Practical tips and tricks: Peer advice for identifying the glaucoma suspect and first line approaches

Determining when to treat a glaucoma suspect—and when to continue monitoring—remains one of the more nuanced challenges in clinical practice. In this Q&A, Mitch Ibach, OD, FAAO; Nate Lighthizer, OD, FAAO; and Austin Lifferth, OD, FAAO, discuss how they evaluate patients with borderline findings but significant risk factors, including the role of optical coherence tomography (OCT) imaging, visual field testing, pachymetry, and longitudinal follow-up in guiding management decisions. The conversation also explores how clinicians incorporate progression analysis software and risk assessment strategies into everyday glaucoma care.

Transcript

Edited lightly for clarity and length.

How do you approach the glaucoma suspect with borderline findings but significant risk factors?

Mitch Ibach, OD, FAAO: I approach the glaucoma suspect risk factors from multiple angles. What is the patients age, their corneal hysteresis, their pachymetry, family history, status of the natural lens. In a patient at what I consider a very high risk of progressing from glaucoma suspect to glaucoma I will shorten the time frame in between visits. Thankfully in open-angle glaucoma most patients aren't going from 0-60 quickly. So if usually you see glaucoma suspects 1 time per year, shorten that to every 6 months. We also now have an in-office cheek swab that will give us a polygenic risk score for the genetic risk for a glaucoma suspect patient.

Nate Lighthizer, OD, FAAO: I think it's going to be a patient where testing and repeat testing and a variety of testing is going to be important. They're a suspect for one reason or the other. Maybe it's optic nerve head cupping, maybe it's OCT findings. You know, maybe it's IOP, just their eye pressures are higher than we'd like. They're a suspect for whatever reason, that's why we get additional testing. Let's get another OCT. Let's get another visual field. Let's test some, like an ERG, to get to see what their photopic negative response is, the ganglion cell function, maybe a color vision test, like the Raven Cone contrast test, ganglion cell on the OCT, ganglion cell structure, corneal hysteresis with our ocular response analyzer. So just doing a variety of tests to get more information. Ultimately we have to make a decision: is this glaucoma, is it not glaucoma, and if it is, how am I going to treat it? We're really going to make that over time, and I think that's important to remember, is that we have time most often in glaucoma to get further testing and get further data.

Austin Lifferth, OD, FAAO: The challenge with the glaucoma suspect to me is it's a clinical gray zone, where there's overlap between normal patients and early glaucoma. Sometimes for me the best way to approach it is to get data, so additional testing over time helps add certainty, so if we can increase testing, that increases certainty, and that helps us know if the patient has early glaucoma, and a lot of times it's just based on progression. So, if there's reliable correlating structural and or functional progression, that would be concerned for early glaucoma, they would need treatment. I think testing and progression would be my 2 to focus on, based on the patient profile and the risk factors.

How do you incorporate newer metrics (ie, OCT-A, progression analysis software) into routine care?

Lifferth: It's complementary. So I feel like the glaucoma evaluation begins with and ends with a thorough systematic evaluation of the optic nerve, but all other tests are complementary to that: visual field testing or structure testing, like OCT angiography (OCTA) or progression analysis, to detect correlating changes, and like with additional testing, add certainty, so does progression if it's correlating. So look for correlation. Any additional testing has to correlate for it to be reliable.

Lighthizer: I think we all know that the definition of glaucoma is a progressive optic neuropathy, so we're looking for progression, so certainly using the tools and the software that assist us in progression analysis is going to be key, whether that's OCT or OCTA, or visual field … So some of the newer tools we are just dabbling in in glaucoma. It hasn't quite reached front clinical prime time yet in glaucoma, we're in our infancy stages of learning about that, so we dabble in a little bit. But using progression analysis and software with OCT and visual field is certainly very, very important, because at the end of the day, that's what we're looking for: is there progression? Now it confirms diagnosis. Or is there progression and now we need to add treatment? So use the tools and the software to your benefit.

What’s your first-line approach to initiating therapy in newly diagnosed glaucoma?

Lighthizer: So, the answer is, we have 2 wonderful first-line options: number 1 is SLT, and number 2 is topical eye drops, which have been first-line therapy for a long time. But there certainly has been a paradigm shift in the last 5 to 10 years with SLT moving to first-line therapy: the likes of the SLT/Med Study released in 2012¹ and the LiGHT trial released in 2019² and new data in 2022³ that has showed SLT is a first-line treatment option. So, when I am talking with patients that we've confirmed diagnosis and we are initiating their first glaucoma treatment, I am talking to them about eye drops, but very much talking to them about SLT and the benefits of SLT in terms of compliance fluctuations of IOP, controlling that diurnal curve of IOP. And if they asked me, I'm saying, “Well, when you ask eye doctors, what would they do for their eyes? Ninety-five percent of eye doctors said I would choose SLT if it was my eyes,” That's what I tell them, so that really is the answer to your questions. I'm directing them to SLT first line, but also giving them the options of eye drops in case they're for 1 reason or the other uncomfortable with SLT.

Lifferth: For every new patient, for every new treatment, if they're a candidate for SLT, I recommend SLT. So every appropriate candidate who needs treatment, and they're a good candidate for it, then I’d recommend selective laser trabeculoplasty, and then it depends on the age and the stage; three things: age, stage, target pressure, or in other words, age plus stage equals target pressure. If I need to get the pressure lower than that determines which other treatment to consider for interventional glaucoma steps or if needed bridge therapy with maximum tolerated medical therapy.

Ibach: In any patient where I am initiating glaucoma therapy, I will start by saying, "We have 4 mainstays in glaucoma treatment with topical glaucoma drops, laser therapies, drug delivery, and glaucoma surgeries." "All of our treatment options revolve around lowering the pressure inside the eye. I will then make a strong recommendation towards which option I think fits that patient best, and will start that statement with, "If you were my family member, I'd do x." I am very careful not to pit one treatment option versus another, because in many cases where we start with glaucoma treatment won't be the only or last option for a given patient.

References

1. Katz LJ, Steinmann WC, Kabir A, Molineaux J, Wizov SS, Marcellino G; SLT/Med Study Group. Selective laser trabeculoplasty versus medical therapy as initial treatment of glaucoma: A prospective, randomized trial. J Glaucoma. 2012;21(7):460-468. doi:10.1097/IJG.0b013e318218287f

2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): A multicenter randomized controlled trial. The Lancet. 2019;393:1505-1516.

3. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al; LiGHT Trial Study Group. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009