We, as a profession, are integral to glaucoma management; we are the most likely to make the original diagnosis and can manage treatment for most cases. But with new advancements in glaucoma surgery, some ODs question our role. These five steps can help us stay in charge:
1. Diagnose it sooner. With new OCT modalities, we can diagnose the disease sooner than ever and begin treatment earlier. However, ODs must use this technology with caution and be sure to have a firm grasp on the data provided. We have to understand what we are looking at with the deceptively simple red, yellow and green charts to avoid over- or under-diagnosing glaucoma.
Other new diagnostics can help as well. Corneal hysteresis may predict visual field loss progression and can play a role in deciding when to treat and in setting treatment expectations. And someday, 24-hour home monitoring of IOP may completely transform our management strategies.
2. Understand the disease better. While we don’t fully understand what causes glaucoma, we know IOP is a risk factor, as is corneal thickness and hysteresis, family history, age, race, high myopia, systemic conditions, previous trauma and chronic inflammation. Knowing the cause will one day allow us to treat the disease more effectively. One theory suggests it’s caused by an imbalance between IOP inside the eye and intracranial pressure (ICP) around the optic nerve, affecting the eye’s metabolic needs.1 For example, patients with idiopathic intracranial hypertension have a bowing of their optic nerve, and 50% of astronauts develop vision loss because their cerebral spinal fluid increases disproportionately higher than their IOP, resulting in a hyperopic shift and optic nerve edema.1 So the key ratio may be IOP minus ICP—not just elevated IOP.
3. Rethink surgery. The introduction of minimally invasive glaucoma surgeries (MIGS) has forever changed glaucoma treatment. We must be ready to help manage patient compliance, understand the options for those on maximum therapy and properly educate and refer patients with both glaucoma and cataracts. Invasive surgeries such as trabeculectomy will go by the wayside, making room for a greater combination of MIGS, laser procedures such as SLT, and next-generation pharmaceuticals.
4. Take advantage of new therapeutics. It’s been two decades since we’ve had a significant new glaucoma drug, but that could change in the next few months. In a recent study, Vyzulta (latanoprostene bunod 0.024%, Bausch + Lomb), a nitric oxide-donating prostaglandin F2-alpha analog, lowered IOP by 9mm Hg compared with timolol at 7mm Hg—a significant finding, considering few, if any, previous glaucoma medications showed superiority to timolol in FDA trials.2,3 A new drug class, rho-kinase inhibitors, may also change the landscape of glaucoma management. Rhopressa (netarsudil, Aerie Pharmaceuticals) gives us a different and perhaps complementary mechanism of action because it increases TM outflow, decreases aqueous production and decreases episcleral venous pressure. A Phase II trial shows Roclatan (netarsudil plus latanoprost, Aerie Pharmaceuticals) has an IOP-lowering effect 1mm Hg to 3mm Hg greater than monotherapy with either of its two components.4 New drug delivery systems may provide significant benefits for patient compliance as well. For example, Phase III clinical trials for a travoprost-eluting punctal plug (Ocular Therapeutix) suggest the therapeutic effect may last three months with each plug.5
5. Treat the ocular surface. Optometrists can’t forget the impact of glaucoma therapies on the ocular surface. Staining, blurred vision, irritation or dryness from chronic meds can cause patients to decrease or even discontinue their use. Something as simple as managing the ocular surface may improve compliance and, ultimately, outcomes.
Glaucoma is a condition that affects all of our practices, and these five elements may well dictate the future of disease management, our understanding and innovations in patient care.
|1. Berdahl JP, Allingham RR. Intracranial pressure and glaucoma. Curr Opin Ophthalmol. 2010;21(2):106-11.|
2. Weinreb RN, Scassellati Sforzolini B, Vittitow J, Liebmann J. Latanoprostene bunod 0.024% versus timolol maleate 0.5% in subjects with open-angle glaucoma or ocular hypertension: The APOLLO study. Ophthalmology. 2016;123(5):965-73.
3. Hedman K, Alm A. A pooled-data analysis of three randomized, double-masked, six-month clinical studies comparing the intraocular pressure reducing effect of latanoprost and timolol. Eur J Ophthalmol. 2000;10(2):95-104.
4. Aerie Pharmaceuticals. Roclatan Mercury 2 Phase 3 Topline Results. http://investors.aeriepharma.com/events.cfm. Accessed June 28, 2017.
5. Ocular Therapeutix. Dextenza. www.ocutx.com/pipeline/dextenza. Accessed June 28, 2017.