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Practitioners still consider drug therapy as first-line glaucoma choice
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--- Murray Fingeret, OD
NEW YORK—Recent research has indicated that argon laser trabeculoplasty (ALT) is as safe and effective as beta-blockers for first-line treatment of glaucoma, but old habits die hard and glaucoma regimens have not reflected this, said Murray Fingeret, OD. However, practitioners are generally becoming more aggressive in employing ALT, and many are placing it higher in their treatment regimen.
Fingeret, a glaucoma practitioner here, said while the Glaucoma Laser Trial Study and its follow-up study (the follow-up study was published in December's American Journal of Ophthalmology gave solid evidence that ALT is as safe as medications for first-line treatment of glaucoma, his experience is that practitioners have been slow to react.
"Right now very few ophthalmologists, at least in the New York area, are performing ALT as the initial modality," he said. "There is evidence that gives them a way to justify this, but most ophthalmologists are being conservative."
ALT used earlier
However, he said, "The twist is that practitioners are being more aggressive in using ALT as a second- or third-line modality, much sooner than they ever did before. Now when one medication doesn't work, intraocular pressure (IOP) starts to rise or the patient doesn't respond, then ALT will be used quicker than in the past."
Fingeret said there are several reasons for the reluctance to make ALT the first-line treatment: the concern that the effects of the procedure do not last indefinitely, entrenched practice behaviors and the potential risks of any surgery.
He said some practitioners also are concerned about possible long-term effects of ALT, "even though the data from the study extended over 8 years."
Also, the procedure does work better in certain glaucomas than others, particularly pseudoexfoliation or pigmentary glaucoma.
Fingeret said his own general practice patterns are starting to change. He does not recommend ALT initially, but, he said, "I am being much more aggressive about recommending it when it appears the patient is noncompliant or runs into side effects. If the patient is noncompliant, I'll usually try an alternative medication, and if there's a problem with the alternative medication then I'll refer for ALT. I am clearly becoming more aggressive in considering ALT rather than going through the litany of medications."
Fingeret's glaucoma regimen usually begins with a beta-blocker. "I make a decision about a beta-blocker based upon two things," he said. "One, the severity of the glaucoma and how much I need to reduce the pressure and, two, the safety profile I want from the medication."
Conflicting treatment goals
Sometimes these goals can conflict, he pointed out. "If I need a home run, a 25%-28% pressure drop and the patient's health is not an issue at all, I'll go with a nonselective beta-blocker. If I need a medication that has a better safety profile or I don't need as huge an IOP reduction I'll go with Betoptic (betaxolol HCl, Alcon)."
Fingeret said it is likely ALT will get increasingly more first-line use in the future. "I think if we have this discussion a year from now," he said, "you will see ALT slowly evolve. It will never be the standard way to treat glaucoma initially, but more and more people will use it earlier."
Latanoprost may change things
However, the emergence of the topical prostaglandin latanoprost (Xalatan, Pharmacia & Upjohn) may again rearrange the glaucoma equation. (Latanoprost has recently been approved by the FDA and should be available by late summer.)
"Latanoprost, I believe, will become a significant player, because it appears to be so safe and effective," he said. "It will be a major player as people become accustomed to it, and if there are no surprises. That may again put ALT down a notch in the glaucoma model of care."
Fingeret said the model for glaucoma therapy is clearly changing, which reflects the individualized approach that glaucoma treatment demands. "You're seeing the entire way people add medications changing," he said. "It's very individualized; if you talk to 10 people, there are 10 different ways to do it."