Read more from the Q&A issue

• Methodology: Keep the questions coming
• How can optometrists efficiently schedule ocular disease patients in light of the COVID-19 pandemic?
• How can optometrists create a successful dry eye disease spa?
• How can O.D.s differentiate the neovascular form of AMD from similar diseases?
• How can an optometrist obtain diabetic patient referrals from a primary care physician?
• What should optometrists know about effective management of myopia?
• What is the value optometrists can provide and communicate for the fee charged?
• How can optometrists set up an appropriate fee schedule for specialty contact lenses?

A: In general, diagnosing and treating some chronic, symptomatic diseases (such as asthma or rheumatoid arthritis) are usually more physician-influenced and, therefore, commonly have a relatively higher level of patient adherence.

On the other hand, diagnosing and treating some chronic, asymptomatic diseases (such as hypertension or glaucoma) are usually more patient-influenced and, therefore, commonly have a relatively lower level of patient adherence.

Although both broad disease groups can be successfully managed with the right medication, the limiting factor when controlling the diseases in the latter group is based ultimately on the patient’s opinion on both the accuracy of the diagnosis and the need for treatment for that specific condition. Such patient opinions come after regular patient-centric education and, ideally, should come before finalizing any treatment therapy options.

So, how should we include the patient’s opinion when it comes to treatment options? I have found the following three action steps beneficial:

1 DO THE TESTS

Do the right tests at the right time. It is hard for both the patient and the provider to have an educated, reasonable, forward-thinking opinion regarding the patient’s diagnosis or available treatment options without sufficient testing. Correct testing, performed at the correct frequency, more likely leads to a correct “opinion” between both parties, resulting in more correct choices. With that in mind, which testing should we do…and at what frequency?

As modified from the American Optometric Association (AOA), see Figure 1 for a recommended general workflow regarding the testing we should do and how frequently (at a minimum) with our glaucoma patients based on the stage of their disease.¹

When progression is suspected and/or when reliability is questionable with the above testing, remember this simple “glaucomantra:” If in doubt, repeat. In my mind, this four-word strategy ensures that any and all testing is done regularly, appropriately and on the patient’s behalf. As a provider, I have yet to regret performing another VF test or another OCT scan to augment the long-term data and, perhaps, help me see more clearly any enlarging, deepening or new structural and functional defects suggestive of progression.

Furthermore, reliable longitudinal, structural and functional tests help bring to the surface glaucoma mimickers, such as past retinal disease, ischemic/inflammatory/compressive optic neuropathies and other neurological diseases that may require further testing and treatment as indicated. Timely testing increases the comfort level of the patient and the level of certainty for the provider.

Most importantly, each clinical visit provides a diagnostic window of opportunity to look for clinical risk factors of glaucomatous progression, including narrowing of the anterior chamber, presence of exfoliation, glaucomatous disc hemorrhages, enlargement of beta zone parapapillary atrophy, vertical thinning of the neuroretinal rim, elevated IOP, disease progression in the fellow eye, medication nonadherence and lower diastolic blood pressure.^2-4

2 INTEGRATE THE FACTS

In addition to testing, another way to add context to the patient’s case is integrating the patient’s results into relevant and demographically matched studies.^5-10 These large population-based studies provide a broader perspective, which can help us, perhaps, better predict where the patient may be headed based on other clinical results, and we can tailor our testing and treatment accordingly.

For example, I am 46 years-old and, for the purposes of this discussion, suppose I am a newly diagnosed patient with ocular hypertension and with the following clinical findings: .45 vertical cup-to-disc ratio, pre-treatment IOP levels of 22 OU, and VF pattern standard deviation of 1.5 dB. If you were my provider, you could continue to see me every four to six months over the next several years or, by applying the results of the Ocular Hypertension Treatment Study (OHTS) and the European Glaucoma Prevention Study in the OHTS risk calculator,* you could provide a real-time, evidence-based estimate of my risk of developing glaucoma in five years if left untreated.^5-7 (As an interesting side note, and to see how pachymetry measurements influence patient risk profile, see Figure 2 (left) for my specific risk based on the above clinical findings, while making my age older and/or my pachymetry measurements thinner.) From these “facts,” the patient can generate a more accurate opinion regarding the need for treatment based on their risk factors. Remember: Their opinion guides the decision of whether to start treatment and will directly impact their adherence to that treatment.

3 PRESENT THE FACTS

After performing sufficient testing and integrating the facts to form an accurate and actionable opinion, should we start, modify or intensify the patient’s treatment? Or, stated another way, if we continue with our current observation or current treatment, what is the patient’s risk of losing visual function in their lifetime?

The purpose of glaucoma treatment is to preserve visual function in that patient’s lifetime. Based on the patient's age and disease stage, will the benefits of treatment modification outweigh their opinion or treatment plan? After discussing this clinical balance with the patient and considering the patient and their opinion in the decision process, I recommend modifying treatment based on: (1) reliable, repeatable structural and/or functional progression and (2) poor adherence with current therapy.^2,3,11

A FINAL THOUGHT

The World Glaucoma Association has said, “In general, treatment is indicated for patients with glaucoma or glaucoma suspects who are at risk for developing functional impairment or decrease in vision-related quality of life from the disease…All treatment decisions should take into account the presence of coexisting ocular conditions, life expectancy and general health status, as well as the patient's perceptions and expectations about treatment.”¹² OM

REFERENCES

1. American Optometric Association. Optometric Clinical Practice Guideline: Care of the Patient with Open-Angle Glaucoma. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/Consensus-based%20guidelines/Care%20of%20the%20Patient%20with%20Open%20Angle%20Glaucoma.pdf . Accessed June 24, 2021.
2. Gedde, SJ, Lind JT, Wright MM, Li T, Mansberger SL. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®. Ophthalmology. 2021;128(1):151-192.
3. Gedde, SJ, Lind JT, Wright MM, Li T, Mansberger SL. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern®. Ophthalmology. 2021;128(1):71-150.
4. McMonnies CW. Glaucoma history and risk factors. J Optom. 2017;10(2):71-78. doi: 10.1016/j.optom.2016.02.003.
5. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701–713. doi: 10.1001/archopht.120.6.701.
6. Gordon MO, Beiser JA, Brandt, JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):714-20. doi: 10.1001/archopht.120.6.714.
7. Miglior S, Pfeiffer N, Torri V, Zeyen T, Cunha-Vaz J, Adamsons I. Predictive factors for open-angle glaucoma among patients with ocular hypertension in the European Glaucoma Prevention Study. Ophthalmology. 2007;114(1):3-9. doi: 10.1016/j.ophtha.2006.05.075. Epub 2006 Oct 27.
8. Lichter PR, Musch DC, Gillespie BW, et al. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11):1943–1953. doi: 10.1016/s0161-6420(01)00873-9.
9. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. The AGIS Investigators. 2000;130(4):429-40. doi: 10.1016/s0002-9394(00)00538-9.
10. Leske MC, Heijl A, Hussein M, et al. Factors for glaucoma progression and the effect of treatment: the early manifest glaucoma trial. Arch Ophthalmol. 2003;121(1):48-56. doi: 10.1001/archopht.121.1.48.
11. European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 2: Classification and terminology Supported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 2 Classification and Terminology. Br J Ophthalmol. 2017;101(5):73-127. doi:10.1136/bjophthalmol-2016-EGSguideline.002
12. World Glaucoma Association. Consensus 7: 7th Consensus Meeting: Medical Treatment of glaucoma. https://wga.one/wga/consensus-7/ . Accessed June 24, 2021.

DR. LIFFERTH practices at Center for Sight. He is a member of the Optometric Glaucoma Society and a Glaucoma Diplomate of the American Academy of Optometry. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at glaucomaqd@yahoo.com.