Managing glaucoma in an ophthalmic practice: An artful approach

A recent Optometry Times case-based roundtable discussion focused on building confidence and clinical impact when managing patients with glaucoma. Justin Schweitzer, OD, who practices at Vance Thompson Vision in Sioux Falls, South Dakota, shared the highlights of the meeting, which included individualized patient care, common management challenges, and practical strategies to optimize long-term care for patients with glaucoma.

Practice challenges

Participants in the roundtable discussion pointed out the barriers that limit the ability to provide comprehensive glaucoma care (treatment adherence was the primary issue), especially when patients were taking 2 or more medications.

Medication adverse effects and quality of life issues were other problems, while patient adherence to follow-up appointments was especially problematic, in that patients may not appreciate the severity of their disease.

Case 1: Glaucoma suspect

The patient, a 71-year-old White woman, had been referred for possible glaucoma. She had undergone bilateral cataract extractions and had a family history of glaucoma, although she never had elevated IOP and bilateral IOP values of 16 mm Hg.

The management considerations: Does the patient have glaucoma, should treatment be started, and is imaging needed? The treatment options can include prescription of a prostaglandin, selective laser trabeculoplasty (SLT), drug delivery, or surgery.

Her uncorrected visual acuity (VA) was 20/20 bilaterally; gonioscopy showed no pigment in the trabecular meshwork. Asymmetry between the right and left optic nerve heads was seen. Optical coherence tomography (OCT) showed some thinning. Visual field testing showed a nonsignificant visual field defect in the right eye but a nasal step in the left eye with some inferior and temporal thinning.

The participants agreed on the probability of low–baseline-pressure glaucoma or normal-tension glaucoma in the left eye and borderline glaucoma, mild low-tension glaucoma, or low baseline pressure glaucoma in the right eye based on OCT.

Schweitzer opted to start treatment with latanoprostene bunod 0.024% (Vyzulta, Bausch & Lomb) once daily at night in both eyes. The goal was to achieve an IOP decrease of 25% or more from baseline. Six weeks after the start of therapy, the IOPs were 12 mm Hg bilaterally.

He pointed out that in a patient such as this, “we need to be more artful in what we’re choosing.” He cited the APOLLO and LUNAR studies and especially the JUPITER study, which included patients with a low baseline pressure with an average pressure of about 19 mm Hg. The results showed that when treated for about 52 weeks, the IOP decreased by about 25%.

At the 6-week follow-up, this patient achieved a 25% decrease in IOP to about 12 mm Hg. In addition, visual field testing over time showed no reduction in the fields.

“That particular prostaglandin fit very well for this patient,” Schweitzer stated. In addition, in this case, the drug was a better choice over SLT, which works well in eyes with high IOPs.

“Latanoprostene bunod is really a great first-line prostaglandin for many patients because it can lower high IOPs, like many prostaglandins, and also decrease low baseline pressure, which allows this medication to be used across a wide gamut of different types of patients with open-angle glaucoma [OAG],” he said.

Case 2: Cataracts and advanced glaucoma

The patient was a 65-year-old White man with an unremarkable medical history. The family history was notable for primary OAG. His best-corrected VA (BCVA) was 20/30-2 bilaterally, and the IOPs were 24 and 23 mm Hg in the right and left eyes, respectively. He also had visually significant cataracts.

The patient was already on a prostaglandin analogue instilled once daily at night.

Examination showed asymmetry of the optic nerve heads in both the cup-disc ratio and the sizes of the nerves. The pachymetry values were 510 and 514 µm indicating thinning.

Corneal staining indicated the likelihood of dry eye disease and the possibility of toxicity from the preservative in the glaucoma medication.

OCT images of the left eye showed a normal retinal nerve fiber layer (RNFL) (average RNFL, 88 µm). The patient may have had some inferior thinning of the ganglion cell layer.

Visual field testing of the left eye showed a paracentral defect with an early nasal step, which fit perfectly with inferior ganglion cell thinning. Schweitzer also conducted a 10-2 test, which localized the paracentral defect.

The participants discussed the importance of 10-2 testing, and they agreed that it is appropriate in the presence of a ganglion cell defect, especially if the RNFL is normal.

Schweitzer pointed out that patients who had repeatable 10-2 visual field defects had a 22 times greater risk of having more visual field progression in the future and needed to be followed closely and receive more aggressive therapy.

The roundtable participants agreed that the right eye had ocular hypertension. However, the left eye had advanced glaucoma because of that central defect.

Quality of life is an important consideration. “If we ignore the ocular surface in a patient like this, we may control the IOP, but corneal staining indicated that the patient was probably uncomfortable, and that can contribute to future progression and visual loss,” Schweitzer said.

The group determined that the left eye should be treated, but the status of the right eye was open to debate.

Further discussion centered around cataract surgery alone or with a minimally invasive glaucoma surgery (MIGS) and the use of additional medication, or drug delivery. He opted for cataract removal plus drug delivery in the right eye; this choice both increased the vision and reduced the medication burden in this eye with ocular hypertension.

He also performed cataract surgery in the left eye and added a 3-stent system.

Schweitzer reported, “At 3 months, this patient did well, with pressures down to 15 mm Hg from 24 to 23 pressure. We also discontinued medications that affected quality of life.”

The participants agreed that patients should undergo cataract surgery plus a MIGS procedure if they have mild to moderate glaucoma and they are on medications.

Case 3: Managing moderate to severe glaucoma

The 71-year-old patient had glaucoma refractory to generic latanoprost. The BCVA was 20-20+1 bilaterally. The IOP was 24 mm Hg bilaterally, with a peak IOP of 27 mm Hg. The patient had undergone previous cataract surgeries.

Some asymmetry to the cup-disc ratio was seen (right eye, 0.7; left eye, 0.65). Pachymetry showed a thin cornea with low corneal hysteresis. Gonioscopy results were normal. OCT imaging showed temporal RNFL thinning bilaterally and a ganglion cell defect in the right eye.

Visual field testing showed a paracentral defect in the right eye, which is consistent with the inferior ganglion cell defect and the temporal RNFL thinning. An early nasal step was possible in the left eye.

The participants agreed that the patient had moderate to severe OAG in the right eye based on the visual field defect and mild OAG in the left eye.

Schweitzer wanted to achieve a 30% reduction in the IOP and noted that the generic prostaglandin had achieved only a 10% reduction to 24 mm Hg, which raised the question of adding a medication.

After addressing considerations about quality of life with extended treatment, SLT, drug delivery, or surgery and adherence, the group agreed that switching the medication was the best option, using once-daily dosing to determine whether IOP lowering could be achieved and minimizing the ocular surface issues.

After switching the patient to latanoprostene bunod, the IOPs decreased to about 19 and 20 mm Hg. “In this case, switching the medication worked, and with the same once-daily dosing as previously, [adherence] was addressed.”

Key considerations

The key factor, Schweitzer noted, is the ability to be artful. “The participants thought about different studies of prostaglandin analogues that they could use for a particular case,” he said.

In case 1, with a low baseline pressure, the attendees wanted to use a medication with available data applicable to the patient.

The discussion of case 2 resulted in the participants realizing that they were likely underutilizing 10-2 visual fields to identify paracentral defects, the presence of which is indicative of a patient with higher-risk glaucoma.

The case 2 discussion also highlighted the importance of managing both the IOP and quality of life. “Ocular surface disease matters,” Schweitzer emphasized.

Case 3 showed that it is not always beneficial to stack medications. “We need to think about switching within the family of medications and obtaining additional IOP lowering within that family,” he said.

In addition, less is more. “With 1 bottle of medication, patients will be more [adherent] than if they’re on 2 or 3 types of medications,” Schweitzer said.