Optometry had nothing to do with an insufficient number of ophthalmologists, especially in rural communities, but this issue must be solved. Access to quality eye care, and in particular laser procedures—as evidenced by the Laser in Glaucoma and Ocular Hypertension (LiGHT) study—is essential. While politicians and lobbyist groups might forget the importance of the patient in medical decision-making, current trends and technologies will soon make it so they can’t.
It is estimated that there are about 19,000 ophthalmologists in the US, similar to what it was 25 years ago.1 There are over four million cataract surgeries performed per year and aging Baby Boomers could increase that to five or six million within a decade. If you remove subspecialities such as retina, oculoplastics, neuro, academics and those who focus on primary eyecare services, there isn’t a sufficient supply of surgeons for the cataract demand alone.
While optometry isn’t seeking to perform complex surgeries, laser procedures—something we’ve been trained extensively in—would allow surgeons to focus on the high number of cataract and intraocular surgeries.
Patient Need for SLT
The LiGHT Trial’s six-year results for POAG and ocular hypertension were released last year. Patients in the selective laser trabeculoplasty (SLT) arm showed equal safety but better long-term disease control than those in the drops arm.2 They also showed a reduced need for incisional or advanced glaucoma procedures compared to those taking drops. Most telling is that a statistically significant number of patients in the drops arm exhibited glaucoma progression compared to those receiving SLT.
In rural communities where there is less access to ophthalmologists and/or glaucoma specialists to perform SLT, patients may not receive these timely and essential treatments.3
Many glaucoma patients discontinue the use of IOP-lowering drops due to irritation and ocular surface disease (OSD). Patients requiring prostaglandin analogs and BAK-preserved drops tend to experience problems sooner and require an alternative to maintain targeted IOP.
Innovations such as the Durysta implant are very helpful, but this requires a procedure that not every optometrist can perform as determined by the state they practice in. SLT is a mainstay and gaining traction as the primary treatment for open angle glaucoma due to OSD issues with drops and the results of the LiGHT Study.
A future springboard to making laser trabeculoplasty the primary treatment for glaucoma is something called direct selective laser trabeculoplasty (Belkin Vision). With a single touch of a button, it can treat 360° (or 180°) of the trabecular meshwork and provides a fully automated treatment experience with built-in safety features. This automated digital technology administers 120 perfectly placed laser shots that effectively lower IOP.4 Significantly, a gonio lens is not required to perform the procedure.
The Future is Clear
The patient needs to be the primary focus in decisions regarding access to essential procedures and technology—it’s that simple. Ophthalmology shortages are due to the low number of residencies, greater demands in subspecialties like retina and an aging Baby Boomer population. The result: limited access to procedures like laser trabeculoplasty and delayed cataract surgery, which is already occurring and will only worsen over time.
Innovative laser technologies and ocular surface–sparing long-duration therapeutics will provide the solutions glaucoma patients need to stave off progression, but there still has to be a well-trained provider; that is where optometry has proven itself in the states where laser privileges exist.
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.
1. Association of American Medical Colleges. 2021 Physician Specialty Data Report. https://www.aamc.org/data-reports/workforce/data/number-people-active-physician-specialty-2021. Accessed June 21, 2023.
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-51.
3. Rothman AL, Stoler JB, Vu DM, et al. A geodemographic service coverage analysis of travel time to glaucoma specialists in Florida. Glaucoma. 2020;29(12):1147-51.
4. Direct selective laser trabeculoplasty in open angle glaucoma and ocular hypertension: A randomized controlled trial, NCT 03750201a.