Recently, the son of a local optometrist spent a day observing in our clinic. On that day, we saw several “glaucoma suspect” patients for either their initial consultation or return visit for additional testing. In recognizing a pattern of “observation with continued testing” for most of these patients, the OD’s son profoundly asked, “why not just start treatment?”

This column serves as a reminder of the terms for treatment.

Term 1: Functional vision loss risk
As the management goal in glaucoma is to prevent functional vision loss from the disease, we must look for both systemic and ocular risk factors (see “Risk Factors for Glaucoma,” right),^1,2 that increase the risk of functional vision loss from glaucoma.

Importantly, and for our glaucoma suspect patients as shown above, determining such risk of vision loss due to glaucoma may take several visits (with appropriate patient-centric repeat testing) over several years. On the other end of the glaucoma spectrum, and for patients with established and/or more advanced levels of glaucoma, we should be sure to see those patients more often (with appropriate patient-centric repeat testing), if necessary, to detect progression sooner. Such increased testing, if reliable, increases certainty regarding stability and potential need for initiating treatment or additional treatment.

Term 2: Correlating progression
Based on such additional testing, if there is a significant risk of functional vision loss based on a patient’s younger age/longer residual life expectancy, (i.e., IOP-causing damage, risk factors)¹ and they show correlating structural and functional progression (see “Look for context and correlation,” at bit.ly/OM 2303ContextCorrelation), then we should start treatment. In other words, while “observation is always a choice,”² “A decision to treat may arise when testing confirms progression.”³ (See “Essential Testing for Glaucoma,” left.)

When initiating or increasing treatment, remember to tailor the treatment to the patient. Strive for patient-centric therapy… Treatment that is sufficient, sustainable, and tolerable, while still minimizing the risk of disease progression and functional vision loss. As such, and because we do not want the treatment to be worse than the otherwise asymptomatic disease, and depending on the patient, perhaps a 20% IOP reduction may be sufficient initially.¹   

What would WGA do?
Although we never want to under-diagnose a patient (with associated under-treatment), we also want to prevent over-diagnosis and associated over-treatment. Related to this, the World Glaucoma Association (WGA) states, “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.”⁴ OM

References

1. Gedde SJ, Lind JT, Wright MM, et al. Primary Open-Angle Glaucoma Suspect Preferred Practice Pattern. Ophthalmol. 2021;128(1):P151-P192. doi: 10.1016/j.ophtha.2020.10.023. Epub 2020 Nov 12.
2. Ahmad SS. Glaucoma suspects: A practical approach. Taiwan J Ophthalmol. 2018;8(2):74-81. doi: 10.4103/tjo.tjo_106_17.
3. Chang R, Singh K. Glaucoma Suspect: Diagnosis and Management. Asia-Pacific Journal Of Ophthalmology. January 2016;5(1):32-37. doi: 10.1097/APO.0000000000000173.
4. Weinreb R.W., Araie M, et al. Medical Treatment of Glaucoma: Consensus Series 7.  Kugler Publications.  2010.

DR. LIFFERTH is clinical editor of Optometric Management. He practices at Center for Sight, 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. Email him at glaucomaqd@yahoo.com.