Take a greater part in medical eye care

About 26.2% of optometrists wrote one or less prescriptions a day, 36.4% wrote two to three prescriptions, and 18.7% wrote four to six prescriptions, according to an online-based survey of optometrists’ ophthalmic medication prescribing from Sept. 26, 2012 to Oct. 3, 2012.¹ Dry eye disease (DED) medications were the most prescribed with a staggering 90% of optometrists stating “very likely” or “somewhat likely” to prescribe. Antihistamines were the second most likely prescribed medication category with an 80% prescription likelihood.

A retrospective study analyzed use and expenditure of DED medications in a Medical Expenditure Panel Survey and showed increased trends in DED ophthalmic drops from 2001 to 2006, especially in women (as measured by median expenditure), perhaps aided by new treatment options approved in that time period.²

DED and ocular allergy management are excellent examples of how to expand an optometric practice into medical eye care. Also, consider an enlarging and aging population in whom need and access to quality care is essential, specifically as it relates to glaucoma.

Consider the following areas of unmet patient need, and create processes to identify and help these patients in your practices.

DED

Why. DED is a result of multifactorial causes, such as ocular inflammation, blepharitis, meibomian gland dysfunction and decreased tear production. The signs and symptoms of ocular dryness often do not correlate.³ Two authors looked at results from the Beaver Dam Eye Study and showed that there is an 8% prevalence of DED in patients younger than 60, 19% prevalence in patients older than age 80, and more women affected than men.³ While the first step in treating DED is often tear supplementation, patients can be overwhelmed by the plethora of products available on the shelves and, therefore, need thoughtful guidance when choosing products.

How. DED can be a symptomatic nightmare for patients. They need care from a doctor well-versed in the pathophysiology and current management of the condition. Standard treatment for DED includes artificial tears, nasal neural stimulation, corticosteroids, tetracycline drugs, punctal plugs, as well as DED-specific medications, such as cyclosporine and lifitegrast. These prescriptive medications provide great relief, often in combination with other adjunctive therapies, such as warm compresses and lid massage. Additionally, prescribing DED-specific medications increases a practice presence in medical eye care by serving a great unmet need.

OCULAR ALLERGIES

Why. Allergic conjunctivitis occurs as a result of the presence of immunoglobulin E (IgE) in an immune response, due to exposure to an allergen in predisposed individuals.⁴ Symptoms of allergic conjunctivitis include itching, conjunctival hyperemia, excessive tearing and conjunctival and eyelid swelling.⁴ The most common allergens include pollen and dust mites.⁵ It is important for optometrists to address these issues, as about 40% of the population is affected by symptoms of allergic conjunctivitis, and the majority of these cases are due to seasonal or perennial allergic conjunctivitis.⁴

How. Patients should avoid exposure to allergens to prevent flare-ups. But, simply avoiding known antigens is often more difficult to do than treating the condition. The most common treatment and first-line therapy includes an antihistamine and mast-cell stabilizing topical ophthalmic agent that is usually prescribed once or twice a day.⁴ Additional treatment options include anti-histamine vasoconstrictor combos, corticosteroids and leukotriene receptor agonists. Ocular allergies can be symptomatically miserable for patients. The numerous prescriptive therapies available, which are both safe and effective, provide an excellent and safe opportunity to enhance the therapeutic aspect of an optometric practice.

GLAUCOMA MANAGEMENT

Why. Glaucoma is a significant cause of irreversible blindness in the United States, with over 3 million people affected by the disease. This doesn’t seem to be slowing down and, in fact, is increasing. People are living longer than ever and, as a result, more people are receiving a glaucoma diagnosis today. From 2000 to 2010, those diagnosed with glaucoma jumped from 2.22 million in 2000 to 2.72 million in 2010.⁶ Additionally, individuals affected by glaucoma are projected to steadily increase to an estimated 4 million in 2030 and 6 million people in 2050.⁶

With the increased prevalence of glaucoma continuing yearly, an increase of prescriptions for hypotensive drugs from optometrists will occur organically. More patients with ocular hypertension or glaucoma will present in the chair of optometrists, and they must make the decision to treat or not. Of course, for this prophecy to come true, it is vital that optometrists are willing and comfortable to treat the condition at hand.

Although prescribing hypotensive glaucoma drugs are within the scope of practice for optometrists, O.D.s are prescribing at a much lower rate compared to their ophthalmologic counterparts (1:6, respectively).⁷ Medications found to be prescribed, from most to least commonly: latanoprost, bimatoprost, brimonidine and dorzolamide.⁷ (For information on recently approved glaucoma therapies, see p.44.)

It can be inferred that many optometrists are not treating the more complex glaucoma cases, and this shows in the numbers: Ophthalmologists seem to prescribe more often and a wider variety of medications — nearly doubling the types of drugs used by optometrists.⁷ Optometrists have proven to quickly refer to ophthalmologists for treatment of glaucoma.⁷

How. So, what can optometrists do to increase their part in the management of glaucoma? Look at the disease, and analyze it appropriately. An array of diagnostic technologies, such as OCT and threshold perimetry, can provide increased confidence in diagnosis. (More on diagnostic technology for glaucoma management: https://bit.ly/2zWF1pJ .) Careful medical history will quickly identify medications to avoid in each patient, while directing the best topical therapy. The ability to manage patients with less invasive treatment, such as drops, should be evaluated.

Most patients with glaucoma will need poly-therapy. (For a list of glaucoma therapies, see http://bit.ly/2GmqVTA .) If beta-blockers are contraindicated, alternative adjunct therapy with carbonic anhydrase inhibitors in replacement of the beta-blocker is a viable option.⁸ Two medications may not always reach target pressures, and three-drop systems pose challenges, such as complicated dosing schedule, side effects and drug washout (reduction of efficacy).⁹ To eliminate these concerns, optometrists can consider prescribing fixed-combination medications.

If optometrists continue to treat select ocular hypertensives, early glaucoma cases and those with more complex disease (with increasing experience), utilizing today’s array of potent glaucoma medications, they have the potential for a greater role in the management of this condition.

TIME TO TREAT

DED, ocular allergies and glaucoma diagnosis and management patients are examples of populations with critically unmet needs. These patients need continuity of care and information regarding their disease and all their treatment options in a relaxed atmosphere, where questions are encouraged and answered. This truly is the aegis of optometry. OM

REFERENCES

1. Gonzalez, A., Bennett, N, Lakhani, R. A survey of optometrists’ ophthalmic medication prescribing. Clinical Optometry. 2014; 6: 11-15.
2. Galor A, Zheng DD, Arheart KL, et al. Dry eye medication use and expenditures: data from the medical expenditure panel survey 2001 to 2006. Cornea. 2012 Dec;31(12): 1403-7.
3. Rhee, M K, & Mah, FS. Clinical utility of cyclosporine (CsA) ophthalmic emulsion 0.05% for symptomatic relief in people with chronic dry eye: A review of the literature. Clinical Ophthalmology, 2017 Jun 21;11: 1157-1166.
4. Carr W, Schaeffer J, Donnenfeld E. Treating allergic conjunctivitis: A once-daily medication that provides 24-hour symptom relief. Allergy Rhinol (Providence). 2016 Jan;7(2): 107-14.
5. Rosario, N, Bielory, L. Epidemiology of allergic conjunctivitis. Current Opinion in Allergy and Clinical Immunology, 2011. 11(5): 471-76.
6. “Glaucoma, Open-Angle.” National Eye Institute, U.S. Department of Health and Human Services, 2019, nei.nih.gov/eyedata/glaucoma . Accessed March 12, 2019.
7. Janetos TM, French DD, Beauont JL, Tanna AP. Geographic and provider variations in ocular hypotensive medication claims among Medicare Part D enrollees. J Glaucoma. 2019 Feb;28(2): e29-e33.
8. Tanna AP, Lin AB. Medical therapy for glaucoma: what to add after a prostaglandin analogs? Curr Opin Ophthalmol. 2015 Mar;26(2): 116-20. doi: 10.1097/ICU.0000000000000134.
9. Hollo G, Topouzis F, Fechtner RD. Fixed-combination intraocular pressure-lowering therapy for glaucoma and ocular hypertension: advantages in clinical practice. Expert Opinion on Pharmacotherapy. 2014;15(12):1737-47.

ALEXANDER MOUSSA is a candidate for the doctor of optometry degree at Nova Southeastern University. He is anticipated to graduate May 2019 and is pursuing a residency in primary care with an emphasis on ocular disease. He has no financial disclosures regarding any company associate with glaucoma.

RAUL RAMOS is a candidate for the doctor of optometry degree at Nova Southeastern University. He plans to graduate in May and to pursue a residency in primary care with an emphasis on ocular disease. He has no financial disclosures regarding any company that sells products for dry eyes or ocular allergies.

DR. JOSEPH SOWKA, O.D., F.A.A.O., Diplomate is a professor at Nova Southeastern University College of Optometry. He is Department Chair, Chief of the Advanced Care Clinic and Director of The Glaucoma Service. He has no financial interest in any products mentioned here.