The challenges of identifying glaucoma progression

Over the years, the ability to diagnose glaucoma has improved dramatically. From advances in medical technology and testing to increased awareness among the public, eyecare professionals are better able to identify glaucoma before it starts wreaking havoc on a patient's vision. But when it comes to identifying glaucoma progression, things get a little murkier.

Damage due to glaucoma can occur over long periods of time, and the changes to a patient's condition can sometimes be subtle. The industry has embraced stereo photographs as the gold standard for identifying progression, but they're not without their faults, either.

"Stereo photographs are difficult to use for detecting progression," says Murray Fingeret, OD, FAAO, chief of the optometry section at the Department of Veterans Administration New York Harbor Health Care System's Brooklyn/St. Albans Campus. "There's often not clinical agreement among clinicians about who is getting worse."

He cites one paper from Johns Hopkins in which numerous glaucoma specialists were shown a series of stereo photographs of glaucoma patients and then asked which patients showed progression. The study found "slight to fair" agreement among the doctors.

"In other words you could flip a coin and do better," he says. "And this is with stereo photographs, the so-called gold standard."

Related: Addressing glaucoma conundrums

OCT is doing a better job

Dr. Fingeret says optical coherence tomography (OCT) appears to be doing a better job.

"The ability to see structural change with the devices removes subjectivity,” he says. “These are reproducible devices improving resolution, reproducibility, and they're getting better in terms of speed of acquisition and ease of use."

But even then, relying on a single test is not a good idea.

"How many tests do you need to do before you can reliably use the software package for the field or the OCT?" he asks. "While at three the thing actually kicks in and gives you a number, you really need five. You can have people who  can change a lot if you do it once a year."

He recommends initially seeing a newly diagnosed glaucoma patient every three months, administering a field and imaging test twice in the first year to properly track changes. Once progression (or lack thereof) is properly assessed, patients can reduce the number of visits.

Next: The age factor

The age factor

Of course, much of this depends on numerous factors, one of which is age.

"I ask my patients now, ‘How long did your mother, your father live? Do you have any older brothers or sisters?’" Dr. Fingeret says. "That also becomes important in how you manage. The idea of simply saying, ‘Well, you're 80, maybe we don't have to treat you,’-that's crazy-you can't do that. You need to keep in mind longevity and mortality."

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As life expectancy goes up, the importance of being mindful of how much time a patient has left becomes a greater influencing factor on how care is managed. Decades ago, seeing steady declines in an 80-year-old patient's testing didn't necessarily mean having to tackle it aggressively. Today, many people grow into their 90s or later, and because managing vision loss due to glaucoma is a lifetime commitment, these new lifespans need to inform how optometrists approach each case.

"And that’s the whole point why we take care of patients," he says. "Because we don’t want them to have any problems visually."

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