Glaucoma—a condition strongly associated with gradual, incremental change—is suddenly moving fast. In recent years the subspecialty has gained a few new medications, several “minimally invasive” surgical procedures and nothing short of a radical overhaul in the capabilities of its diagnostic technology. OCT and other new imaging modalities can document changes to the optic nerve head, ganglion cell complex and retinal nerve fiber layer with previously unheard-of precision.

Have you observed these trends and decided glaucoma is just not for you? If your practice is primarily comprised of young, healthy patients seen for routine eye care and refraction, it may not seem worthwhile to place much emphasis on glaucoma beyond the obligation to screen and refer. Managing glaucoma requires a different mindset and workflow than the wellness visits typical of many optometry practices. These patients need chronic, lifelong care, and even your best efforts will only help to slow progression, not restore vision.

But the opportunity for greater OD involvement is compelling. “I consider glaucoma the consummate optometric disease because the majority of patients can be managed successfully and without too much complexity,” says glaucoma specialist James Fanelli, OD.

We all know about the demographic inevitability that is giving rise to a greater need for care of age-related diseases like glaucoma.
Ophthalmology’s ranks are overloaded with glaucoma patients. That field, although never too friendly toward optometry, is in need of qualified assistance in providing long-term care. MDs prefer surgery, and will eventually cede most routine glaucoma care to optometry. But the wide disparity in capabilities among ODs makes it difficult for optometry to advance.

Some ODs find OCT invaluable in documenting glaucomatous changes, but many still rely on fundus photography. Some use an ocular response analyzer to correct IOP calculations for the influence of corneal biomechanics—but about one in four ODs don’t even own a pachymeter, thus omitting the role of central corneal thickness entirely. A few ODs use ultrasound biomicroscopy to visualize the anterior chamber angle in ways that surpass even OCT; most others get by with a humble gonio lens. Oklahoma and Kentucky ODs can perform SLT; their colleagues in Massachusetts can’t even prescribe Timoptic.

It’s confusing, to say the least. “The future is already here, it’s just not evenly distributed,” sci-fi novelist William Gibson said. He was remarking on the rise of technology culture in Asia (when it eclipsed the west in the 1990s) but the point feels especially true of glaucoma care in optometry.

A Team Approach
This issue’s focus on glaucoma hopes to level the playing field a bit. This month's OSC, "The Impact of Imaging Devices on Glaucoma Management," reveals the breadth of the latest imaging capabilities. But be mindful that adding a new piece of technology alone won’t be sufficient for advancing your practice. “One doesn’t—or at least shouldn’t—buy the equipment and then see if you develop the interest and acumen to use it,” Dr. Fanelli says. “The decision to buy is a conscious one and should be a part of the goals of the practitioner and the practice.”

Not everyone needs to gear up, of course. “I think of ODs as the general practitioners of eye care,” says Dr. Fanelli. “GPs manage a wide variety of ailments, and each one practices to his/her comfort level. Some may treat GI abnormalities, while others may hand off those folks to gastroenterology.” The same is true in glaucoma, he says.

Instead of turning to ophthalmology as usual, explore the idea of OD-to-OD referral. Dr. Fanelli says he’s getting more and more of those, where a fellow optometrist sends the patient to him for either a second opinion or for testing that they don’t have—and they dictate the terms of the encounter.

“Letting the other OD tell me what they want me to do sets the stage for how much involvement I have in the patient’s care,” he says. “That’s easier for non-chronic conditions, as it’s usually a treat-and-stabilize situation. For glaucoma, I want to know from them exactly what they want me to do.” It keeps you in control, and the patient in your practice, while improving care. Everybody wins.