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ODs should take a measured approach to glaucoma management that considers the big picture, treat the disease carefully, assess all known risk factors, interpret results carefully, and more than anything else, use clinical evidence as a guide.

There is a commonly held but false belief within the general public that 

 only affects individuals over the age of 50. Experience has taught optometrists (ODs) to spot that myth from a mile away, but other untruths catch even the most practiced ODs off guard.

Edward Chu, OD, FAAO, and David Hicks, OD, FAAO, explored glaucoma facts and myths with research and evidence-based theories for glaucoma management during their lecture at the 

Related: Year in review of optometric advancements

, it is important to keep in mind that while optic nerve size and shape matter, they do not indicate an increased risk for glaucoma, and normal variations in disc size can explain normal variations in cup-to-disc (C/D) ratios. Asymmetry in C/D values doesn’t necessarily indicate glaucoma either, Dr. Chu says.

When it comes to diagnosing glaucoma itself, it is important to note that glaucoma definitions fall on a spectrum. 

According to Dr. Hicks, there are many ways to define and diagnose glaucoma. Optical coherence tomography (OCT) imaging, visual fields, and physical inspections of the optic nerve heads all contribute to variations.

Most glaucoma cases detected by ODs fall within the asymptomatic disease category in which progression can be detected by imaging tools.

Related: ODs: Redefine your role in glaucoma collaborative care

ODs need to understand a range of conditions to make the correct 

assessment. For example, traumatic glaucoma is not as common as secondary glaucomas and features two peak incidences:

– Within one year of the initial trauma

– More than 10 years after the initial trauma

Related: Look at more than the optic nerve head in glaucoma patients

 is complex with a myriad of risk factors, though some are less known than others.

Research suggests that obstructive sleep apnea is a risk factor r glaucoma. One study showed that 47.6 percent of patients with primary open-angle glaucoma had sleep-disordered breathing.

Perhaps surprisingly, research on erectile dysfunction shows a link to open-angle glaucoma.

These lesser-known risk factors underscore the need for ODs to take extensive case histories from patients during their initial evaluation before making glaucoma care decisions.

Related: Your glaucoma patients also have ocular surface disease

ODs are well aware of visual fields’ varying results. However, false positives are a particular point of concern because they have a significant effect on visual field reliability. Patients may worry that they are underperforming visually. This could cause them to overcompensate and become trigger happy, leading to skewed test results.

This is just one contributing factor to another unfortunate glaucoma fact: determining progression through visual field tests is a challenge. Aside from reliability and variability concerns, rates of visual field change are often inconsistent. 

As a result, available classification systems, event analyses, and trend analyses, are used to determine progression.

Clinicians must use their own judgement and apply evidenced-based approaches to their decisions, Dr. Hicks says.

Related: ODs must raise awareness about glaucoma

Value of retinal fibers and ganglion cells 

A patient’s retinal nerve fiber layer (RNFL) and ganglion cells can prevent data on glaucoma progression. For example, asymmetry in RNFL is common in 

 patients; however, increased age itself is not associated with increased RNFL asymmetry.

Furthermore, research indicates that ganglion cell analyses can detect glaucoma. Evidence shows that retinal ganglion cell counts are better than average RNFL thickness when detecting glaucoma with minimal visual field loss.

And beyond that, the minimum ganglion cell inner plexiform layer (GCIPL) is th best parameter for early perimetric 

Related: Technological advancements in glaucoma management

Related: Know what common glaucoma mistakes to avoid

Glaucoma is manageable with right approach 

When it comes to glaucoma, diagnosis, management and follow-up can be difficult for ODs to assess. There are a myriad of reasons for this but one that makes it particularly difficult, maybe moreso than the rest, is the fact that 

 is a 24-hour disease. Additionally, when it comes to the challenge of patient compliance, intraocular pressure (IOP) presents difficulties because it is subject to considerable fluctuation throughout the day.

In fact, most glaucoma medications do not work well to curb IOP spikes overnight, Dr. Chu says.

Because of this, ODs should use 24-hour IOP monitoring tools with their patients. In the absence of these tools, they’ll need to rely on isolated IOP measurements. But as Dr. Chu points out, ODs must exercise caution when extrapolating glaucoma diagnoses and treatment plans from isolated IOP measurements.

More by Greg and Marek: Macular diseases: Emerging best practices for diagnosis, management and follow-up protocols

1. Onen SH, Mouriaux F, Berramdane L, Dascotte JC, Kulik JF, Rouland JF. High prevalence of sleep-disordered breathing in patients with primary open-angle glaucoma. Acta Ophthalmol Scand. 2000 Dec;78(6):638-41.

2. Chung SD, Hu CC, Ho JD, Keller JJ, Wang TJ, Lin HC. Open-angle glaucoma and the risk of erectile dysfunction: a
	population-based case-control study. Ophthalmology. 2012 Feb;119(2):289-93.
	3. Sihota R, Gupta S, Angmo D. Evaluation of macular ganglion cell analysis compared to retinal nerve fiber layer thickness for
	pre-perimetric glaucoma diagnosis. Indian J Ophthalmol. 2018 Apr;66(4):491-493.
	4. Xu XY, Lai KB, Xiao H, Lin YQ, Guo XX, Liu X. Comparisons of ganglion cell-inner plexiform layer loss patterns and its diagnostic performance between normal tension glaucoma and primary open angle glaucoma: a detailed, severity-based study. Int J Ophthalmol. 2020 Jan 18;13(1):71-78.

Articles

More knowledge helps dispel myths in diagnosing and treating this sight-stealing disease.

Glaucoma facts: Essential perspectives for long-term management

Given that 88 percent of annual eye exams are conducted by optometrists, it might seem strange that merely 20 percent of LASIK cases are referred to ophthalmologists by ODs. What’s the disconnect? Kyle Sandberg, OD, FAAO; Bobby Saenz, OD, MS, FAAO; and Michael Shumski, MD, sought to answer this question by providing an overview of the spectrum of modern 

Related: Managing dry eye key to patient satisfaction after cataract, refractive surgeries

Among the treatment options for refractive surgery, 

 in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and the more recent small incision lenticule extraction (SMILE) techniques are the most common.

Modern laser technology for used in these approaches is improving, offering more accurate results and better outcomes for patients. It is easier than ever for surgeons to create corneal flaps at the proper depth, improve refractive outcomes, and reduce side effects during procedures. For example, the blackouts experienced by some patients during flap creation can be addressed with newer laser platforms.

“With VisuMax Femtosecond Laser (Zeiss), it’s down to zero,” Dr. Shumski says.

These advances apply to PRK as well with new protocols to prevent corneal haze and better bandage contact lenses that accelerate epithelial healing.

Related: How to determine an ideal LASIK candidate

For patients who don’t fit the criteria for more traditional refractive therapies, phakic implants such as Visian Implantable Collamer Lens (ICL, Staar Surgical) and Verisye (AMO) offer a new fresh approach.

New options on the market, such as toric ICLs, were approved to treat myopic reduction up to 20.00 D, and they are changing the way we deliver refractive care. Just like with LASIK, patients receiving phakic implants must undergo a pre-surgical evaluation to determine whether
	they will be successful. But ODs using these newer implants will need to make sure they’re evaluating the right criteria.

In particular, temporary intraocular pressure (IOP) spikes are a concern for ICLs. As such, the vault measurement is crucial to monitor.

“Troubleshooting early on with IOP is really important for grading the vault,” Dr. Saenz says.

Related: Measurements matter in cataract surgery, the new refractive procedure

For concerns like presbyopia, ODs may need to take a blended approach to refractive care.

“You can do blended vision with any of the laser vision correction procedures or even ICL,” Dr. Saenz says.

Blended options for presbyopia management include the following approaches:

ODs should also consider the presbyopic IOLs on the market, including monovision, accommodating, trifocal, and extended depth of focus lenses.

Related: Surgical, medical approaches making waves in presbyopia

Particularly for patients with more complex vision needs like presbyopia, it is crucial for ODs to screen 

candidates carefully and establish clear expectations for outcomes from the beginning. 

 is someone who is low risk for complications. 

The best way to make assessments and help patients understand what to expect from their treatments is to become familiar with available research and technologies. 

Getting familiar with current research and the technologies available are the best way to make these assessments and help patients understand what to expect from their treatments. 

“Patient-reported outcomes are critical,” Dr. Saenz says, especially in managing after-effects of refractive cataract surgery. 

This is a key aspect of managing outcomes for patients undergoing refractive 

. ODs should make sure to understand their patients’ activities of daily living and what type of correction they’re used to. 

Related: Cataract surgery problem solving: Is technology the answer?

 options available to ODs is a change in attitude. Optometrists should avoid falling into a referral mindset in which patient care is managed by individual providers and instead embrace the concept of collaborative care. 

Both optometrists and ophthalmologists have their own strengths and roles to play in patient care. “Ophthalmologists want your help,” Dr. Shumski says. 

From patient education to inter-office communication to follow-up evaluations, there is a lot that ODs can do to facilitate these collaborative relationships. 

“Know who is in your area, know what they offer, and discuss those offers with them,” he says.

Modern refractive surgery offers additional approaches for collaborative patient care.

Unlock the potential of refractive surgery

 may be common, but managing complications can be challenging for ODs. Each year, new and old technology is adopted and reimagined to explore the best surgical approaches to cataract surgery. The goal is to improve safety, speed and simplicity to make it safer, faster, and easier.

This year has been no different, and Clark Chang, OD, MSA, MSc, FAAO; and Jim Owen, OD, MBA, FAAO, explored some of the complications and solutions during their lecture on the subject at Las Vegas’s Vision West Expo 2019.

Advantages of laser-assisted cataract removal 

 and manual cataract removal each have advantages, Dr. Owen says that the two have noteworthy distinctions.

 is five steps, the laser can be three,” Dr. Owen says.

The primary advantage of the femtosecond laser is precision. When compared to manual surgical methods, the femtosecond laser may offer better wound closure and less endophthalmitis, he says.

“If you can get better closure and better sealing, you get less endophthalmitis.”

This supports the optometrist’s goal of minimizing pro-inflammatory mediators during any type of 

“That is going to eventually lead to quicker recovery for our patients,” he says.

The femtosecond laser also offers advantages for managing capulorhexsis-a key challenge in cataract management.

“Believe it or not, capsulorhexis always has been touted as the hardest step in cataract extraction,” Dr. Owen says.

Dr. Chang described the reasons why a well-performed capsulorhexis can be crucial to good 

 outcome. In addition to lens capsule being very thin, not knowing the level of adherence between cortex and capsule also make it challenging to obtain a well circumscribed and tear-free capsulorhexis. Once you have capsular tear that may extend to the posterior capsule, the risks of vitreous loss and even endophthalmitis significantly increases.

The laser-assisted cataract procedure subverts many of these challenges.

“The femtosecond laser gets a perfectly concentric circle, perfectly centered,” Dr. Owen says.

He also details new methodologies to come, such as the Zepto cataract capsulotomy system.

But optometrists are not limited to referring patients for one surgical methodology over the other, says Dr. Chang. Many surgical practices use a combination of technologies, such as femtosecond laser to assist in lens defragmentation in order to reduce the overall ultrasound energy during subsequent phacoemulsification. Less mechanical energy in the eye means less collateral tissue damages and lowered inflammatory induction; hence, quicker recovery and potentially better visual outcome.

“It doesn’t always have to be 100 percent femtosecond laser,” he says.

But, like any procedure, complication management starts at the beginning of the procedure. Dr. Owen cautions ODs to keep this in mind.

“Making sure lids and lashes are as clean as possible and as healthy as possible, pre-operatively, is important,” he says.

Related: New guidelines in OSD evaluation before surgery

There is a large, fast-growing market for 

. People are living longer and working longer careers, presenting changes in the way optometrists deliver cataract care.

“The patient is definitely different, so we have to approach it a little differently,” Dr. Owen says.

Chief among these developments changes is the way ODs manage patient care, from the earliest pre-operative appointments to post-surgical follow- ups. Primarily, Dr. Owen says that optometrists need to start prioritize thinking of cataract management in terms of vision clarity.

portion of this is crucial for patient outcomes,” he says.

ODs need to walk patients through the process and make sure that patients’ expectations are clear from the beginning. Although the procedure is common and low risk, patients are often concerned about eye surgery. ODs will need to mitigate these concerns in the patient’s early consultations.

Overall, it’s important for the patient to have confidence in his OD as he neuroadapts during post-operative care.

“That’s probably the most important piece,” Dr. Owen says.

More by Greg and Marek: Unlock the potential of refractive surgery

New techniques and technologies are expanding the optometrist’s role in cataract surgery

Cataract surgery problem solving: Is technology the answer?

Macular and retinal diseases are some of the most common eye conditions optometrists see, and each year advances in associated treatments allow ODs to expand the care they provide.

Mohammad Rafieetary, OD, FAAO (moderator); Richard Hamilton, MD; and John Randolph, MD, (presenters) reviewed some of the latest advances in macular and retinal disease management during a lecture at the Retina Scientific Group (SIG) symposium at the American Academy of Optometry 2019 meeting in Orlando.

Inherited retinal diseases and etiologies 

Treatment of macular and retinal diseases begins with understanding etiologies. Inherited macular dystrophies are a growing concern for optometrists because many are complex and can manifest symptoms outside of the retina itself.

; sometimes the vitreous, the retinal pigment epithelium, and the choroid present problems,” Dr. Hamilton says.

Related: Unlock the potential of refractive surgery

For managing retinal conditions like inherited retinal disease or retinitis pigmentosa, optometrists need to be clear on which systemic manifestations indicate retinal concerns and which do not. Dr. Hamilton notes that systemic manifestations from infections can lead to a picture of retinitis pigmentosa, for instance.

“Two of the famous masquerade symptoms are syphilis and toxoplasmosis,” he says.

But optometrists can rely on specific rules to make these decisions, depending on the condition. For example, Dr. Hamilton states that for retinitis pigmentosa, peripheral vision loss is a key concern.

Related: Offer support to patients with inherited eye diseases

“Most people with retinitis pigmentosa will manifest with some degree of peripheral vision loss,” he says.

While older therapies are limited in what they can do, newer technologies address common challenges. The Argus II Retinal Prosthesis System (Second Sight), for example, sits on the surface of the 

 and connects to computerized eyeglasses that allow interfacing between healthy inner retinal layers and patient vision.

Another new therapy is Luxturna (voretigene neparvovec-rzyl, Spark Theraputics) 

 for retinitis pigmentosa. While this therapy works only on 

, it has the distinction of being the only approved gene therapy procedure in the United States.

Related: Cotton-wool spots lead to tissue loss and RNFL defect

Optometrists are on the front lines for catching macular disease early, and they play an essential role in a patient’s long-term prognosis. But Dr. Randolph notes that there will be some cases that need referrals earlier than later.

“Know when to refer these patients,” he says.

Related: Go beyond medical treatment for recurrent corneal erosion

Of the inhered macular dystrophies, Best Disease and Stargardt’s Disease are the most likely presentations ODs can expect to see.

Optometrists should look out for two things, according to Drs. Hamilton and Randolph.

“The first is progressive atrophy,” Dr. Hamilton says.“The second thing that is more acute is choroidal neovascularization.”

If patients with macular problems experience rapid vision loss, or the optometrist notices evidence of bleeding or hemorrhaging, patients should be referred to a specialist.

Another concern to watch for is lamellar macular holes. They can be tricky to spot because the stronger eye may compensate for the compromised vision of the weaker eye and the patient may have no idea that anything is happening. The longer these holes go untreated, the more likely they are to swell and create further complications.

“When you encounter these patients, the key thing is you want is to refer them quickly,” Dr. Randolph says.

Related: SD-OCT shows schisis advancements due to sickle cell

CSCR is another ccommonly confused condition.

“Classically, we’ve been taught to observe it,” Dr. Randolph says, noting that the condition resolves itself in approximately 98 percent of cases.

For cases that do not resolve on their own, several pharmaceutical and laser-based treatments are available, including technology like MicroPulse Laser Therapy (Iridex), which allows providers to safely treat the central fovea.

Related: Toxoplasmosis retinochoroiditis pictorial review

Optometrists should be aware of changes to Plaquenil (hydroxychloroquine sulfate, Sanofi-Aventis) toxicity screening. Eyecare practitioners have begun to understand that many patients have been overdosed with Plaquenil in the past, and now they require new guidelines on how to administer the drug, Dr. Randolph says.

“It’s a cumulative toxicity,” he says.

He suggests that optometrists stress this to patients: the longer the drug is taken, the higher the risk of toxicity.

In terms of evaluating candidates, optometrists must think beyond the 10-2 visual field and consider adding ocular coherence tomography (OCT) imaging, fundus autofluorescence, and possibly 30-2 or 24-2 visual field screening to better visualize the retinal pigment epithelium.

Dr. Randolph also recommends monitoring these patients over time and increasing appointment frequency as the patient continues to take the drug.

Related: Know the latest on classifying and referring hypertension

Although presentations of age-related macular degeneration’s (AMD) vary, technology is improving and opening options to catching the disease early. When evaluating dry macular degeneration, Dr. Randolph notes that drusen size is one of the most important factors.

“The bigger the drusen, the higher the likelihood it is going to cause trouble,” he says.

In terms of evaluating the more dangerous wet macular degeneration, new technologies like the ForeseeHome AMD Monitoring Program (Notal Vision) can catch symptoms early-outpacing even the Amsler grid.

“This machine will pick up wet AMD far before the patient even notices any changes on the grid,” Dr. Randolph says.

So while treatments and screening assessments for macular and 

 complications are improving, optometrists are still the first line of defense in catching emerging problems.

“If you are not sure, always refer,” Dr. Randolph says.

More from Greg and Marek: Cataract surgery problem solving: Is technology the answer?

A modern approach to macular disease means previously untreatable patients can be helped.

Author | Marek Biernacinski

Articles

Glaucoma facts: Essential perspectives for long-term management

Unlock the potential of refractive surgery

Cataract surgery problem solving: Is technology the answer?

Macular diseases: Emerging best practices for diagnosis, management and follow-up protocols