Embrace uncertainty to prevent overtreatment in glaucoma
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CHICAGO — Mitigating overtreatment in glaucoma requires a willingness to wait to treat patients, which can be cultivated by embracing the uncertainty of common glaucoma measurements, according to a speaker here.
“We overtreat because we’re worried about what is going to happen to patients,” Pradeep Y. Ramulu, MD, MHS, PhD, of Wilmer Eye Institute, said during the American Glaucoma Society Subspecialty Day Lecture at Glaucoma Subspecialty Day at the American Academy of Ophthalmology meeting. “And we also overtreat because we think that things are happening which may or may not be happening based on the measurements that we derive.”
Image: Anthony DeFino | Healio
A key step is to understand the uncertainty of glaucoma measurements and decide whether to approach with an interventional treatment mindset or a wait and monitor mindset. For example, it is uncommon for patients with preperimetric glaucoma to experience functional impairment, while those with normal-tension glaucoma rarely experience progression before the age of 68 years, according to Ramulu.
“If you have a patient who fits into this low likelihood of worsening category and their diagnosis is uncertain and they’re probably not very affected by disease, why are you treating them?” he said.
Ophthalmologists must look at the combination of IOP, imaging results and patient symptoms to determine whether symptoms are worsening.
“If you have somebody who may be worse in their visual field but everything else is well controlled, I think you can oftentimes, if they’re very well controlled and have a long history of being controlled, just keep interval follow-up, or you may want to repeat testing sooner,” Ramulu said.
For high-risk patients, Ramulu recommended clustered visual field testing compared with evenly spaced follow-ups as a more accurate means of assessing visual field changes due to a reduced likelihood of false positives. He also emphasized the need to improve communication with patients, noting that symptoms are “the patient’s truth,” which may impact how they feel about undergoing a more aggressive treatment regimen.
Questionnaires may help ophthalmologists target different domains that affect the patient but are not discussed at each visit due to time constraints.
“The better we understand uncertainty and the better we learn how to deal with it, the more we can save ourselves for those who really need our help,” Ramulu said.
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Ramulu PY. The unknowable truths of glaucoma: Dealing with uncertainty in clinical practice. Presented at: American Academy of Ophthalmology meeting; Oct. 18-21, 2024; Chicago.
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