When I was an optometry student, I couldn’t wait to treat glaucoma. Refractions were cool, but saving people from the biggest “thief of sight” there was—now that was sexy!
Like the old saying goes, “Be careful what you wish for.”
Nearly three decades later, 40 percent of my schedule consists of glaucoma or glaucoma suspect patients. Each week, more patients hop onboard the train, jostling for position in the “q3mo FU line” like rush-hour commuters.
My subspecialist consultants and I have captured and held a lot of ground on the glaucoma battlefront, winning far more often than losing.
Winning, of course, being defined as “some light at the end of the tunnel up until the day they die.”
Previously from Dr. Brown: A tale of two state boards
Still, there are some aspects of glaucoma care that continue to bedevil and frustrate me. Here are five:
1. Lowering intraocular pressure (IOP) remains the mainstay of treatment
For the majority of patients, adequate IOP reduction will halt, or at least slow down, the progression of the disease. Thanks to advances in both medical and surgical treatments, lowering IOP is easier today than it’s ever been.
But what do you do if a patient is maxed out on meds and/or surgery, and the disease continues to progress?
We haven’t advanced as far as we’d hoped on the conceptual disease front, and glaucoma remains an optic neuropathy whose precise multifactorial causes continue to elude us.
Adding more weapons to our treatment belt, like neuroprotection or increased optic nerve perfusion, would be nice. But so far, we don’t have much to show for our efforts at figuring out exactly what this disease is and what to do about it.
2. We have better topical medications, but compliance remains a problem
I’m glad it’s not like “the good old days” when the only decent options we had were timolol and pilcocarpine.
Prostaglandin analogs were a revolutionary development in glaucoma care that saved the sight of millions. From what I read and hear, some new topical meds in the pipeline might be even better.
But still, drops are only as good as the patient’s willingness and ability to comply.
And we all know how that one goes.
It’s a tough sell convincing patients to submit to the ball and chain of daily medication when they’re symptomless—or at least were until they started using the drops that you prescribed that made their eyes turn red and sting like fire.
Which leads me to my next point…
3. Ocular surface disease (OSD) is prevalent among glaucoma patients and is one of the biggest reasons for noncompliance
It just so happens that the very same patients who often require topical glaucoma drops either already have OSD or latent OSD, which is made manifest by the preservatives (often benzalkonium chloride [BAK]), active ingredients, or drug vehicles in topical glaucoma medications.
Fortunately, non-preserved glaucoma medications and others with “soft preservatives” have come online. I have personally used many of these to great effect to improve compliance and maintain IOP lowering without scorching the ocular surface.
Still, you’ll almost always end up treating two chronic, frustrating diseases at the same time, especially as patients age.
“But Doc, I was fine until you put me on those pressure drops. I stopped them because my eyes feel so much better without them.”
Are we having fun yet? Do you still think this is sexy?
4. Glaucoma surgery is better and safer—but not always available when and where you need it
Improvements in glaucoma surgery have been a welcome relief for eyecare practitioners in the trenches and for patients.
In particular, selective laser trabeculoplasty (SLT), improved filtering/shunting techniques, and minimally invasive glaucoma surgery (MIGS) are enabling many patients to reduce the number of their topical meds, and in some cases, eliminate them all together.
But this happens far less often than it should. Among the many reasons are a lack of accessibility to glaucoma surgeons performing state-of-the-art procedures, cost, and a persistent culture in the U.S. of saving surgery as a “last resort.”
This needs to change. Here’s hoping the emerging generation of glaucoma specialists will be able to provide the full array of surgical options earlier and more often than in the past.
All I know is that at this point in my career, if I could refer all my glaucoma patients out to “get fixed” once and for all, they’d leap for joy—and I would, too.
5. People are living longer
But wait, that’s a good thing, right?
Generally speaking, sure. But with increased longevity comes the fact that even patients who have been followed closely and managed as well as possible will be more likely to continue to suffer glaucomatous vision loss as they age.
Related: It's not easy seeing green
I’ve seen patients with low IOPs in their 70s and 80s who have suddenly progressed, as if programmed cell death was a fait accompli all along.
My clinic is becoming increasingly full of older patients with fragile optic nerves and severe visual field loss who nobody wants to touch surgically (and I understand that for many, there is the possibility of more harm than good in such cases).
“As long as the IOP stays in the low teens, just follow them in your office,” my consultants will often say.
Thanks a lot. So we wait, cross our fingers, and hope that the light at the end of the tunnel will stay lit just a little longer.
Losses stick with you
I mentioned at the beginning that we win far more than we lose while treating glaucoma. If this were football, I’d have a winning percentage that would put me in a hall of fame.
But the losses stick with me more than the wins. I even remember their names and faces.