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Glaucoma: a challenge of new technology, procedures, therapeutics, philosophies
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It used to be relatively easy. Only if the pressure was high was it glaucoma. And if it was glaucoma you lowered the pressure. The diagnosis was fairly straightforward, and with only a few therapeutic agents treatment wasn’t that complicated. Indeed, it was relatively easy. Easy, but not always correct.
Today, glaucoma is one of the most perplexing entities encountered in clinical eye care practice. From a diagnostic standpoint, intraocular pressures (IOPs) no longer reign supreme, as a fair number of glaucoma patients never present with pressures above 20 mm Hg. And optic nerve evaluation is more sophisticated. We no longer just look for an enlarged cup to disc with the direct ophthalmoscope. Instead, we use 60-D, 78-D or 90-D lenses to stereoscopically scrutinize cup contour and neuroretinal rim.
From a perimetry perspective, we no longer rely on late-stage defects to make the diagnosis. Instead, today’s perimeters provide a tremendous amount of information from which to make an early diagnosis. Unfortunately, given the subjective nature of patient-driven perimetry, the challenge lies in extracting consistent and reliable data to formulate a sound therapeutic plan.
With respect to treatment, our decisions are equally challenging. As the newer drugs have been available for a few years, treatment protocols are being reprioritized. In certain cases, alpha agonists and prostaglandin agents have replaced beta-blockers as first-line therapy, and topical carbonic anhydrase inhibitors have found a solid niche as a second-line therapy.
Surgically, we better understand the indications for laser trabeculoplasty and various filtration procedures. Unfortunately, the choices don’t stop there. Nd:YAG laser-selective trabeculoplasty appears to be a viable alternative to the time-honored argon laser. And deep sclerotomy with collagen implant may eventually rival mitomycin trabeculectomy with respect to efficacy, while enhancing safety.
Finally, glaucoma may be yet another disease in which nontraditional therapy plays a small — yet noteworthy — role. Certainly, smoking, poor dietary habits and a sedentary lifestyle are counterproductive to ocular health in general and may well be to glaucoma in particular. In this respect, it appears as though one’s general well-being can affect glaucoma and its management. Ultimately, a well-balanced diet, appropriate supplementation and regular exercise may benefit glaucoma patients.
Of course, I don’t mean to portray glaucoma as a conundrum of complex and unanswerable issues. However, it’s imperative we no longer perceive glaucoma as a simple issue of structure (compromised trabecular outflow) and function (elevated IOP compressing the optic nerve).
Instead, it’s essential that we view glaucoma as a disease in which there are also vascular (optic nerve perfusion) and neurologic (retinal ganglion cell neuroprotection) implications. Interestingly enough, it’s this ever-changing landscape that challenges, stimulates the intellect and ultimately results in better patient care.