The Interventional Mindset in Glaucoma Care

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6 min read

Dr. Radcliffe discusses what adopting an interventional mindset means to him in glaucoma care.

Over the last decade, Nathan Radcliffe, MD, has observed a renaissance in the realm of glaucoma management with a major area of unmet need being filled by microinvasive glaucoma surgeries (MIGS) and the expansion of laser procedures.
He notes the three pillars of glaucoma therapy have long been topical ophthalmic formulations, lasers, and glaucoma surgery, with the latter two leaving much room for improvement. MIGS has been able to provide an efficacious and safe answer.
Now, a fourth pillar has emerged in the form of sustained-release drug delivery systems for glaucoma medications. However, often, new therapies can be met with resistance with limited enthusiasm initially by patients.

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.

Understanding the psychological aspect of glaucoma care

A large component of the art of glaucoma management as an interventionist is in understanding the obstacles that may prevent a roadblock in fully implementing a protocol. One of the biggest barriers is the patient’s hesitancy to accept interventional therapies.
Dr. Radcliffe underscores that recognizing and addressing the psychological principles at play is paramount to success, as many individuals with primary open-angle glaucoma (POAG) want to maintain the status quo and tend to cling to the hope of disease state reversal through pharmaceuticals alone.

4 pearls for implementing glaucoma interventions

Dr. Radcliffe offers four clinical pearls for dealing with potential reservations held by patients.

1. Understand that no therapy is the preferred therapy.

He points out that, as an ophthalmologist, it is imperative to understand that, if given the choice, glaucoma patients would opt to avoid treatments of any kind altogether.
Of course, with the chronic and progressive nature of the disease, this, unfortunately, is not possible. Therefore, it is important to remind patients that glaucoma at this time is considered irreversible, and progression can lead to blindness.
In addition, make certain individuals with glaucoma understand that topical medications alone are typically not sufficient treatment for many people, and that even with intraocular pressure (IOP)-lowering management in place, progression can occur. He also points out that eye drops could promote ocular surface disease and likely have a negative impact on both the quality of vision and overall daily comfort.
When a patient is resistant to treatment, it is crucial to help them see how taking an early, interventional approach increases the likelihood of improved outcomes in both the short and long term. Taking time upfront to enhance their understanding of the disease and reset their base expectations tends to pay dividends, especially with patient therapeutic adherence and maintaining a consistent follow-up schedule.

2. Address the patient’s primary complaints.

In his clinical experience, Dr. Radcliffe has found one of the most effective ways to get patients to embrace new therapies is by demonstrating how the treatment directly correlates to their chief complaints.
If they have expressed difficulties in maintaining compliance due to cost, forgetfulness, inconvenience, or running out of medications—acknowledge these and point out how the proposed MIGS therapy could lower their medication burden. If they have voiced distress about dry eye, pain, redness, or itchiness, explain that these might be related to eye drops and that eliminating these therapies could minimize these symptoms.
When making a recommendation for a MIGS procedure, focus on how the intervention is going to address their concerns and potentially improve their quality of life (QoL).

3. Demonstrate your confidence in the treatment.

If the surgeon wholeheartedly believes in the therapy they are recommending, this confidence is easily conveyed to the patient. Dr. Radcliffe shares his own personal journey with laser trabeculoplasty.
He discovered the earlier he intervened, the better the results were in his surgical experience. He realized, when introducing the procedure to patients, his conviction was contagious, and people became eager to move forward with the intervention.
Practice utilizing the technology until you are comfortable and confident. Then, demonstrate to the patient that, in your professional medical opinion, this procedure is an appropriate treatment option that could garner favorable results based on the case presentation.

4. Recognize the right candidates.

For the majority of interventions, there can be many different candidate types. With this thought in mind, the cornerstone of success is leveraging surgical experience to match the procedure up to the “right” candidate.
However, Dr. Radcliffe urges surgeons to keep an open-minded approach toward who these candidates may be, especially in lieu of the fact that many MIGS can be tailored to individual patients. Different patients can benefit for different reasons from an interventional approach.
Physicians with limited exposure to MIGS might ask, “Who are the patients who can benefit from these interventions?” He suggests redefining the context of the question by asking, “Are we, as doctors, doing all we can to become interventional specialists?”

Final thoughts

The primary goal of Interventional Mindset is to provide clinicians and surgeons with actionable information on how to implement new technologies and progressive practices into their day-to-day operations.
However, to truly embody this mindset, ophthalmologists must impart the value of intervention to their patients as well.
Changing the antiquated attitudes of individuals suffering from glaucoma is one more way to elevate their level of care, especially with the goal of optimizing visual preservation.
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
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