Bring together the evidence to make treatment case

San Diego—Although heuristic factors always will be part of the art of ophthalmology, the profession currently faces an era in which payments for medical treatments will be scrutinized increasingly for their effectiveness. Ophthalmologists may be well-advised to focus on an evidence-based approach to identifying high-risk glaucoma cases, said Ivan Goldberg, FRANZCO, FRACS, University of Sydney and Sydney Eye Hospital, Australia.

This advice applies to treating both patients with glaucoma at highest risk of progression and patients suspected of having glaucoma at highest risk of conversion.

“We must focus on the why, when, what, and how as we try to tailor our treatments to the risk of future disability,” Dr. Goldberg said. “We base that on a number of things, such as the stage of the disease when we make our diagnosis and start our treatment, our determination of the risk factors for progression, and an analysis of the patient’s overall heath status and life expectancy.”

Reassessments of risk must take place on each patient visit.

“As practitioners, we must always be asking ourselves, ‘Is there damage, structurally or functionally, that can be demonstrated? Is there new damage that demonstrates progression? Is there a change in the patient’s general status?’ Those are the changes that affect the risk profile,” Dr. Goldberg said. This process, in turn, drives the aggressiveness of therapy, he said.

Although control of IOP is important, IOP should not be the sole focus of assessments and therapies, according to Dr. Goldberg. Measure pressure in terms of corneal parameters such as central corneal thickness, assess cup-to-disc ratios in terms of disc size, and look at pressures treated versus pre-treatment, he said. In addition, remember the patient’s general status and look for other factors that may contribute to the risk of progression or conversion, such as variable volatile blood pressure levels and sleep apnea, he concluded.