How to treat and what’s on the horizon for glaucoma

In the second part of this video series on Glaucoma Awareness Month, Optometry 360 Editorial Advisory Board member Marc Bloomenstein, OD, FAAO, an optometrist in Scottsdale, Arizona, discusses the treatment options for glaucoma.

Question:

What are some of your recommended treatment options for glaucoma, and what patient characteristics determine which treatment you prescribe?

Marc Bloomenstein, OD, FAAO:

Yeah, when we’re talking treatment, obviously we want to try to minimize the treatments to either just one treatment of monotherapy or at best, something that’s going to be very cohesive with our lifestyles.

The biggest challenge I think we have, especially today, is that we’re limited by access. I mean, we live in a world where we have great opportunities and great medical treatments for patients, but they’re limited by how well or how easily they can get it. Medication expenses are a burden, so most patients are going to start on a prostaglandin, whether it be a generic, I try to avoid those. When I’m looking at younger patients, I want to start them off as best as possible on something that’s a monotherapy but that maybe is also going to be a little additive. There’s certain medications that kind of do two things at one time without being specific about them, and more importantly, I also try to go preservative-free. It’s 2025, and right now I think we realize the negative effects that preservatives have and glaucoma patients, more than 50% of them have dry eye associated with that. As every time we add another drop on there with more preservative, we elevate that ocular surface disease. I try to minimize the medications as much as possible and try to go preservative-free as best as possible.

When I’m looking at a patient who has cataracts, I’m thinking MIGS, the minimally invasive glaucoma surgeries, those can bring our patients down. Even patients that have a mild amount of glaucoma where maybe they have a slight elevation in their pressure, we can lower that pressure with patients specifically by using MIGS in and around cataract surgery. Maybe they won’t even have to be on treatment, we could just monitor them. Much like I would do something like selective laser trabeculoplasty, SLTs, to try to get them off drops.

I think my modus operandi is, like I said, to be honestly, as minimally invasive in my treatment options for patients, but look for new opportunities to manage them. One of the things that is kind of exciting to me is thinking about the slow release or the kind of tablets that can be placed in the eye that basically release the medication. We have some of those that have just come out. I think as more come out, as more become affordable, I think that’ll be a benefit for patients.

One of the things that I try to look at too is, for patients that have either normal tension glaucoma, or patients that have secondary glaucomas, it might change the way I look at their treatment, but the goal for me always is, like I said a few minutes ago, is trying to put a treatment that is going to be synergistic with a patient’s lifestyle, because I think sometimes it’s easy for us to sit there and say, “Well, you need to do this,” and yet it is just not opportunistic. Trying to find something that’s going to benefit a patient.

Question:

What are some recent advancements or things on the horizon that you think are important to highlight regarding glaucoma?

Marc Bloomenstein, OD, FAAO:

Actually, it’s interesting, as I was rolling into this, The Glaucoma Society had their meeting recently, and so I reached out to a few of the members there to ask them what they’re excited about, to see if it’s kind of something I would be excited about. I think first and foremost is, like I said before, is making things more seamless for patients.

For example, during COVID, we were kind of lucky during the pandemic shutdown, we had some virtual reality visual field tests that were just coming to market. Being able to do a visual field outside of the practice, like any place that you had WiFi, we could do it because it went up into the cloud. I think being able to do at-home visual fields is something that’s going to be coming. More virtual reality, visual field testing is going to be coming.

But along those same lines is, as much as I think most of us are a little apprehensive of AI, the technology that AI is bringing and has already kind of started a little bit before with telemedicine, being able to interpret retinal photos better than we can. Being able to interpret OCTs, being able to look at visual field and kind of draw out some relative risk factors associated that. AI is on, I think, that’s something we’re going to probably see in the next few months some of that technology.

Genetics is something else that’s coming around. We’re seeing more genomic capabilities to make personalized treatments, and I think that’s really, really critical, because we can’t treat this disease. All we can do is kind of manage it and keep it at bay. If we could fine tune the treatment specific for each patient, I think it’s going to be a big deal.

Something else I think that’s also kind of important or kind of cool, is that we’re going to get reimbursed for OCTA, so for the angiogram OCTs, which are new and kind of more creative ways of seeing the perfusion and blood flow. Being able to get compensated for that.

One other thing that I think that’s kind of coming out that’s going to be, you asked me about treatment, is there’s a device that basically works to create a negative pressure on the eye through these goggles. It just got FDA-approved, or I believe sometime this year we’re going to see it, it’s from Balance Therapeutics. What it does is these goggles that patients sleep in and it’s attached to a little monitor and it monitors the negative pressure. By creating a negative pressure, then you’re not inducing a higher ocular pressure, and that’s when most of the challenge is, at nighttime. This benefits patients that have low tension glaucoma. Although it’s not a huge percentage of the patients that have it, but they’re the most challenging to kind of manage because their pressure is low. What are we doing? We’re trying to make it lower. Some of those things are the things that I probably tell you that I’m kind of excited about.

Again, anything that I can do or any information I can give patients to kind of help them. Having, like I said, that AI, having that, better interpretations, I think it just makes us better as clinicians and it’s better for the public.