We are experiencing a renaissance in the management and treatment of glaucoma. From diagnostics to therapeutics, we have seen an explosion of technology and resources for this condition.
So, how has this influx of information and technology changed our mindset? I see us now approaching glaucoma more as active participants. The “let’s wait and see” approach has been replaced with the “let’s treat as early as possible, address the pathology of disease and look for changes over time” mentality. It’s one that has been growing over the last decade. This shift has taken the burden of treatment away from the patients and given us more control over the disease. Poor compliance is extremely common and is a significant risk factor for glaucoma progression. Therefore, the impetus for many of the recent advancements stems from the desire to treat as early as possible and maintain high safety while also maintaining a high level of patient quality of life — an increasingly significant part of a successful treatment.
DIAGNOSTICS: EARLIER, ACCURATE TREATMENT PLANS
Playing an active role in glaucoma patient care starts with identifying and treating the patient as early as possible. Diagnostics tools, such as corneal hysteresis and OCT/OCT angiography, allow us to identify patients who need treatment earlier in the disease. The earlier we treat, the less aggressive target IOP we tend to need and often less chance of progression over time. The more nerve damage, the lower the target IOP often needs to be, which then requires more aggressive treatment options and, therefore, risk of noncompliance and progression. These diagnostic tools have also helped us to determine which patients are at higher risk for progression and thus need more aggressive IOP reduction. In addition, we can identify patients who may not need as aggressive IOP reduction and can possibly reduce their treatment regimen.
THE EFFECT OF NEW DRUGS
Being an active provider also means understanding pathology and mechanism of action of the disease and subsequent treatment. New drugs on the market, such as netarsudil (Rhopressa, Aerie Pharmaceuticals) and latanoprostene bunod (Vyzulta, Bausch + Lomb), target parts of the conventional outflow pathway and may have a synergistic effect with other topical medications, such as aqueous suppressants and uveoscleral outflow drugs. A question yet to be answered is whether these drugs, started early in the disease, have the potential for halting the progression of outflow resistance?
THE MIGS DIFFERENCE
With the minimally invasive glaucoma surgery (MIGS) explosion, we have many surgical options involving the conventional outflow pathway. But, the decision of which procedure to perform is a difficult one. We need to need be active in our thinking of how these various devices and procedures work, since each procedure may address one or multiple different levels of outflow.
We may want to consider staging glaucoma both in terms of “stage of outflow resistance” as well as the standard “stage of disease.” In other words, a mild stage glaucoma patient with fairly healthy optic nerve head may still have advanced outflow resistance if he needs three or four medications to keep the IOP in the 20s vs. the same stage of disease patient needing only one drop to keep the IOP in the teens (mild outflow resistance). Outflow resistance staging is more of a recognition of where and how many levels the pathology might be located, while disease severity staging helps determine target IOP. Both need to be considered to help guide the optimal procedure for the patient.
I believe the future will provide us with more objective noninvasive diagnostic tools to determine where the resistance to outflow is occurring. This would no doubt help guide our treatment decisions.
Another question is whether these new drugs, and even selective laser trabeculoplasty (SLT), potentially help with outcomes, or even help predict outcomes, of various MIGS procedures. Using these newer drugs or SLT before or after certain outflow procedures may enhance the outcomes depending on pathology and mechanism of the MIGS device. Our early non-published data also demonstrated SLT may have a predictive benefit to certain MIGS procedures. For instance, those patients in our clinic who historically did not have a robust response to SLT tended to demonstrate less IOP reduction post trabecular bypass stenting. This could be due to the fact that SLT works primarily at the level of the pigmented trabecular meshwork (TM); therefore, if no response to SLT, the resistance might be distal to the TM. This same logic might hold true for some of these new outflow drugs on the market. Only time will tell if these relationships hold true.
There is no perfect drug or procedure, so we must be cognizant of what a patient may need next, especially when educating patients prior to initiating treatment or even surgery. As providers, our treatment regimen needs to evolve as the patient and the disease change over time. We must be aware of all pharmaceutical and surgical options available today and that a patient may require more than one agent or MIGS procedure now or in the future.
Also, as new drug delivery methods become available, it will be interesting to see how paradigms change — will we utilize these delivery devices in just a select few patients where compliance is a significant issue, or will these become more of a first-line treatment? Much will depend on cost, office flow, access to the product, ease of procedure and long-term outcomes.
Many questions still need to be answered as this technological explosion continues. It behooves us all, as active providers, to pay attention to the outcomes in our offices, look for trends and identify the needs. Some of the most impactful advancements and research have come from analyzing our patients’ outcomes. Let’s continue to stay active and learn from each other to help us navigate through new and future technologies. OM