Defer to clinical judgment when glaucoma study recommendations vary

NEW ORLEANS – A patient with a pressure of 21 mm Hg would have a 12%, 4% or 30% risk of visual field loss according to the Collaborative Normal Tension Glaucoma study, Collaborative Initial Glaucoma Treatment Study and Early Management Glaucoma Trial results, respectively, said a presenter here at the Optometric Glaucoma Society meeting.

“Do the studies really apply to our patients? Here’s where your clinical judgment comes in,” Jonathan Myers, MD, of Wills Eye Institute, told attendees at the society’s conference, held prior to the American Academy of Optometry meeting.

Myers shared his recommendations for managing glaucoma suspects and patients with glaucoma.

Low-risk glaucoma suspects do not need treatment, but they do need observation, he said. “If they stay in the system, they will probably be OK.”

A high-risk glaucoma patient needs frequent monitoring, and the patient must consider if they want treatment, Myers said.

“Once you have clinical progression, we have a different scenario,” he said.

Ask patients what they do on the weekends. “Pinochle? Skydiving? They carry different levels of risk,” he said. “Once I see clinical progression, the optic nerve is telling me it knows how to go blind.”

Myers said his treatment strategy is “getting much simpler.”

“We’ll start with a prostaglandin unless contraindicated,” he said. “Second-line therapy is laser trabeculoplasty or a second medication. A lot of clinicians start with a prostaglandin, and if pressure isn’t substantially reduced, they’ll throw on a combination agent. Patients only come back a certain number of times. They want effective care. We lose something when we go to combination agents right away; sometimes we get to the end of the story quicker.

“If the patient is on a prostaglandin and a combination agent, and the pressure is 23 mm Hg, we have reached a logical conclusion,” he added. “We should have a three-bottle maximum (they don’t use them all).”

Myers said he performs many microincisional glaucoma surgeries.

“The iStent (Glaukos) is dramatically less risky than a trabeculectomy, but it’s also less effective,” he said. “Talk to the patient. See if they’re OK coming back if necessary or if they want it all fixed now.”

Myers said he is a “big fan” of the iStent, but “the worse the disease, the less well it works.”

He said therapy choices must be balanced by severity, rate of progression, systemic health and estimated life span.

“Discuss this with the patient,” he said. “If the patient is not along for the ride, we’ll have complications down the road.”

There are three types of glaucoma patients, Myers said: “Those who have iron nerves and won’t get worse, a second group who can go either way, and a third group that gets worse no matter what I do. I don’t mind observing as long as the patient is content with the risk. However, if they have field loss, I get concerned.” – by Nancy Hemphill, ELS, FAAO

Disclosure: Myers has served as a consultant or speaker for Alcon, Allergan, Inotek and Sucampo. He has received research support from Alcon, Allergan, Diopsys, Glaukos and Merck.