Practical tips and tricks: Real world advice for peers when treating glaucoma

Advances in diagnostic technology and evolving treatment strategies continue to reshape how clinicians manage glaucoma in everyday practice. In this Q&A, Mitch Ibach, OD, FAAO; Nate Lighthizer, OD, FAAO; and Austin Lifferth, OD, FAAO, share practical insights on identifying early disease, balancing monitoring with intervention, and communicating risk to patients. The discussion also highlights real-world approaches to imaging, progression analysis, treatment selection, and long-term patient management in a busy clinical setting.

Transcript

Edited lightly for clarity and length.

How do you explain glaucoma progression and risk in a way patients understand without causing undue anxiety?

Mitch Ibach, OD, FAAO: In many patients I will say, "I am glad you're here and under our care. The worst thing you could do would be to take a 10-year hiatus from seeing eye doctors, and as long as you don't, we will do everything we can to keep your vision." For glaucoma progression, I really like to simplify the visual field using VFI (visual field index score). In the presence of guided progression analysis (GPA) I will show a patient their slope line as a correlate to maintaining their visual field. In explaining risk, very relatable to patients is their IOP. I am always educating patients we want to keep their IOP lower, but we care more about how their pictures (OCT) and visual field react.

Nate Lighthizer, OD, FAAO: I always tell them that number one, glaucoma is a condition of years and really decades, and very few patients lose vision, meaningful vision – to you as the patient – from glaucoma. So, again, there's no reason to freak out here. We have time. This is a slowly progressive disease, and we're going to do testing now. The most important thing for you to know, Mr. Jones or Mrs. Jones, is to come back to have routine exams 2 to 4 times a year, depending on your severity of glaucoma. So, we're going to see you every 6 months or every 4 months, and we're going to repeat this testing, because the more data that I have, the better decision maker that I can be when determining, do we have progression or not. So, rest assured, this progresses very, very slowly, but we need you to come to your visits. If you missed 3,4, 5, visits, now we're missing data points, and that makes us have to guess more when the progression is happening. So, the importance of follow-ups, the importance of more testing to have further data, and that will guide me with progression.

What’s one small adjustment in your approach that significantly improved outcomes?

Austin Lifferth, OD, FAAO: I would say refined decision making, trying to become a better decision maker as far as, do I have enough data to make a good decision now that'll impact their vision 1 year, 5 years, 10 years from now. And so I would say one thing I'm trying to do is become a better decision maker, and to become a better decision maker, that means we, and [the patient] have good, reliable data.

Ibach: After finishing my residency I became a little lackadaisical on setting target pressures. I think target IOP's are very important in managing glaucoma for multiple reasons. First, I practice in a tertiary referral center where most of my glaucoma patients are in a shared-care model with another optometrist or ophthalmologist. Having an agreed upon target IOP keeps everyone on the same page. Second, patients like to have a goal or a target, and I think target IOPs may strengthen treatment compliance.

Second adjustment is becoming more interventional in my glaucoma approach. Utilizing laser therapy earlier and more often in my glaucoma patients has been a big win. This doesn't exclude drops, but rather focuses on putting our treatment approaches in a different order.

Lighthizer: The answer goes back to the third question, which is adjusting and doing SLT more often and earlier in the course of therapy. Patients do better when they're on fewer medications, and we can ease the burden on patients, and if we can be more gentle to their ocular surface. Because you're putting eye drops on your eyes or in your eyes every single day, multiple times a day, there's preservatives that are going on to the eye, and that can irritate dry eye and ocular surface disease. So, really, such a positive change by doing SLT more often, and doing it earlier, and that has been beneficial to patients from a compliance perspective, from an easing the burden perspective, and from an ocular surface perspective as well.

Do you have any other practical tips and tricks for physicians specific to glaucoma?

Lighthizer: I would just encourage all the eye care practitioners out there that interventional glaucoma is a thing, and it's here to stay. And what does that mean? It means let's intervene on behalf of the patient, so they don't have to shoulder all of the burden of the treatment themselves. And what I mean by that is, drop number 1, and drop number 2, and drop number 3. We have a wonderful laser called SLT. We have wonderful surgeons that can do MIGS procedures at the time of cataract surgery or stand alone, and we have drug delivery, where implants can be put inside the eye and can release their medication over months and months. So whether it's drug delivery, whether it's MIGS, whether it's SLT, all of those are in-office procedures that are part of interventional glaucoma to ease the burden on patients. So I would encourage eye care practitioners to continue to think about interventional glaucoma when managing glaucoma.