Check out these five ‘glaucomantras’

With the overarching goal of preserving vision among our glaucoma patients, coupled with the principle of “uncertainty reduction” (i.e., looking for risk factors, especially for characteristic glaucomatous optic nerve damage, correlation with testing, repeating testing when needed, and ensuring medication effectiveness and compliance), here are five key phrases to recenter our glaucoma care regardless of disease stage.

1 Diagnose sooner vs. later

Although we should monitor for glaucoma in every patient, we should be particularly attentive to patients who have “clinical findings and/or a constellation of risk factors that indicate an increased likelihood of developing primary open-angle glaucoma.”¹

More specifically, and in addition to a “…family history of glaucoma or glaucoma suspect, thin central cornea, race, older age, myopia, and type 2 diabetes,” these patients have “…a consistently elevated IOP, a suspicious-appearing optic nerve, or abnormal VF.”¹ (See bit.ly/OM2301GlaucomaColumn ), so we must diagnose these patients sooner rather than later.

2 Correlate and carry on

Not every VF defect or retinal nerve fiber layer defect is glaucomatous. In fact, such clinical findings can be due to other past (or present) optic nerve disorders, such as optic neuritis, retinal vascular occlusions, neurological conditions, such as compressive lesions and/or high myopia.^1-9

To differentiate glaucomatous vs. nonglaucomatous optic neuropathy, we must conduct a thorough patient history and a systematic evaluation of the optic nerve to see whether structural and functional tests correlate with the optic nerve appearance. Specifically, is there structure-structure-structure-function correlation or S3F correlation (see bit.ly/OM2303GlaucomaColumn )?

3 Repeat, repeat, repeat

If the tests do not show S3F correlation, we must look at the reliability factors, specifically the false positive indices associated with the testing. If we deem the tests unreliable, then we should try to repeat the testing while looking for reliable, correlating progression (see bit.ly/OM2307GlaucomaColumn .) Additionally, repeating the VF tests also helps us better determine the rate of VF progression.¹⁰ Repeat testing increases certainty.

4 Remember lower is better

When we decide to initiate treatment after confirming the diagnosis, let’s remember that lower target IOP levels equate to less VF progression.¹¹

To determine target IOP range, we must remember age and stage, and continually re-evaluate the IOP range and the current treatment^12-14 to preserve “…vision and vision-related quality of life throughout the patient’s lifetime.”¹⁵

5 Minimize treatment when possible

We must balance IOP reduction with the potential risks and/or side effects of treatment. More specifically, less topical treatments mean a healthier ocular surface^16-19 and, thus, better adherence to treatment. As we know, lack of adherence leads to unstable IOP levels, deteriorating optic nerve health, and VF progression.^20-23

Concentrating on care

Remembering and applying these “glaucomantras” can help us recenter our glaucoma care among our glaucoma patients at any stage of their disease. Do you have any “glaucomantras” that help you reduce uncertainty and recenter your glaucoma care? If so, shoot me an email at the address listed below. OM

References are available in the online version of this column.

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.