4 big questions in glaucoma care
Daniel Epshtein, OD, of the SUNY College of Optometry, spoke with Optometry 360 about his recent presentation at the American Academy of Optometry 2025 Annual Meeting. He outlines 4 controversies that need to be address in glaucoma care.
Daniel Epshtein, OD:
Hello. My name is Dan Epshtein. I’m an optometrist, associate clinical professor at the SUNY College of Optometry. I was lucky enough to be invited to speak at the American Academy of Optometry 2025 in Boston, which is not too far away from my home here in New York. It’s always nice to be able to take a train straight there instead of flying. My session was on controversies in glaucoma where, me and my co-lecturer, Dr. Anu Laul, we spoke about four different questions in glaucoma. They’re not really true controversies, but, really, they’re these things that just have a lot of gray areas. It’s not black-and-white questions there, and it’s things that have come up in our regular day-to-day clinical practice between me and Dr. Laul.
We had 4 questions that we tried to answer or at least try to give some more information and data evidence about. The first one was are disc hemorrhages true signs of glaucoma’s damage and progression or are they simply just risk factors for glaucoma? Number 2, does OCT angiography have a role in the clinical management of glaucoma patients and glaucoma suspects? Number 3, is myopia a confounding factor or is it a significant risk factor for glaucoma? Number 4, should we be using non-IOP treatments such as lifestyle changes, supplementation in the management of our glaucoma patients?
For the first one, the disc hemorrhages, really, there’s a lot of gray area in this one that we really didn’t give much answers to this, but what we do know about disc hemorrhages is that, number 1, they’re relatively rare events in our glaucoma patients, in our glaucoma suspects. We know it happens in normal patients as well and that it’s sometimes very difficult to pick up on our clinical examination. In fact, in many studies, the use of fundus photography picks up many more of these disc hemorrhages than it’s able to be detected clinically. We do know this happens in all types of patients and that we really have to scrutinize the optic nerve head on every single visit, whether it’s a dilated examination or an undilated examination. We probably should be using fundus photography more often in our glaucoma suspects and glaucoma patients to detect disc hemorrhages.
In terms of risks or is it an actual sign of glaucoma damage, well, I think the jury is still out on that one. But, at bare minimum, it’s a very significant risk factor that, if you do detect it in your patient, it warrants a full glaucoma workup and close monitoring for years to come. In terms of OCT angiography, I think the preponderance of literature out there kind of tells us that OCT angiography is not really ready for prime time for their clinical use in glaucoma management. The main reason why is not because there’s no clinical utility there. It does seem to have a great relationship in terms of OCT angiography measurement of vessel density as they relate to visual function and, of course, the use of OCT angiography in progression. We can check for progression with OCT angiography probably even more readily in the more advanced stages of glaucoma with OCT angiography than with structural RNFL thickness measurements.
But the main reason keeping us away from prime time is the fact that we still have to answer are OCT angiography changes happening before, during or after structural changes to the peripapillary retinal nerve fiber layer that we pick up with OCT that we all use day-to-day in clinic? Until we answer that question, it’s really going to be hard to say is this just an adjunctive measurement for our structural changes or really should we use it as more of a primary role in the assessment of glaucoma patients and glaucoma suspects.
In terms of myopia and glaucoma, we know, at bare minimum, it’s a significant confounding factor. It affects our visual fields. It affects our OCTs. It affects our clinical examination of the optic nerve head and peripapillary space. We probably think, I say probably because the literature is a little bit wishy-washy sometimes on this is that, patients that are more myopic than maybe a -6 or -8, those patients most likely have a higher risk for developing glaucoma, but we still know exactly why. The theory is there’s probably some shared biomechanical risk factors there. But, until we answer that question, it’s really hard to say whether 100% myopia is a significant risk factor for glaucoma.
Our last question was should we be using non-IOP treatments in the management of our glaucoma patients? There’s a lot of literature out there, and a lot of it kind of goes back and forth. It’s unfortunate because our patients are always asking us what else can I do other than take medications, get surgery or do a laser procedure? At this time, we have no great answers because the literature goes back and forth of what’s useful, what’s not useful. We really do need better evidence. We need large, randomized clinical controlled trials to really detect if there’s significant improvement in glaucoma management using some of these lifestyle changes like breathing exercises, yoga, meditation or using supplementation like AREDS formula or nicotinamide type of medications, or supplementation I should say.
We do know that we should be looking at the horizon. We do want to help our patients as much as we can, so we should all keep up with the literature because many people are doing research in this area. Hopefully, even though we might not have given our attendees too many answers, hopefully it spurs one of them or many of them to do some research on their own and to come back with us and give us some more answers so we can all help our glaucoma patients in the future.
