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Subspecialties Glaucoma, Glaucoma

On the Offensive

When it comes to the diagnosis and treatment of glaucoma, there is a culture of being reactive. The old glaucoma “playbook” has mostly been “prevent defense”: when damage is seen, just enough treatment is initiated with the hopes of avoiding blindness. But we need to take a step back and evaluate what our primary goal is when we take care of patients with glaucoma. We focus on lowering IOP because this helps slow disease progression and deterioration of visual fields. The result is that patients can retain good functional vision, but more importantly achieve the true goal of maintaining the highest quality-of-life for our patients. We shouldn’t lose sight of that.

Why have physicians taken a reactive approach for patients with glaucoma? It might be because until recently the treatment options were limited to eyedrops which have compliance issues, and gold-standard trabeculectomy or tube shunts which are risky procedures. Now, with micro-invasive glaucoma surgery (MIGS) growing in popularity, the paradigm is starting to shift towards more proactive care – which is a good thing. But while effective procedures, MIGS commonly isn’t sufficient to cover all our pressure reduction needs. That is why there’s also this growing trend for the idea of “MIGS and meds.” And that brings me to my next point: why do we always resort back to handcuffing our patients – and ourselves – to medication? We know that there are multiple issues with eyedrops, whether it be patient compliance, side-effects, or treatment cost. Surely, we can do better for our patients. If we are adopting a more proactive approach to treatment with MIGS, why aren’t we also being more proactive with a laser procedure such as selective laser trabeculoplasty (SLT)?

Ask ophthalmologists or glaucoma specialists what first-line glaucoma procedure they’d perform on themselves or a family member, and most will choose SLT before medications. This is because they can see the benefit. It’s effectively a minimally invasive light therapy that restores aqueous flow. It can be performed in the office, it’s repeatable, patients tolerate it well, and it removes the issues of non-compliance, and the many other difficulties that you have with drops. I’ve found that patients tend to be happier after SLT because they can minimize or stop their medications. Also, with the paradigm of care shifting towards a greater acceptance of surgical interventions, patients are becoming increasingly open to hearing about a laser procedure. And when they hear that it is more like a light therapy, I find that they’re even more willing to consider it. I tell my patients in California, “It’s like getting a tan to the eye!” A video of myself performing an SLT procedure plays in the waiting room to help patients appreciate what the procedure entails – and they’re more likely to discuss it as an option when they come into the exam room.

So as paradigms are changing, why resort to medications when you can perform SLT? We should break our drops addiction, and consider taking a “MIGS and SLT” approach before accepting “MIGS and meds”. The result is a process that can consistently lower IOP safely and allow patients to minimize or stop medication. It is time to stop being reactive and instead be offensive. This means performing proactive procedures that can offer our patients the chance to have the highest quality-of-life.

Teymoorian reports the following disclosures: Consultant for Aerie, Alcon, Allergan, Bausch & Lomb, Ellex, Glaukos; Research for Aerie, Allergan, Bausch & Lomb; and speaker for Allergan, Ellex, Glaukos.

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About the Author
Savak “Sev” Teymoorian

Teymoorian is a glaucoma and cataract specialist at Harvard Eye Associates in South Orange County, California.

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