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While at the American Academy of Optometry annual meeting in San Francisco, I attended a 2-hour “Glaucoma Grand Rounds” continuing education (CE) course presented by Drs. Paul Ajamian and Anthony Litwak. While providing great education – and entertainment – these gentlemen captivated us for 2 hours. Two hours that seemed to fly by. Two hours in which we discussed four cases. That’s right, just four cases.
True, it seems impossible to devote an entire 2 hours to just four glaucoma cases, or four cases of anything for that matter. However, when considering the complexity of each case, one understands why. There was the issue of definitive diagnosis, as each patient presented with a convolution of symptoms, risk factors and familial history. Then there was the decision of whether to treat or not to treat. And, if not, for how long could it wait? Finally, there was the dilemma of how to treat.
Beta blockers: treatment mainstay
It didn’t seem that long ago when an elevated intraocular pressure resulted in an immediate prescription for beta blocker drops twice daily. And for good reason. Elevated pressures often mean eventual optic nerve and visual field compromise. Beta blockers have been the mainstay of glaucoma treatment for almost 2 decades, perhaps because, more than for any other reason, we have grown comfortable and complacent with this strategy.
Comfort isn’t such a bad thing. If you do enough of anything – prescribing progressive-addition lenses, fitting contact lenses, performing phacoemulsification – you get pretty good at it. Likewise, if your initial treatment protocol for all glaucoma cases is a beta blocker twice daily, you get a good sense of their clinical worthiness — a sense of what they can do, can’t do and attending pitfalls. Complacency, however, is another story, and with respect to glaucoma it’s just plain dangerous.
Certain glaucoma cases are fairly straightforward, necessitating an almost cookbook approach. Others cases are more complex, from both diagnostic and therapeutic perspectives. For instance, does a slightly elevated intraocular pressure – in the absence of optic nerve compromise, visual field loss, positive risk factors or familial history – warrant indefinite treatment? It appears most patients would rather do without the side effects, hassle and expense of chronic medications, glaucoma treatments included. If intervention is indicated, are eye drops always the most logical initial treatment?
Surgery as first-line treatment
Whereas everyone agrees that trabeculectomy, sclerostomy, drainage implant and cyclocyrotherapy are reserved for recalcitrant cases, there is compelling evidence for argon laser trabeculoplasty as a first-line approach. This is especially true for those with pigmentary dispersion or pseudoexfoliation.
By and large, however, topical agents remain the most logical first choice. The dilemma involves which agent and how often. Many patients do perfectly well on beta blockers, some on a once daily basis! Other patients are better served by newer medications – topical carbonic anhydrase inhibitors, alpha agonists, prostaglandin agents – or a combination thereof. Simply put, there is no universal “glaucoma medication of choice.”
In the final analysis, successful glaucoma management follows three dictums. First, we must have a healthy respect for the insidious, yet destructive nature of this disease. Second, we must be willing to learn, accept and adopt newer treatment protocols. And, finally, we must take a competent, conservative — yet somewhat creative — approach to each patient’s management. I hope that you, like me, will never have your “fill” of glaucoma CE.