Sadri: How MIGS And Other New Tech May Change His Practice

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Ehsan Sadri, MD, FACS, FAAO discusses the impact MIGS will have on ophthalmology practices and offers his insights on how ophthalmologist will handle pressure from Obamacare and other external forces going forward.


Tom Salemi: Hi, everyone. This is Tom Salemi. I am the host of the OIS Podcast which you are listening to. Thank you for joining us today. We’ve been talking quite a bit about MIGS and glaucoma over the past few weeks, looking at it from a company perspective, from a technology perspective. Today we’re going to hear from a physician who is employing MIGS technology, hopes to employ more of it going forward. Dr. Ehsan Sadri is a board certified and fellowship trained surgeon in cataract surgery, Lasik and glaucoma surgery, of course. He is with Atlantis Eye Care in Orange County, California. And Dr. Sadri and I talked a bit today about the impact that MIGS will have on the practice of ophthalmology and on the impact on individual physician practices. And not only did we hit upon MIGS and new technologies and how they’ll influence the delivery of medicine and the management of practices, but talked as well about some external macro forces like Obamacare. So it was a really great conversation. I enjoy talking with Ehsan. He’s got a lot of energy and insight. So please enjoy this conversation.

TS: Dr. Ehsan Sadri, welcome to the Podcast.

Ehsan Sadri: Thanks, Tom, it’s a pleasure to be here.

TS: It’s great to have you. We’ve had a lot of fun lately talking about the MIGS space, and I’ll just jump right into it, and we’ve been looking at it more from a financial and sort of a company creation perspective with the IPO of Glaukos and the acquisition of Aquesys. There’s obviously a lot of movement on the business side. What I was hoping we could talk a bit about today is just sort of see how this success on the commercial side including the launch of iStent is really – and how the potential launches going forward of Xen and some of the other products, how that’s influencing the physicians. What sort of reverberations are you seeing on the clinical side? So what does the rise of MIGS and other startups mean to you as a practitioner?

ES: Great question, Tom. So as we were chatting earlier, MIGS is an exciting sort of evolution in the glaucoma space. What maintains the excitement, I think, for a lot of guys is the fact that the patient population is growing. So from a demand standpoint, there’s a lot of patients in this pool. The technology, let’s face it, that we’ve had, the filtration devices, the glaucoma surgeries, they’re very invasive, so there’s a big disruptive force. So MIGS in general I think is creating a very big buzz in the community because it’s going to give better patient satisfaction, rapid recovery, right, and the ability for patients to have really minimal morbidity. Glaucoma surgeries, when I trained, were very invasive. And I was lucky enough to train with Richard Hill, who’s the founder, as you know, and inventor of iStent. So we did some of the early work looking at how this design is sort of put into practice. And no one really knew how bit it’s going to be. But if you look at the data and the usage and increased – and usage of iStent specifically because it’s the only FDA approved device thus far, you can see a nice incremental increase every year. And I think that you’ll see that trajectory increase with the other exciting technologies coming into the space. For instance, Transcend is going to be coming down, Aquesys is coming down the pike, and I think that’s going to be really good for everybody. I think it’s going to create a much better patient outcome experience for the doctor and the patient. So clinical practice and my own specific practice as a glaucoma surgeon, I do a lot of end stage glaucoma. But with the iStent specifically being approved, what it allows me to do is give patients choice. And that’s really critical. Meaning if a patient came in to have – they need a cataract extraction surgery, it allowed us to offer that treatment protocol earlier so the patient didn’t have to have a more invasive later down the pike. And that’s the space where this is growing the most: patients who have what we call traditional glaucoma that is stable but can be remedied with the iStent. And I think as we get more advanced technologies, better IOP reduction, you’re going to see the other spaces, meaning the advanced or severe patients have better choices as well.

TS: One of the benefits we hear about of the clinicians who attend our OIS conferences, and you’re obviously one of them, you’ve been at many, is that the insights on the technology coming down the pike – MIGS is a space we’ve talked about a lot – how have you been able to prepare for this coming technology? I know iStent’s been out for a couple years, but what impact will the introduction of these technologies have on your practice? What kind of preparations are you making on the front lines as these things come forward?

ES: Yeah. So first of all, kudos to you and everyone on the team for doing a great job with OIS. You guys are doing a terrific job with it. I think it’s exciting. I see a lot of the guys who are in this space, clinicians love to sit there and see what’s coming down the pike. I think everyone’s really excited to see not only just MIGS but other devices and technologies coming out. I think it’s very exciting for patients who have glaucoma in this country and abroad to have choices. I think that MIGS being a big space if you can call it, and Glaukos did frankly say that they did a lot of the heavy lifting. They got the regulatory out of the way, commercialization out of the way, and I think if you look at the next few choices coming down the pike – I’ll be giving a talk in a couple days at a Millennium Eye on this subject of MIGS space. And if you look at the next choice is Transcend, right, and you’re looking at Aquesys and Hydrus. All these different technologies are going to create better efficacy with minimal downtime and morbidity for the patient. So that means happier patient. That means the patient can go back to work. Not only does it have satisfaction when it comes to patient outcomes and how we actually get paid financially in the next 5 to 10 years and how Medicare’s evolving, you can actually dollarize that. But also from a standpoint of you can actually put a dollar figure on these patients going back to work because traditional glaucoma surgery, like the Ahmed valve or the Bar valve or Molteno, like I did one yesterday, requires the patient pretty much out of the work force for at least a week or so. And it’s going to be very uncomfortable for them to go back. Downtime is much longer. And so we needed this space to grow and expand. And that’s what we’re seeing now, and it’s exciting for doctors and patients.

TS: And do you see, looking forward, you mentioned all the devices that are coming this way, MIGS, Transcend, Glaukos and Aquesys and the like. How do you see this playing out? Do you see a need for multiple products? Or do you see one technology emerging? You don’t have to pick a winner if you don’t feel comfortable doing that. I’m not asking that. But how do you see this? Will your practice offer all of these different products? Or do you think there’ll be one that’s your clear-cut favorite?

ES: It’s a great question. You know, Tom, any time you have competition it’s a good thing for the space that the patient and user, if you will, for both, from the doctor’s standpoint and the patient’s standpoint because actually it drives innovation, right? In other words, when you look at the different technology platforms coming out in this MIGS space, I think it’s healthy to have several competing technologies. It’s too fluid to determine right now how specifically what is going to be the sort of predominant device being used, just because of the fact that quite honestly, not all of them are approved. But I think if you look at the data set, I’m excited to see Transcend showing up some really good numbers. You see the Aquesys with minimally invasive treatment of phakic patients. I think these technologies are all either going essentially get bought out or expand. And I think if you look at the model that Glaukos has done, and kudos to Tom and Chris for doing a great job with the IPO, if you look at what they’ve done essentially is it says, Look, we’re obviously going to need to exit and he creates, by doing the IPO now, they’re creating a much more – more resources to bring in better people. And that’s what they’re looking at now. How do we expand this internationally, for instance? So I think you can look at it in different ways. Clinically, I think if you look at just – if you believe in the FDA data, I think they’re all looking pretty good in my opinion. I think the space we have the most need is the moderate to severe disease states. Because you need the higher efficacy reduction there, right? So because trabeculectomy is still the gold standard and is very invasive and, as you know, can cause issues like blebitis and ophthalmitis, and quite honestly failure, this space is going to be the sort of gold rush. Whoever gets to the point where they have a nice, steady IOP reduction of 30 to 40% on moderate to severe glaucoma patients is going to win, and they’re going to win big.

TS: We’re going to take a break from this conversation just for a moment to remind you all that if you want to present at our upcoming OIS event, or perhaps a future event, if your story isn’t far enough along, go to, provide us with your information. Find the presenting companies link, click on that, give us the information that we’re seeking, and you will be considered for a presenting slot at an upcoming conference. And of course, if you want to attend, that information is there as well. Go to to register. Now back to this conversation.

TS: Has your view as a surgeon trying to run a practice in today’s evolving healthcare field, has your view of new technologies changed at all from perhaps even just 5 or 10 years ago? Is it still bringing me everything you’ve got, new technology better ways of doing things, I’ll find a way to make it work? Or do you look at new technologies differently and really have to decide, well, yeah, that sounds great, but how am I going to pay for that? How’s the patient going to pay for that? What are the additional challenges that you see when you’re looking at new products coming down the pike?

ES: Yeah. So the good example here would be the initial launch of Glaukos’ iStent. So initially, when there’s no CPT code and it’s really hard to get reimbursement in second and third tertiary companies, for instance, payers, it’s difficult and challenging for a practice to really take the numbers and really show meaningful volume. Meaning any technology that comes out, to your point, not only has to be efficacious and safe, but also has to have a model where the doctor can actually get reimbursed, and so that it begins to take off. Otherwise, it sort of becomes a boutique cash product, which is very rarely used, quite honestly, because patients cannot afford these fee for service technologies. It is not to say there’s no space there, but it’s not the volume that you’re looking for. So if you look at, for instance, the data of iStent usage prior and after approval with the CPT codes, you’ll see a big jump. And the reason is because to your point, it allows for the patient and the doctor to be able to be in the carpool lane, alignment, right? Doctors would like to have the best technologies for the patient, but if there’s no reimbursement channel and they can’t commercialize, it’s going to be very hard for that product to take off. So I think to your point, it’s really prudent for us to sit down and it’ll be important for us to focus on this, meaning is this technology going to allow us to incorporate it and commercialize it properly so the doctors can be on board or not? And if it is, then I think and if it’s efficacious, I think it will be great. But on the other hand, if it’s not, you’ll see the good example in the retina space, for example. If you look at what happened to Avastin, Lucentis and Macugen. You see these more expensive products sort of withered away. Was it a technology driven decision or was it a cost? I think cost is a bit factor, and I think as Medicare becomes much more regulated when it comes to cost, it’s going to be frowned upon to do those things that are going to be – technologies that are not essentially excellent when it comes to being little in cost.

TS: And that’s really the issue that’s overriding I think everything you do now is just the financial success of your practice as we’re seeing in other specialties, private practices are disappearing. What are the challenges in ophthalmology today? Just making the practice grow and bringing in new technologies, and of course giving the best care? Where are you finding the greatest challenges?

ES: I think the biggest challenges that we – so we talked about this briefly prior. But if you look at the overall sort of payer mix in the country, the area in the Eastern Seaboard and the West have been very progressive. If you look at Hawaii, for instance, a lot of managed care, Southern California being another, where I practice. There’s a tremendous amount of sort of we did all the heavy lifting already. We went through the reform. The patients are in these big pools of sort of connected, coordinated care already. You see with EHR that we’re interfacing with the primary care physician almost instantaneously. The patient actually leaves my room – I leave the room and the doctor already has a note on his desk about the patient’s diabetic retinopathy or cataract. So what you see is one, a lot more coordinated care when it comes to communication, and frankly, payment; two, you’ll see that the patient population that used to be what we call traditional fee for service or private are now being aligned with big groups. And those groups either have a pool of doctors that they can send the patients to or not. And to your point, physicians who are purely private practice where they are not aligned, it’s going to be very hard for them to maintain a private practice because let’s face it, I mean my rent is going higher, the girls are getting paid more, our insurances, liability are all increasing. So it’s this mass. And so for us to be able to incorporate new technologies and have good outcomes, maintain a good, thriving practice, we have to adapt. And that adaptation requires either, number one, you sell to a hospital, or two, you become part of a bigger group and cost share. So look, that’s what we’ve done. I think you’ll see an increase in multi-specialty practices. I think you’re going to see some areas in the country incorporate ophthalmology as a staff model. We’ve seen that already in Southern California. Believe it or not, there’s a few ophthalmologists that actually work for the hospital. They’ve sold the practice; they’ve said we’re out. So I fundamentally believe in what we were talking about earlier, in maintaining an independent private practice of ophthalmology because ophthalmology tends to enjoy really good innovation and technology, and that’s going to continue to be there. And I think there is a balance there. There is an ability for us to be able to maintain good, solid innovative technologies like the MIGS, like the IOLs like femto in our practices. But at the same time be able to play ball, if you will, with big groups and have access to these patients. I think traditionally there’s always been this thought in physicians’ minds there, well, I’m not going to accept any HMOs or I’m not going to be part of a health plan. I think that’s a mistake. I think you have to look at that as an opportunity and not a liability.

TS: What might the multi-specialty practices look like? We’re obviously already seeing ophthalmology and optometry. I know you do some aesthetics there at Atlantis. So you see going beyond that into even more different specialties? And what other services might your practice provide in five years that you’re not providing now?

ES: I think this is a very fluid space. If you look at multi-specialty, for instance, the lowest hanging fruit for the general anterior segment practice, which means that typically one or two docs, maybe three, just do cataract surgery, they have their own standalone ASC, is, number one, is incorporating their own retina doctor. I think you’re seeing that more and more across the country. And the reason is because the enormous cost and expansion of treating of the macular degeneration patients is huge, tremendous cost savings if you have your own retina physician within the practice. I think that’s number one. Number two, I think you’ll see more of alignment with the – in areas that are very populated, you’ll see multi-specialty care in surgical centers. Meaning, for instance, it may not be very weird to say that the GI guys, the gastroenterologist doctors and the ophthalmologists and the orthopedic surgeons may get together and buy a surgical center together. We’re seeing that right now. Essentially before, we would just do ophthalmology in a practice. But we realized, well, wait a minute, if we hook our wagon up with the GI guys, and maybe the orthopedic surgeons, we can actually cost benefit and have more flow through the surgical centers. So that’s another aspect. You mentioned aesthetics. I think that’s a really interesting, exciting part because patients are frankly interested in getting their aesthetic work done. It’s something that started in ophthalmology. Botox was started with the ophthalmologist, and look how expansive and how amazing that product has been. And sort of we’ve fallen behind a little bit in that. I think as an ophthalmologist we’ve been very academic in a little bit, way, and when I look at aesthetics, we’ve been so focused on doing anterior segment. But if you look at the larger practices, they’re incorporating a lot of plastics, a lot of these facial fillers and facial rejuvenation technologies in their practices because the patients want it. Just because a patient comes in and has a glaucoma treatment, it doesn’t mean that she not going down the street and getting Botox from someone else. Believe me, they are. They tell me they are. And so why not capitalize on that? And so those are different creative way of maintaining a thriving practice. You have to get creative, right? So you have to be adaptive and create value based propositions for patients. And if you’re able to do that successfully, then you’re going to be OK.

TS: Well, innovation is certainly happening all over the place, both in the clinical side and the practice side and the technology side. And so thanks for –

ES: That’s right.

TS: – thanks for sharing your insights on all of them, and I’m glad we finally had a chance to connect on the Podcast.

ES: Thanks, Tom. Keep up your great work. I always enjoy listening to your Podcasts.

TS: Thanks. And we’ll see you in November.

ES: That’s right, Las Vegas.

TS: Thank you, Ehsan Sadri for joining us on the OIS Podcast. It was a pleasure to get a different perspective on the technologies that we talk about at our OIS events. Of course we’ve got great surgical leaders attending our OIS conferences as well, and want to get more of their voices on this Podcast. So it’s great to have that perspective. If you’d like to meet with Dr. Sadri or other leading surgeons in glaucoma, you should be at OIS. So go to to register. Again, that’s to register. We’ll be holding our next conference just before AAO in Las Vegas on November 12. So sign up and we will see you in Las Vegas.