MINEWSAPRIL 1, 2024 AUTHOR: MIVISION
The way we manage glaucoma has changed and, as evidenced by a recent evening of discussion, ophthalmologists have different perspectives on management – even for the same patient.
At a dinner event hosted by Glaukos in Hobart, Tasmania during the Australia New Zealand Glaucoma Society conference, Professor Helen Danesh-Meyer (Eye Institute, Auckland), Dr Colin Clement (Eye Associates, Sydney), and Dr Judy Ku (OKKO Eye Specialist Centre, Brisbane) discussed the reasons and strategies for interventional glaucoma management.
While all were in firm agreement with the concept of early intervention for glaucoma management, they had different ideas on the specific management of patients who were presented as series of challenging case studies by Dr Ku. As did the audience, a group of surgeons who were also well experienced in glaucoma surgery.
Controversial discussions about a 23-year-old tradie with asthma and early pre-perimetric juvenile open angle glaucoma with alarming high intraocular pressure, for instance, drilled down on issues concerning treatment compliance, the impact of beta blockers on cardiovascular health and sexual dysfunction, and whether to take more aggressive action early.
And this was exactly what the organisers at Glaukos had hoped for. As Glenn Fawcett, Glaukos’ General Manager for Australia said, the evening was not planned to be “just about Glaukos”, instead it was to be an “agnostic… evening of discussion” about various new concepts in glaucoma management, and the emerging concept of interventional glaucoma.
WHAT IS INTERVENTIONAL GLAUCOMA MANAGEMENT?
As moderator for the evening, Prof Danesh-Meyer set the scene by stating that as an emerging concept, interventional glaucoma “should really be discussed and formed by us as part of the larger glaucoma community”.
To her, interventional glaucoma management is important because “our patients are changing, and the profile of our patients is becoming different” due to the ageing population.
“When people are living longer, we have to consider treatments earlier and preserving their ganglion cells for longer in life. So, you look at someone and if they’ve got 65, 70 microns on their OCT (optical coherence tomography imaging), you have to think, ‘gosh, how much can they live with that? How long can they see with that?’”
She quoted results from a study by Professor Anders Heijl and colleagues, who showed that the cumulative rate of blindness in one eye was 26% at 10 years and 38% at 20 years postglaucoma diagnosis. Bilateral blindness was 5.5% at 10 years and 3.5% at 20 years.1
EARLIER, SAFER
Speaking with mivision, Prof Danesh-Meyer said to ensure people with glaucoma are not blinded before they die, it is necessary to “be a bit more aggressive early… You can’t just wait and let them die before the disease blinds them, because people live long enough now that they will be blinded before they die. So, I think it’s important to have more tools so we can do less invasive treatments earlier on and save the more invasive things for later.”
And fortunately, the evolution of glaucoma treatments means ophthalmologists can now safely and effectively intervene earlier.
“Before we had drops and selective laser trabeculoplasty; then there was this big gap… there were trabeculectomies, which we all know have high risks and potential significant risks of blindness. But there was this void in the middle – how you do things in the transitional period? Now with the iStent and Preserflo, we have safer options to do something to lower pressure if you don’t need to do those very aggressive procedures.”
She said looking at the evidence and understanding what specific treatments can offer individual patients in terms of pressure reduction and safety is essential, taking into consideration factors such as their ability to handle drops, and their availability to come back for follow-up visits and checks.
“So, for a patient who doesn’t want to be on eye drops because they have significant disease, or significant issues with using drops, the iStent is perfect because it may offer them less drops or no drops and improve their quality of life.” Others, who want to reduce their drops may be suitable for a Preserflo ahead of a more invasive procedure later.
“The more instruments you have, the more you can say right for you, this is the best combination and discuss it with them,” Prof Danesh-Meyer said.
It was Dr Clement’s role to present the evidence for interventional glaucoma management and he did so by drawing lightly on six studies to deliver “a taste of how we should apply what we know and what’s emerging into changing our approach”.
“It’s hard to unlearn things you’ve been trained in, but I think it’s a process of bringing our new knowledge to the whole front of your mind, not having it there in the background,” Dr Clement explained to mivision. “You have to actively think about it. A classic example of that is a new diagnosis: you would reach for the script pad, write out your prescription for your drop of choice, and off you go. However, we need to be actually thinking, is this the right treatment approach for the patient sitting in front of me? Is there something I can do that’s better?”
Reference
- Peters, D., Bengtsson, B., and Heijl, A., Lifetime risk of blindness in open-angle glaucoma. American Journal of Ophthalmology. Am J Ophthalmol. 2013 Oct;156(4):724–30. DOI: 10.1016/j.ajo.2013.05.027.