High POAG risk informs treatment for African American patients
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In my first year at a primary care and specialty referral practice in Memphis, Tennessee, I have treated patients at every stage of glaucoma.
Our patients come from Tennessee, Mississippi and Arkansas, all of which have above-average rates of diabetes, hypertension and heart disease, so it is common for us to see complex cases with diabetic eye disease or central retinal vein occlusion as well as primary open-angle glaucoma (POAG).
Source: Osemelu Aburime, MD
About 75% of our patients are African American, facing a four to five times higher rate of POAG, faster progression of glaucoma and thinner corneas compared with people of European descent. When we add these risks for African American patients to the medication compliance challenges faced by virtually all patients with glaucoma (inconvenience, dementia, financial hardship), treating POAG takes on added urgency. We need to intervene and treat POAG aggressively before their visual fields deteriorate.
Evaluating the best treatment options
To determine the best treatment for patients with POAG, we need to evaluate their disease state and progression by looking at their history, IOP and visual fields. It is especially important to move quickly and aggressively for African American patients, whose condition can go downhill quickly. I saw this firsthand when my patients had major changes in visual fields as a result of deferred care during COVID lockdowns.
Both medications and minimally invasive glaucoma surgery can be effective in maintaining target pressures. If a patient is newly diagnosed with glaucoma or has been successfully managed with medication, I offer drops as an option, combined with careful, routine follow-up to ensure the patient is compliant and there is no progression. I explain that if drops do not work or if they find them difficult to use, then we have other options.
My choice of medication depends on the patient, but I like to keep things simple, so I start with a single agent, usually a prostaglandin analogue such as latanoprost, Lumigan (bimatoprost ophthalmic solution 0.01%, Allergan) or Vyzulta (latanoprostene bunod ophthalmic solution 0.024%, Bausch + Lomb). For some individuals, I choose Rhopressa (netarsudil ophthalmic solution 0.02%, Alcon/Aerie) from the newer class of medications called Rho kinase inhibitors. As a second-line choice, I am a fan of combination medications, such as dorzolamide and timolol, brimonidine and timolol, or netarsudil and latanoprost. For patients with cardiac issues or pulmonary issues, we need to be careful about prescribing beta-blockers, so I always consider a combination of brinzolamide and brimonidine.
In cases in which medications and/or previous surgeries have been ineffective, I recommend surgery. I also turn to MIGS when patients have barriers to compliance, such as dementia/forgetfulness, ocular surface toxicity, difficulty using the eye dropper or frustration with eye drops. If they need cataract surgery, we have several options for MIGS, including Hydrus (Ivantis), iStent (Glaukos) and the Xen gel stent (Allergan).
For my younger or pseudophakic patients, ab externo use of Xen allows me to reliably reduce IOP by about 40%. In addition, in complex cases with scarring from previous surgery, in which there may not be a lot of real estate for another procedure, Xen has the advantage of not taking up a lot of space and giving me flexibility for placement. I can do some needling to rejuvenate problem areas and still find a nice unscarred area to implant Xen. I explain to patients that Xen will allow them to reduce their medications, and in many cases, they can stop medication completely. They are usually happy about the possibility of that happening with a minimally invasive procedure.
Xen procedure in African American patients
I use an ab externo approach to implanting Xen because it gives me better visualization than ab interno delivery, so I know I am not in Tenon’s from the start. The procedure is straightforward. To begin, I grab the conjunctiva and make sure it is separate from Tenon’s. Then, with tip of the Xen injector, I enter 7 mm to 8 mm from the target location, lifting the conjunctiva back a little bit and delicately performing a light side-to-side motion, avoiding the Tenon’s (Figure 1). I insert Xen into the subconjunctival space and remove the injector (Figure 2).
To reduce postoperative inflammation and scarring, I apply 0.4 µg of mitomycin C and inject 20 mg of Kenalog (triamcinolone acetate, Bristol-Myers Squibb). Patients go home with an antibiotic drop, which they use for a week, and a tapered 1-week course of a steroid (difluprednate or prednisolone, or loteprednol for obvious steroid responders). I see patients back at 1 day, 1 week, 1 month and 3 months, and then at 6 to 8 months depending on their status at month 3.
To minimize complications, it is important to keep in mind that African American patients have a higher risk for rebound inflammation after ocular surgery. The injected steroid and 1 week of topical steroid usually control inflammation, but I follow patients carefully when we taper the steroid and advise them to alert me about any light sensitivity or discomfort. If they have rebound inflammation, I want to get them back on a topical steroid quickly.
After the Xen procedure, my patients’ day 1 pressures are usually 8 mm Hg to 12 mm Hg, allowing them to stop all glaucoma drops. In a population at high risk for progression, this is a significant move toward averting vision loss as well as a major improvement in their quality of life.
- References:
- Diabetes and obesity maps. https://www.cdc.gov/diabetes/data/center/slides.html. Updated Sept. 30, 2022. Accessed Oct. 19, 2022.
- Interactive atlas of heart disease and stroke. https://nccd.cdc.gov/DHDSPAtlas/Default.aspx. Accessed Oct. 19, 2022.
- Khachatryan N, et al. Am J Ophthalmol. 2015;doi:10.1016/j.ajo.2015.01.011.
- LaMattina KC. Racial and ethnic disparities in rates of rebound iritis after uncomplicated cataract surgery. Presented at: Association for Research in Vision and Ophthalmology annual meeting; June 12, 2020 (virtual meeting).
- Reddy AK, et al. Am J Ophthalmol. 2019;doi:10.1016/j.ajo.2019.02.016.
- Tan NE, et al. Clin Ophthalmol. 2021;doi:10.2147/OPTH.S292007.
- For more information:
- Osemelu Aburime, MD, can be reached at Eye Specialty Group, 5350 Poplar Ave., Suite 950, Memphis, TN 38119; email: oaburime@gmail.com.
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