Savak Sev Teymoorian, MD, MBA

Over the last 10 to 15 years, procedures such as LASIK and intravitreal injections have started to change patient perception on ophthalmic care. There is now growing acceptance for patients to not only have more “aggressive” therapy used in their care but also to do so at an earlier stage. This allows physicians the opportunity to talk about treatment options that may truly benefit patients without the concern that it will be simply deferred by patients because it sounds too invasive. One area in which this change in perception is making a difference is the use of selective laser trabeculoplasty in glaucoma. This is especially important for providers and patients because SLT can be used throughout the entire spectrum of glaucoma care with low risk.

Whether ophthalmologists are ready or not, there will be a large increase in the number of glaucoma patients in the near future. There are two major factors driving this fact. First, the average length of time glaucoma patients need to be treated is expanding because they are being diagnosed earlier yet living longer. Second, the number of older patients, representing the subclass most likely to develop glaucoma, is increasing as baby boomers are entering that age category. Someone will need to help with this drastic need for care that can’t be sustained with our current level of glaucoma specialists. The centerpiece of this will involve how these patients will be cared for surgically. The natural source of aid will come from anterior segment surgeons, given that they already perform cataract surgery.

Within the last few years, there has been significant innovation in the field of glaucoma care. What is currently available, along with the products working their way through the pipeline, offers hope to ophthalmologists and our patients for better glaucoma care. One area of therapy that is taking form involves new drug delivery systems. A unique category of treatment in this space includes those that provide medication in a sustained-released fashion but located outside of the eye. I refer to this class of medications as “AMPED,” standing for alternative method, pressure-lowering, extraocular depots.

This rapidly progressing era of glaucoma treatment is exposing providers to new medical and surgical options for patient care. However, sometimes improvement of older surgical procedures can provide alternative solutions that can be just as successful.

Just like in life, the old saying of “when it rains, it pours” exists in cataract surgery. It is not uncommon when planning on how to perform cataract extraction in a patient with a dense lens that we also encounter other complicating factors. These include smaller pupils that poorly dilate even with pharmacological and mechanical means of stretching, adhere to the anterior capsule of the lens with posterior synechiae and/or demonstrate floppy iris syndrome. To further increase the level of difficulty, these types of cataracts are seen in patients with weak or loose zonules of the lens and delicate endothelium of the cornea.

The landscape of glaucoma therapy, in particular surgical, is rapidly changing. It was not that long ago we were introduced to the Glaukos iStent for use as a MIGS. Now with the iStent taking a position in the foreground of surgeons and their practice of patient care, our focus will soon be turning to the next wave of products in the pipeline for minimally invasive surgery. One of the most valuable pearls I learned during my business training is that successful people are able to look at the horizon in the landscape they work in to see what the environment will be like in order to position themselves in that setting.

The forces controlling how medicine is practiced are pushing doctors to see more patients in less time. Compounding this time crunch is the growing pool of information that needs to be discussed between the patient and the entire health care staff. There are two solutions to this problem. First, providers can increase the number of work hours while keeping patient volume the same in order to create more time for each encounter. The reality, though, is that time is a limited resource, and there is only so much that can be delegated to non-physician staff. The second option involves thinking outside the box to find a more efficient use of time between doctors and patients. This can be done by separating when the time is spent from both sides for this interaction by not requiring this time to occur at the same period temporally. Fortunately, the ability to do this is not just a theory but can be achieved with current technology.

In the past, treatment for glaucoma involved two main options. It trended from the use of eye drops until the disease was not controlled through medical means, which led to surgical interventions. Patients would be started with prostaglandin analogues with a stepwise addition of various adjunctive therapy that ultimately converted to trabeculectomy or tube shunt surgery later in life. Somewhere along the way, laser trabeculoplasty may have been attempted.

With no cure for glaucoma, the goal in caring for these patients is to have good, functional vision at the end of life. Providers spend so much time treating glaucoma patients with the belief that they will be living for many more years or decades that when we are presented with a patient near the end of life, we have difficulty changing gears. In fact, sometimes we may have trouble recognizing this change in patient goals — going from an aggressive treatment course aimed at preserving vision to one that focuses on maximizing the patient’s quality of life.

The more the scientific community tries to understand glaucoma, the only fact that gets clearer is that it is more complicated than we thought. The hope of all this work is to one day better understand the underlying process in order to either prevent or minimize the effects of the disease process. However, the main question for providers of care today is the same: What can we do to treat our patients?