Interventional management of glaucoma offers big advantages

Reviewed by Lee S. Peplinski, OD, FAAO

Interventional care in patients with glaucoma—sooner rather than later—is advantageous in the disease process, according to Lee Peplinski, OD, FAAO, of Focal Point Vision in San Antonio, Texas. Peplinski described the rationale for interventional rather than passive treatment.

Traditional glaucoma care can be associated with obstacles such as medication toxicity to the ocular surface, cost, patient adherence to drug instillation, and treatment fatigue associated with chronic care.

Art of glaucoma care

In this scenario, the care is patient-centered, patient-specific, and individualized, Peplinski explained. He outlined 4 objectives for embracing interventional glaucoma management.

Objective 1

Clinicians should identify the differences between passive and interventional glaucoma management. Engaging in passive glaucoma treatment involves reacting to outside influences such as insurance formularies and/or following a cookie-cutter approach to treatment; yielding control as in adherence failures; lethargy on the part of the patient (or the clinician); and finally, failure to take an active role in treatment, according to Peplinski.

In contrast, interventional treatment exerts 3 actions:

1. Interference with the course and outcome of glaucoma; for example, performing selective-laser trabeculoplasty (SLT) or stent placement that stops progressive obstruction of the trabecular meshwork and more visual loss.
2. Modifications that hinder the natural disease progression, such as lifestyle changes that improve circulation and perfusion.
3. Promotion or prevention of an action that initiates lowering of intraocular pressure (IOP).

Objective 2

Recognize the advantages of early intervention in the glaucoma disease process.

“Early intervention decreases visual field loss, functional visual loss, blindness, and the need for more invasive surgical procedures,” Peplinski said.

Objective 3

The third criterion is gaining an understanding of the various interventional methods and when to use or recommend them.

Peplinski suggests lifestyle counseling that may include promoting moderate exercise, with the goals of improving circulation and perfusion, specifically 30 minutes of cardio exercise 3 times weekly; preventing nocturnal hypotension by avoiding the use of systemic hypertension medications before bedtime; being aware of the effects on the IOP of weight lifting and head-down yoga positioning, which can cause significant transient pressure elevations; and recognizing the benefits of yogic breathing, which has been associated with lowering IOP.

Alternative therapies such as Ginkgo biloba, Mirtogenol (a combination of two phenolic extracts from bilberry and French maritime pine bark),¹ black currant, and other nonallopathic drugs may have a supportive place in glaucoma management.

Peplinski also suggests minimally invasive procedural care that carries the following advantages: less or no impact on the ocular surface, decreased long-term cost, less or no reliance on adherence, and less patient burnout. In addition, although not achieving a cure or eliminating patient monitoring, such care, buys time until the next best procedure is needed.

Optometrists can perform some procedures, such as SLT and insertion of intracameral medical implants (ie, Durysta [bimatoprost 10 µg; Allergan]) in some states. Optometrists can engage in comanagement of these procedures in every state.

Other interventions that ease the patient burden are implantation of the iStent (Glaukos) and Hydrus Microstent (Alcon) during cataract surgery. Stand-alone devices include the Xen Gel stent (Allergan) and the Ex-Press Mini Glaucoma Shunt (Optonol).

Minimally invasive glaucoma surgeries (MIGS) that do not involve device implantation include the Kahook Dual Blade (New World Medical), the Trabectome (NeoMedix), and OMNI (Sight Sciences)—all of which enhance aqueous outflow.

Procedures that suppress aqueous production flow are endocyclophotocoagulation and diode cyclophotocoagulation.

Objective 4

The last criterion involves developing a mindset and approach to providing interventional care. Peplinski emphasized that no one approach fits all patients.

“Knowledge is power and provides options. Be a patient advocate. Listen to your patients and they will help guide your intervention,” he concluded.

This article was adapted from Peplinski’s presentation at the SECO 2022 annual meeting held March 9-13, 2022, in New Orleans, Louisiana. He can be reached at lpeplinski@focalpointvision.com.

References

1. Steigerwalt RD Jr, Belcaro G, Morazzoni P, Bombardelli E, Burki C, Schönlau F. Mirtogenol potentiates latanoprost in lowering intraocular pressure and improves ocular blood flow in asymptomatic subjects. Clin Ophthalmol. 2010; 4: 471–476. doi: 10.2147/opth.s9899