AJ: So, why does the stage of glaucoma matter?

AL: I think the stage matters as far as diagnosis and as far as treatment. No one ends up with end-stage glaucoma overnight. Something has happened along the way…

RF: I always think of glaucoma as a continuum going all the way across to end stage, but the beginning of that continuum is normal. So, as people are moving on that journey, the earlier that we can capture them, the better our chances of not letting the [disease] progress.

AJ: You both made a point that, “Everyone is a suspect, until they are not.” Is that right?

AL: I think you are right…guilty until proven innocent. But how long does that take?

RF: A lifetime.

AL: To that point, Rob’s world is more advanced glaucoma. As ODs, we see a lot more cases of early glaucoma and glaucoma suspects, and that is our area where we can really make a difference.

RF: The greatest entry for glaucoma patients will be through the optometrist. So, these topics we are talking about of early detection and appropriate initial treatment, to me, are what will change the course of people’s lives with glaucoma.

AJ: I have seen it said that one of the most common reasons for malpractice in any eye care providers’ office is failure to diagnose the glaucoma. Why are we not diagnosing glaucoma when we should?

RF: I see the patients who have advanced glaucoma. But my first thought about that is what we were discussing earlier — that everybody is a glaucoma suspect. So, when you are doing an eye exam, you just have to maintain that curiosity — “Does the nerve look OK? What do I think of the IOP levels in the context of the corneal thickness? What is the family history?” Look for risk factors. If we change our philosophy from “I am going to try to find glaucoma,” to “I am going to assess your risk,” then we are going to make the diagnosis earlier and more accurately.

AL: Unfortunately, what happens is we over rely on IOP readings. If they are normal, we may not look objectively. So, when we over rely on IOP readings, we may under-evaluate the optic nerve. If we can evaluate the optic nerve more systematically, more carefully with every patient, then we are more likely to detect early glaucoma in our patients…start treatment earlier, and have a better prognosis.

AJ: Does IOP matter?

RF: Of course, IOP matters in the context of glaucoma, but the example I give is that if you have a patient who comes in and their IOPs are 22 mmHg or 23 mmHg, are you going to treat? I think that answer is, “Well, I do not know enough.” If we flip that upside down and say that a patient comes in and the optic nerve is notched, there’s a disc hemorrhage, the OCT shows an retinal nerve fiber layer bundle defect, and the VF corresponds with that, are you going to treat? Of course, we are…and I didn’t even tell you the IOP.

AL: I will say “yes” and “no.” It matters if we put it in the context of the optic nerve. I think we look at the nerve differently depending on the IOP reading. So, if we look at the IOP first and it’s 15 mmHg, we might not pick up early notching or early thinning. However, [if] the IOPs are 23 mmHg, we might be more careful and have a more systematic evaluation. So, with any test we do, especially IOP readings, we need to put it in the context of the optic nerve.

RF: If you approach every patient and imagine that every patient’s IOP is 23 mmHg, then you will not miss those patients. We shouldn’t be reassured by a statistically normal IOP.

AL: If we didn’t have IOPs, would we examine the nerve more carefully and more systematically? I think we need to have a more qualitative evaluation beyond the quantitative evaluation of cup-to-disc ratios.

AJ: Let’s talk about early treatment. What is the first treatment step that you take?

AL: I would say that there is a difference between first-line therapy and first-choice therapy. First-line therapy might be a prostaglandin. First-choice therapy might be different. It might be SLT… What would I prefer? Let’s strive for adherence-independent IOP reduction.

AJ: Whose choice, the patient’s choice, or your choice?

AL: Both. I think in these settings, the patient has to have the last word.

RF: With unilateral treatment, I am very cautious about using a prostaglandin to avoid orbital fat changes causing a cosmetic impact. As far as whose choice, I would say that it up to the patient, but they turn to us for guidance. I try to steer them to a good choice. A good choice could be starting a medication or having a laser.

AL: Is the treatment worse than the disease?

AJ: When is SLT first?

RF: There are certain situations where it is obvious to me that a laser should be first. The patients with pseudoexfoliation or pigment dispersion glaucoma tend to respond well with a laser. The people who are averse to medications or who have arthritis or some other dexterity challenges are great candidates for laser first. Regarding the LiGHT study,^1,2 at least over the duration of that study, initial therapy with a prostaglandin or with a laser, laser did just fine. If you are talking about starting therapy, laser should be part of that discussion. If you are thinking about a second eye drop bottle, then laser should definitely enter the discussion.

AL: Another group are younger patients who have the potential for life-long glaucoma therapy. If we can have some bridge therapy with SLT and repeat as needed [with them, that could be beneficial]. Another group to consider are those patients who have a one-month prescription that has lasted three months. Let’s take adherence out of that factor and have a little more control with SLT.

AJ: Let’s talk about those patients who are non-compliant. How can you detect non-compliance, and what do you do about it?

RF: Quite dismally, we do not know if they are compliant. I use the term “adherence” because that is “stickiness”…Will patients stick with the therapy? I think that education and understanding of the condition helps.

AL: I think that having a layered approach helps with adherence. In having our staff members ask patients questions, such as “How do you take your eye drops?” or “What troubles do you have taking your eye drops?” many times, patients may be a little more honest with the staff than the provider — for whatever reason. Then, we need to ask patients as well, and recognize the potential barriers. Unfortunately, adherence spikes right before and right after an office visit, and what happens is then the IOPs are really good and, perhaps, at that time the tests are also really stable, so we encourage the patient to keep doing what they are doing, and we are reinforcing the negative behavior. Studies have shown that, as providers, we do a poor job at detecting adherence.

RF: Nobody is noncompliant with SLT — as long as they show up for their SLT appointment.

AJ: What is the biggest challenge that we face inglaucoma today?

RF: The biggest challenge is for us to appreciate that we need to be more intensive at the start rather than letting patients progress. The worse [the patient], the greater the likelihood [they] will get worse.

AL: To me, the biggest challenge is cup-to-disc (CD) ratios. As providers, if we just focus on CD ratios, then we may not look at the nerve as well. If we do not look at the nerve as well, then we are less likely to diagnose glaucoma and pick it up in the earlier stages. We need to elevate our examinations with qualitative evaluations.

AJ: What tips do you have regarding VF testing?

RF: I try to get at least three VFs over the first year. Once I have three VFs in the computer, I can start doing progression analysis. I try to front-load those tests. There is also a role for central VF testing. Glaucoma patients do not just lose vision in their periphery.

AL: The first point is that we probably do not do enough VFs. We need a baseline to track for progression. The World Glaucoma Association has said that 24-2 or 30-2 is sufficient, but whatever field you do, I would just recommend you keep it the same type, so that we can get long-term data. We need reliable results.

AJ: Related to glaucoma, how do you feel it best for optometry and ophthalmology to work together?

AL: If we see patients progressing and we have done the right tests to confirm that they are progressing despite treatment, I would recommend working with a glaucoma specialist sooner rather than later. The patient is always our top priority.

RF: The key word is partnership. So, as a glaucoma specialist, I would want you to refer the patients when you are uncomfortable. I want the useful information, so that my initial evaluation can be comprehensive. I would like to know the untreated and treated pressures, I would like to have a series of VFs, I would prefer that you not fax the color exams because they are unreadable as a fax, and email would be better. Then, let me know what you want. Let’s talk about roles and responsibilities. Do you want a consultation? Do you want an intervention? Do you want transfer of care? OM

REFERENCES

1. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial [published correction appears in Lancet. 2019 Jul 6;394(10192):e1]. Lancet. 2019;393(10180):1505–1516. doi: 10.1016/S0140-6736(18)32213-X.
2. Garg A, Vickerstaff V, Nathwani N, et al. Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naive Open-Angle Glaucoma and Ocular Hypertension during the LiGHT Trial. Ophthalmology. 2020;(4):467-476. doi: 10.1016/j.ophtha.2019.10.023.