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Approach glaucoma treatment choices with common sense
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I really admire Mrs. B. She’s a remarkable woman of almost 90 years. She has a keen intellect, a tremendous sense of humor and a ton of common sense. She also has a bit of a complicated ocular history.
Her right eye is pseudophakic, 20/400 with atrophic age-related macular degeneration (AMD), while her aphakic left eye manifests less AMD and is 20/40. For years, Mrs. B has worn an extended-wear rigid gas-permeable lens. We see her every 2 months for a brief office visit and contact lens cleaning. We’ve discussed other options – daily wear contact lens or a secondary IOL – but Mrs. B sees no benefit. Common sense prevails.
Recently, Mrs. B was lamenting that her internist insists she have a mammogram. Rallying to her physician’s side, I chimed in “You know Mrs. B, considering the diagnostic benefits and the number of years since you last had one, don’t you think a mammogram is a good idea?” Her response, “At my age, why?” Common sense prevails, again.
Preserving vision
In practice we deal with common sense issues on a daily basis. Especially with respect to glaucoma. On one hand, glaucoma is an insidious disease – never to be taken lightly. For this reason, it is our professional and ethical responsibility to do our best to preserve vision in any glaucoma patient.
On the other hand, we must balance the benefit of any therapeutic regimen with the potential risks, compliance issues and financial burden it places on our patient. More common sense.
It’s in this spirit that we’re seeing an emerging trend in glaucoma management. A trend away from “maximum tolerated medical therapy” and toward “minimum required medical therapy.” Consistent with this trend is a more holistic approach to patient care — an effort to better understand the roles of exercise, diet, lifestyle and supplementation in managing glaucoma.
But let’s not be so naïve. Whereas this trend makes sense, one cannot deny decades of peer-reviewed scientific research supporting time-honored glaucoma prescribing habits. Indeed, the challenge is in balancing the old with the new.
Technology provides balance
The good news is that today’s technology provides us with this balance. We are better equipped to quantitatively “image” optic nerve heads and identify subtle visual field defects, thereby allowing us to more confidently monitor ocular hypertensive patients. Our newer-generation therapeutic agents provide patients with a greater degree of safety and efficacy with less dosing frequency. Furthermore, in those cases where monotherapy is inadequate, we now have a variety of viable combination agents for consideration.
Finally, in the “medically resistant” glaucoma patient the prospect of surgery – argon laser trabeculoplasty, selective laser trabeculoplasty, deep sclerectomy, trabeculectomy and shunts – holds greater promise.
Indeed, with technology comes a tremendous opportunity. An opportunity to no longer consider a patient’s glaucoma therapy as “status quo,” but rather to see if there’s room for improvement — in safety, efficacy, compliance, cost and/or quality of life. In fact, my guess is that most of our patients will think this just makes good sense.