Diagnostics, evaluations, and treatment algorithms for patients with glaucoma
In part 1 of a 4-part panel discussion, optometrists Drs. Schweitzer, Bloomenstein, Dunbar, and Ibach discuss their best practices for diagnosing and treating glaucoma.
Justin Schweitzer, OD:
Well, hello everyone. My name is Justin Schweitzer, an optometrist at Vance Thompson Vision, and welcome to this Glaucoma Roundtable event brought to you by Optometry 360. I’m really excited to be joined by 3 of my good friends, colleagues, Dr. Marc Bloomenstein, Dr. Mark Dunbar, and Dr. Mitch Ibach. Gentlemen, thank you so much for joining me and really looking forward to our discussion here today. I’d love it if you just briefly could introduce yourselves to our viewers. Mitch, we’ll go ahead and start with you.
Mitch Ibach, OD:
I’m Mitch Ibach, I practice at Vance Thompson Vision in Sioux Falls, South Dakota. We’re an OD/MD Tertiary Referral Center for collaborative care. My office sits about a foot and a half from Justin’s.
Marc Bloomenstein, OD:
Dr. Marc Bloomenstein. I’m in Scottsdale, Arizona. I actually kind of practice in a very similar setting, an OD/MD, not quasi-referral center, but just more kind of a general ophthalmology. I’m happy to be a part of this square -table that we got going on here.
Mark Troy Dunbar, OD:
I’m Mark Dunbar. I practice at the Bascom Palmer Eye Institute in Miami, Florida. It’s an academic university center where I do primary comprehensive medical eye care.
Justin Schweitzer, OD:
Thanks so much guys. Let’s jump right into this. We know when we think about glaucoma, by the year 2030, there’s going to be 4.3 million Americans with this disease. We know that optometry plays a key role in managing these types of patients. I’m going to do just a overarching early discussion here around, it may seem basic, but I think important to talk about with our colleagues is what kind of diagnostic technology should we have in our clinics? Dr. Dunbar, I’ll go ahead and throw it to you. What do you feel like is the right diagnostic technology to be able to manage patients at a high level with glaucoma?
Mark Troy Dunbar, OD:
Sure. No question, visual fields is paramount. We still use the Humphrey Visual Field, typically 24-2. I’m moving more and more to 24-2C, dabbling a little bit with some of the virtual reality visual fields as I know some of you are. Then obviously in terms of imaging, OCT I think is critical. It’s really the missing piece of the puzzle that kind of marries objective testing with subjective testing and obviously your clinical findings, looking at an optic nerve and measuring the intraocular pressure. Fundus photography, especially stereo disc photos used to be and obviously, a picture of the disc is critically important, but I think it’s because of reimbursement issues, it’s become less critical I think in a primary care setting. OCT visual field, short answer.
Mitch Ibach, OD:
If I was going to say my 4 absolute minimums, you have to be able to look at the optic nerve with a lens and biomicroscopy you have to be able to measure the IOP. Then OCT and visual field. If I was going to add a fifth, if I was going to add 1 more thing in our practice, it’s probably going to be corneal hysteresis. We’ve fallen in love and continue to really like that technology. It helps us make decisions both at the time of diagnosis and as we watch patients over time.
Marc Bloomenstein, OD:
Yeah, I would chime in exactly, Mitch, you took the words right out of my mouth. I mean, we’ve been using hysteresis in our practice for a little bit over a decade. I think for those who don’t really know, I mean it’s really a measure of the integrity of the collagen. Although you’re doing a non-contact kind of quasi-tonometry, it gives you a optimized pressure because it uses that hysteresis value and it’s contingent, I guess, the collagen all the way through the optic nerve. I see a really strong correlation between low hysteresis values and patients that have glaucoma. The other thing that I would probably add is 24-hour IOP measuring, and I know we’re talking about now, I think both Mark and Mitch really nailed what we need now. But I think for us and in our profession, and I think everything we do, it needs to be more proactive, but it has to be preventative.
I think with glaucoma care especially, I almost kind of felt like we waited until there was so much damage before we started treating these patients. Mark, you talk about visual fields, like 40% of the nerve may be damaged by the time we even see fields. I think earlier intervention, so maybe 24-hour monitoring of IOP, greater awareness of different types of profiles that I was speaking with somebody, and they were reminding me that there’s a greater awareness that women develop open angle glaucoma differently than younger men. In fact, more women develop open-angle glaucoma than men by a lot. I think just skewing how we evaluate these patients might be where we need to kind of be a little different.
Mark Troy Dunbar, OD:
I don’t disagree with that at all. Obviously as the technology has advanced, 24-hour IOP will be something that will probably become, I don’t know about regular because I don’t know that you need it on every patient. There’s certainly a subset of patients that you think are controlled and every time they come in, their intraocular pressure seems to be good. Then we know that probably something happens when they’re not in. Justin, I’m reminded of one of your great, great cases that you’ve presented where every time the patient came in, I think it was her only eye. When you did 24-hour IOP, the pressures were in the 30s or something crazy like that.
Justin Schweitzer, OD:
Yeah, pressures were typically in the morning, 12, 13, and she just kept progressing on me. I recall our discussion and it was a lecture together and thinking to myself, I’m just doing a terrible job of caring for this patient. She keeps getting worse, but her pressures were spiking to 28 and 30 at times during the late afternoon. I love the discussion around, that you’re talking about what the future is. I love that we need the diagnostic technology we have now. You talked about risk assessment as well, corneal hysteresis, corneal pachymetry, all those things are great. We’re covering assessment, we’re covering diagnoses, and then we got to get into treatment. Mitch, I’m going to throw this at you. Just an overarching, what is your treatment algorithm? We’re going to dive into medications here in a little bit. We’re going to dive into talking more specifically about SLT and MIGS and those types of things. But overarching, what’s your treatment algorithm when you’re managing a patient with glaucoma?
Mitch Ibach, OD:
I always start with what we’ve already talked about. We make the diagnosis and then I have that patient in front of me and I have to try to assess, maybe guess, what is the risk of progression and what is the rate of progression. I love setting a target. Because I want the patient to know this is what we’re hoping to get to. Also, I think patients buy in when they have a target IOP as well. Then next I’ll talk about how we’re going to get there. I always will give patients the 4 mainstays of treatment modalities. We have 4 things. They all revolve around lowering the interocular pressure. We have topical glaucoma drops, we have laser or light therapy, we have drug delivery, and then we have glaucoma surgery. Of course there’s a spectrum in all of those different modalities.
But I really like to try to assess risk versus reward. How much risk do I have to take for this patient to get the reward of non-progressing glaucoma? Depending on where that patient’s at in his or her glaucoma journey, I’m going to say, this is what I would do if it was my own eye. A sneak peek behind the curtain, if it was my eye with ocular hypertension or very mild open-angle glaucoma, I’m probably going to do laser therapy first. Drops are maybe a close second, and then things will go from there. But very rarely do I pin one treatment modality versus the other because if we’re doing a great job of diagnosis, like Dr. Bloomenstein said, we’re catching these patients really pre a lot of damage, we’re going to need 3 or 4 different modalities to really keep non-progressing glaucoma. It’s just where do I enter them in the phases.
Marc Bloomenstein, OD:
I think too, Justin, it also depends on where they’re at in their journey. I mean, if it’s a younger patient, I’m probably more apt to try to start them on a drop just at nighttime. One of our prostaglandins or prostamides. If it’s somebody who’s cataract age, then I’m absolutely thinking more MIGS, adding something else in there. Maybe, in between there, I’m just like you, Mitch, I’m thinking SLT. I feel, because we have so many different options now, it almost just boils down to just not doing something is what is not the option. It’s finding something that’s going to fit the patient’s lifestyle.
Because I think that’s the other thing too, is you have to think of quality of life in these patients. You’ve just now given them a drop or a procedure, and we’ve kind of anchored them to something that they’re going to be doing more than likely forever. How does that affect the ocular surface? How does that fit into their lifestyle? It’s great that we have options, but those are the things that kind of come forefront for me.
