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Consider offering laser surgery as initial glaucoma treatment
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Surgery could be offered as a first-line therapy for glaucoma to patients who are not able to comply with the often expensive medications, according to practitioners.
“Some individuals cannot afford eye drops or live by themselves and are unable to successfully administer eye drops because they have poor manual dexterity,” Alan L.. Robin, MD, told Primary Care Optometry News in an interview. “The preferred practice patterns of the American Academy of Ophthalmology say that every new patient diagnosed with glaucoma should be given the option of medical, laser or surgical therapy, if appropriate, for their glaucoma. When doing that, the issues that exist are the state of disease, the patient’s ability to have one of the therapies and the patient’s quality of life.”
Dr. Robin, a PCON Editorial Board member who practices in Baltimore, said between 5% and 10% of his patients, when given the option now, would rather have surgery than endure a lifetime of drops.
More options available
Surgeries, including the more recent selective laser trabeculoplasty (SLT) and the more established argon laser trabeculoplasty, help lower IOP with minimal invasion. Trabeculoplasty may be repeatable, although good long-term studies are not currently compelling, according to Dr. Robin.
Trabeculectomy, a filtration procedure where an opening is created to allow the aqueous humor to flow out of the eye, is another option. If that fails, due to scarring, surgeons may opt to perform a tube-shunt, which involves placing a tube and drainage pouch in the eye.
Thomas W. Samuelson, MD, who practices in Minneapolis, said his glaucoma patients opt for laser surgery as an initial therapy about 20% of the time. That number appears to be growing, he said.
“We are at the point where offering laser as an alternative to medicines as initial therapy is quite reasonable,” Dr. Samuelson told PCON in an interview. “There’s adequate data to support that laser trabeculoplasty is as good an initial therapy as medicines, and it takes compliance out of the picture. Laser would be the only procedure that I am aware of right now that would have adequate safety and efficacy balance that could compete with one-drug therapy.”
PCON Editorial Board member Jerome Sherman, OD, FAAO, said all of the patients at the Eye Institute and Laser Center in New York who are diagnosed with glaucoma for the first time are given the option of taking the eye drops or having the SLT procedure performed.
“We estimate that well over half of our ‘virgin’ glaucoma patients choose SLT,” Dr. Sherman told PCON.
He said that one drawback to the procedure is a potential IOP spike. “The spike is not typical, rarely a problem and is due to the inflammatory reaction in the anterior segment to the laser,” he said. “When it does happen, it can be controlled with steroid drops.
“However, it is generally believed that the inflammatory reaction is beneficial,” Dr. Sherman continued, “because SLT works by inducing phagocytes that presumably ‘eat’ debris in the trabecular meshwork. Routine use of strong topical steroids in every case following SLT may cancel, to some extent, the beneficial outcome.”
Factors to consider
Several factors might lead a practitioner to consider laser trabeculoplasty as a first-line treatment for glaucoma.
The patient is incapable of administering the drops. Dr. Robin and his colleagues just completed a study in which they videotaped experienced glaucoma patients putting drops into their eyes. Twenty percent of those patients were unable to get a drop in their eye, even though 93% of them said that they had done a perfectly good job of doing so.
The patient is unable to tolerate the medication, either systemically or because of cosmetic concerns. A curious side effect of taking prostaglandin analogs is that in 10% of cases it changes the color of a patient’s iris. Many patients, when told this, ask about alternative therapies, Dr. Robin said. Patients who have had heart failure or asthma also might not be good candidates for topical beta-blocker therapy, depending on their daily drug regimen.
The patient regards the stringent drop regimen as a “hassle.” “Some patients are already on multiple medicines and can’t remember to take eye drops,” Dr. Robin said. “They’re too busy. It’s not something they want to do, and you have to respect that.”
The patient cannot afford the extra expense. Cost has been a sticking point for many glaucoma patients, especially when it is difficult to perceive the benefits of the costly IOP lowering drops, according to Joseph Sowka, OD, of Nova Southeastern University.
“Glaucoma is a chronic disease with very few symptoms, and the medicines, if they make the patient feel anything different, it’s usually worse,” he said in an interview. “The patient usually never perceives a benefit from the medicines other than the doctor stressing how well they’re doing or the doctor’s pleasure with their therapy. They have no intrinsic value from treatment.”
Not always the final option
Dr. Sowka said that he first makes sure that patients understand the risks of surgery and set their expectations accordingly.
“People equate surgery as being definitive,” he said. “I have to explain that any surgical procedure is strictly to lower IOP, not to cure the disease. They still are obligated to maintain the same follow-up schedule. They still must be doing visual fields and disc photography yearly and they may end up back on medicines.
On the horizon
Several glaucoma procedures to lower IOP are currently being tested in clinical trials, Dr. Samuelson said. Researchers are studying alternative ways to augment the outflow of the aqueous, which traditionally has flowed through the sclera.
“New techniques being developed are quick, easy to do, relatively safe – if they work – and are being designed for individuals as a primary therapy because we realize the problems with medicine,” Dr. Robin said. “As more surgical techniques become available that offer the same kind of results now but with fewer complications, we will see more and more individuals who would like to have surgery rather than medical therapy.
Dr. Samuelson agreed and remains cautiously optimistic.
“There is hope that we will find a procedure with good enough efficacy and safety that glaucoma can become a surgical disease,” Dr. Samuelson said. “We are not there just yet, but I believe we have reason to be optimistic indeed.”
Dr. Samuelson is particularly hopeful about canaloplasty with suture stent. “A microcatheter is used to visco-dilate the entire 360· Schlemm’s canal and facilitate outflow via conventional outflow pathways,” he said. “A suture is used to put the meshwork on stretch, further enhancing outflow facility. The 18-month data has been published and looks promising.”
For more information:
- Alan L. Robin, MD, can be reached at 6115 Falls Rd., Ste. 333, Baltimore, MD 21209-2226; (410) 377-2422; fax: (410) 377-7960; e-mail: arobin@glaucomaexpert.com.
- Thomas W. Samuelson, MD, can be reached at Minnesota Eye Consultants, 710 E. 24th St., Suite 106, Minneapolis, MN 55404; 612-813-3600; fax: (612) 813-3636; e-mail: twsamuelson@mneye.com.
- Jerome Sherman, OD, FAAO, can be reached at SUNY College of Optometry, 33 West 42nd St., New York, NY 10306; (212) 938-5862; fax: (212) 780-4980; e-mail: jsherman@sunyopt.edu.
- Joseph Sowka, OD, can be reached at Nova Southeastern University, 3200 South University Drive, Ft. Lauderdale, FL 33328; (954) 262-1472; e-mail: jsowka@nova.edu.
Reference:
- McIlraith I, Strasfeld M, Colev G, Hutnik CM. Selective laser trabeculoplasty as initial and adjunctive treatment for open-angle glaucoma. J Glaucoma. 2006;15(2):124-130.