Proactive glaucoma management: Tailoring treatment for enhanced patient outcomes

(Image Credit: AdobeStock/muratart)

During a recent Ophthalmology Times Case-Based Roundtable discussion, Albert S. Khouri, MD, professor of ophthalmology at Rutgers New Jersey Medical School in Newark, shared his pearls in proactive glaucoma management. The discussion focused on the proactive glaucoma management of 2 cases, considering the technological evolutions that individualize patient management and move away from using only eye drops.

Case 1

A Hispanic woman aged 69 years was referred for evaluation. She has a history of high IOP measured during a routine spectacle examination and myopia. Her medical history was otherwise unremarkable.

The bilateral best-corrected visual acuity (BCVA) was 20/25, and the IOP was 22 mm Hg bilaterally. The tear film was abnormal, and mild cataracts were present. The central corneal thickness was average (541µm and 539µm); the optic disc was slightly tilted.

Evaluation of the left eye showed greater cupping with some nerve fiber loss superiorly and inferiorly, which was confirmed bilaterally by optical coherence tomography (OCT) and macular ganglion cell scans that confirmed the loss. The visual fields were relatively preserved in both eyes. The patient was diagnosed with primary open-angle glaucoma.

Khouri commented on treatment options, adding that some physicians would prescribe a prostaglandin eye drop as a first line. However, some roundtable discussants felt strongly about laser trabeculoplasty (LT) for this patient, whereas others mentioned slow-release products such as the bimatoprost intracameral implant (Durysta; Allergan) and travoprost intracameral implant (iDose TR; Glaukos) to eliminate daily drop instillation and adverse effects.

The participants agreed that this patient with early glaucoma requires treatment, and the IOP should be reduced by 20% to 30%. Discussed treatments included prostaglandin analogues or a combination of prostaglandin with netarsudil or a nitric oxide–donating moiety.

“Most importantly,” Khouri commented, “this patient should be monitored over time to ensure that this pressure reduction stops disease progression, that the tests remain stable…and that the drops are being instilled properly.” Khouri also underscored the importance of patient education about glaucoma and adherence to the treatment regimen to prevent disease progression.

Many participants favored selective LT (SLT) as the initial treatment for this patient. Although the treatment effect can vary, SLT also negates adherence issues and requires follow-up to detect any loss of treatment effect.

Khouri mentioned a recent survey of physicians who are members of the American Society of Cataract and Refractive Surgery. The survey found that younger ophthalmologists or those who treat a large number of patients with glaucoma tend to favor SLT as a first-line therapy over the initiation of a medication.

Case 2

A White woman aged 68 years presented with more severe glaucoma, with the complaint of “darkening” vision. Her ocular history included latanoprost for elevated IOP, brimonidine tartrate solution (Lumify; Bausch & Lomb), artificial tears, and bilateral SLT. The medical history was remarkable for hypertension,
diabetes, and hyperlipidemia. The BCVAs were 20/30 and 20/25, respectively, in the right and left eyes. with an early cataract that had some vacuoles in both eyes. There were signs of ocular surface disease and dry eye, likely from her topical medication; the respective IOPs were 21 mm Hg and 20 mm Hg. The corneal thickness values were below average (522 µm and 519 µm). The angles were open, and the disc in the right eye was more cupped than the left. OCT images over 1 year showed clear disease progression bilaterally.

Khouri commented that despite treatment, this patient was not doing well and had structural and functional loss. She underwent another SLT and received an additional fixed-combination eye drop. However, disease progression continued with further retinal nerve fiber layer and visual field loss.

The participants agreed that the patient needed significantly lower IOP. The majority agreed that cataract removal combined with angle surgery could lower the IOP and decrease the medication burden. Some participants suggested that an incisional surgery like a trabeculectomy, a Xen gel stent implant (AbbVie), or a tube shunt might be appropriate.

Further discussion considered that the progression was early, the patient had a small nasal step, and the mean deviation was low. Reconsideration of the options focused on a stand-alone minimally invasive glaucoma procedure vs a combined cataract procedure to improve the vision, with an angle procedure to address the glaucoma and ease the medication burden.

Khouri pointed out that opinions about glaucoma management remain versatile. Still, the majority believed that intervening in those patients is better than adding more medications or repeating SLT beyond the second time in this patient, who was on a worsening trajectory.

He concluded by emphasizing that physicians must prevent the progression of glaucoma because its effects on vision are irreversible. The optimal time to intervene is early in the disease process when patients are still functional and their visual function is preserved. The most favorable interventions are the ones that are safe, effective, and less reliant on patient adherence to eye drop instillation. “Keeping things simple and being proactive with treatment is the way to go with most of our patients,” he concluded.

Albert S. Khouri, MD

E: albert.khouri@rutgers.edu

Khouri is a professor of ophthalmology at Rutgers New Jersey Medical School in Newark, New Jersey. He receives grant support from the New Jersey Health Foundation and the Fund for the New Jersey Blind. He is a consultant for Alcon and Glaukos and is a speaker for AbbVie and Bausch Health.