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Subspecialties Comprehensive, Glaucoma

Challenges in the Visual Field

As medical and surgical interventions for glaucoma become increasingly sophisticated, ophthalmologists have more options than ever to address disease management and progression. However, it can often be difficult to keep up with new ideas, and in the midst of increasingly busy practice, it’s all too easy for ophthalmologists to stick to what they know. This is increasingly important when disease treatment shifts from a medicine first approach towards more interventional techniques and this has absolutely been the case with glaucoma. So, aiming to spread the word about the changes in the field and the shift towards interventional treatment, recent roundtables brought together some of the leaders in ophthalmology to discuss the current state of glaucoma treatment. The panels, moderated by Ike Ahmed, consisted of Nate Radcliffe, Paul Singh, Mark Gallardo, Deborah Ristvedt, John Berdahl, Tom Samuelson, Davinder Grover and Sahar Bedrood – all of whom agreed that treatment options have markedly increased and that ophthalmologists are slowly moving toward a much more interventional approach.

But they also agreed that, despite these advances, one of the principal challenges in glaucoma treatment is patient compliance. Medication adherence – or lack thereof – is a major factor in disease progression so, as Paul Singh pointed out, when patients are struggling to effectively use a particular therapy, doctors should be decisive in recommending the newer alternatives that have emerged over the past decade.

Deborah Ristvedt concurred, making the point that it’s important for the wider ophthalmic community to be not just reactive to patients – who may progress even to the point of vision loss as documented in numerous studies (1) – but proactive in preserving both visual acuity and quality of life. This involves a challenge to the wider optometric and ophthalmic communities to shift their mindset away from simply relying on drops that can too often be detrimental to quality of life and visual acuity. Coming straight from his own clinic, Nate Radcliffe described a day of listening to patients share the various hurdles from forgetfulness to cost to the challenges of navigating an increasingly complex pharmaceutical system.

Clearly, the traditional regimen of front-loading medication isn’t working for far too many patients, irritating the ocular surface (and even, as Ike Ahmed pointed out) leading to progressive dry eye disease and failing to halt disease progression. So, the move to make interventional treatment the standard in glaucoma is vital because the longer ophthalmologists take to treat, the more advanced the disease can become and the lower the IOP needed to manage it successfully. At the level of pathology, a longer wait time for interventional treatment leads to physiological changes in the trabecular meshwork, such as fibrosis and scarring, that can make treatment less effective and cause secondary health problems in the long term.

Cataract treatment has moved relatively easily to a more interventional mindset in the past two decades, so the question has to be asked: why is an interventional approach to glaucoma treatment not as common? Tom Samuelson pointed out that recent data showed that even the most simplified drop treatment – one drop a day – got results that were not as good as even a minimally invasive procedure like selective laser trabeculoplasty (2). With experts calling for change – and Ike Ahmed pointing out that the current treatment model is in crisis – we must confront the challenges in precipitating this shift. As Davinder Grover explained, there are more resources available than ever before to help precipitate a mindset shift to a more interventional approach with everything from wet labs, to peer support and more online resources to give surgeons the best, most up to date information.

On the patient side, the main obstacle is nervousness around surgery – even a minimally invasive procedure. Patients might also be more comfortable with the non-invasive option of using drops (even though, as the panel pointed out, stacking drops to manage IOP can also increase toxicity and ocular surface irritation over time and patients often fail to administer them properly).

From the doctor’s perspective, hesitance comes from questions around whether early surgery is both safe and necessary. MIGS, and other approaches to Interventional glaucoma management can prevent disease progression but, as several doctors pointed out, it requires physician confidence to intervene earlier – as Deborah Ristvedt pointed out physicians also need to think about the patient perspective – if the doctor needed treatment what would they want? John Berdhal concurred, highlighting that in their own experience eye-care professionals would personally much rather go straight to something like selective laser trabeculoplasty rather than drops if they needed treatment. For doctors, confidence in that early intervention comes not just from thinking about the increased availability of surgical tools but also from reliable data showing consistent IOP reduction and visual acuity – emphasizing the importance of continued research into the efficacy of new and emerging treatments. Keep a lookout for our next piece, exploring the current surgical options available in the interventional glaucoma armamentarium as we dive deeper into the world of interventional glaucoma.

Supported by an unrestricted educational grant from Glaukos.

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  1. M. Mehrdad et al., “Long-Term Trends in Glaucoma-Related Blindness in Olmsted County, Minnesota,” Ophthalmology, 121, 134, (2014). PMID: 24823760
  2. G. Gazzard et al., “Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial,” The Lancet, 393, 1505, (2019), PMID: 30862377
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