improvements by treating dry eye symptoms and reducing medication burden for patients.
These pieces fit together to demonstrate that MIGS can provide a layered and versatile treatment for glaucoma. Adopting this interventional approach can be a win for doctors and patients alike.
Nathan Radcliffe, MD
About Nathan Radcliffe, MD

Nathan M. Radcliffe, M.D. is a highly-experienced glaucoma and cataract surgeon.

Dr. Radcliffe graduated Alpha Omega Alpha from the Temple University School of Medicine and was named transitional resident of the year at the University of Hawaii in Honolulu. He was Chief Resident at New York University for his ophthalmology residency and Chief Glaucoma Fellow at the New York Eye and Ear Infirmary.

He was the Director of the Glaucoma Services at NYU and Bellevue hospital and currently, is part of the advanced Microincisional Glaucoma Surgery Center at New York Eye and Ear Infirmary. Dr. Radcliffe is unique because he is active in both academic and private practice settings. He is a microincisional glaucoma surgery (MIGS) innovator and instructor and has given lectures all over the United States.

Dr. Radcliffe was the first surgeon in New York to offer patients the CyPass Supraciliary Microstent, the Kahook Dual Blade Goniotomy, Visco 360 and Trab 360, the G6 micropulse laser, and Allergan’s Xen subconjunctival implant.

Dr. Radcliffe has managed some of the most difficult glaucoma and cataract cases from all over the world and is truly able to offer a tailored glaucoma and cataract surgery to his patients, being able to perform all of the available glaucoma surgeries that are currently FDA approved, and knowing the procedures and the efficacy and safety data well enough to correlate the optimal procedure with the patient’s disease.

Nathan Radcliffe, MD
Deborah Gess Ristvedt, DO
About Deborah Gess Ristvedt, DO

Dr. Ristvedt is a board-certified ophthalmologist who leads our Alexandria, MN location where she treats her patients with respect and compassion. She is skilled in cataract and minimally invasive glaucoma surgery and oculoplastics.

Deborah Gess Ristvedt, DO
💙 Interventional Mindset Sponsors
Tarsus Pharmaceuticals