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An exciting, and potentially confusing, time for glaucoma management
We’ve all been there before. A long term, satisfied patient asks if you’ll see his or her parent who has glaucoma. You gladly agree, and upon initial consultation you find that the parent is taking a beta-blocker and that the intraocular pressure (IOP) readings are 25 mm Hg OU. Even though you know that an isolated IOP does not constitute a treatment failure, you can’t help but to think about your next therapeutic move.
Even though you’ll review the patient’s history for risk factors, stereoscopically assess the optic nerve head, perform gonioscopy, perform a threshold visual field and get a few more IOP readings before you do anything, you still can’t help but contemplate your next therapeutic move. And for good reason. Even though we’re currently challenging the very core of glaucoma – its pathogenesis, diagnostic criteria and treatment protocols – we still strive for lower IOPs.
So many choices
The reality is that the next step in glaucoma management is not as automatic as it once was. In the case of the aforementioned patient, one might consider switching to another beta-blocker: one with early morning dosing. Another viable approach would be to just add a second agent.
The dilemma here lies in selecting the appropriate agent – alpha-agonist, topical carbonic anhydrase inhibitor or prostaglandin agent. In fact, in this approach it might make more sense to simply choose from the variety of exceptional combination drugs available today. Of course, the final strategy would be to simply discontinue the beta-blocker and prescribe a different class of agent as an alternate monotherapy approach. And if this doesn’t prove effective, we can always consider adding a second drug (here we go again).
An exciting time
There is no doubt that this is an exciting time in glaucoma management. With so many new diagnostic technologies and therapeutic agents, our patients’ prognosis is greatly improved. However, it’s also an equally confusing time in glaucoma care. Confusing in the sense that as the time-honored “beta-blocker b.i.d.” regime is challenged, no specifically defined treatment algorithm has taken its place. This is understandably so, as we know that glaucoma will never be a simple disease with a simple solution.
Our selection of an appropriate treatment protocol will always balance a drug’s systemic risk factors and potential side effects with the agent’s mechanism of action, efficacy, likelihood for compliance and cost. As clinicians, our job is to thoroughly understand each agent: a goal attained only through ongoing education and implementation.
So the next time you contemplate a therapeutic change, think carefully and consider each option. Always grant yourself the poetic license to challenge conventional wisdom, but always be sure your prescribing efforts are well grounded. After all, it’s ultimately this thought process that makes us better clinicians and best serves our patients’ needs.