One of the biggest changes to happen in the field of glaucoma surgery over the past decade has been the growth of tube shunt surgery along with the decline of trabeculectomy. In many respects, this was the result of the publication of the Tube Versus Trabeculectomy study.1 After this paper was published, Dr. Joseph Caprioli wrote a fantastic editorial in which he stated that things might not change as much as we thought they would after the publication of this paper.2 He noted that the “inertia of long-established clinical practice” was difficult to overcome. Indeed, as we look to other areas of glaucoma management, these words could not have been more prophetic.
Take, for example, the rather straightforward case of primary laser trabeculoplasty. When I survey a group of over 100 ophthalmologists, this laser treatment is the preferred initial therapy. Yet it is probably offered first only 10% of the time. Not only would most ophthalmologists prefer this treatment for themselves, but also most of them want to offer it first to all of their patients yet find it difficult to do so. Why? I think it is clinical inertia. And why is it easy to change from trabeculectomy to tube shunt but not from drops to laser? In the case of tubes over trabs, inertia was perhaps the only barrier, as tubes have similar insurance coverage and safety but are perhaps easier to perform. With laser over meds, the insurance coverage for laser is likely better with the perception of extra effort, inconvenience, or mostly imaginary safety problems with the laser, and this may be where the inertia comes in to play.
If we want to fight inertia in our practices, then we need a plan to become interventional glaucoma specialists (and we should thank Ike Ahmed for coining this term). My advice? Make decisions about what new therapies you want to offer when you aren’t in a room, pressed for time, with a patient in front of you (after you finish reading this is a great time). Recognize that these changes are not going to happen on their own and that you have inertia working against you, and think about what else will need to change in your practice to make the choice easier. Tell someone what you are thinking to make it more real. Talk to your technicians about introducing the concept of laser to patients earlier. Tell your surgical scheduler that you are going to be sending in more patients for standalone MIGS. Talk to your billing team about how to implement a buy and bill sustained glaucoma therapy once it becomes available. The final step is to change your own mind and to share your convictions with your patients. The difference between saying “Laser is a great alternative to drops,” and “Laser is clearly better than drops and most eye doctors agree with me,” is the difference between having 2% vs 98% of your patients receive SLT first.
As our field evolves, we must evolve our own beliefs and behaviors to choose a path of interventional glaucoma over inertia. GP
- Gedde SJ, Schiffman JC, Feuer WJ, et al; Tube versus Trabeculectomy Study Group. Treatment outcomes in the Tube Versus Trabeculectomy (TVT) study after five years of follow-up. Am J Ophthalmol. 2012;153(5):789-803.
- Caprioli J. The tube versus trabeculectomy study: why its findings may not change clinical practice? Am J Ophthalmol. 2011;151(5):742-744.
On the cover: From "A Case of Iridocorneal Endothelial Syndrome," page 38 (photographer: D. Harris, MD)