Traditionally, people have always thought of glaucoma treatment as eye drops. Today, there are a lot more options that we can offer our patients.
That’s why an early and accurate diagnosis is so important — because that’s where you can modify the course of the disease with all the options now available. The earlier you are in the disease course, especially with mild to moderate disease, the more options there are. Patients need to know that it’s perfectly reasonable to talk to their eye care professional about that.
Drops are still the first line of therapy. There are multiple modes of action for the different types of drops out there, and they all work very well. In general, the first line of defense tends to be a prostaglandin. “Polypharmacy,” where patients are prescribed several different drops (usually more than two), taken several times a day, is being used less today because the more you have to take drops, the more likely you are to forget, and your chances of compliance are less than 70%.
Therefore, other options such as selective laser trabeculoplasty (SLT) are a wonderful option for people who have primary open angle glaucoma (POAG), the most dominant form of glaucoma. A landmark study a couple of years ago reported that in many parts of the world, SLT is offered as a first-line therapy. Here in the United States, it’s usually offered after one or more drops, but much of this depends on the discussion between the patient and physician. Some patients may opt for it first-line versus the trouble of using a drop daily.
New solutions
Today, there are different minimally invasive glaucoma surgeries (MIGS) that we offer to our patients in their glaucoma treatment journey. In addition to being used in conjunction with cataract surgery, some MIGS can be used as stand-alone surgeries — even 15-20 years before cataract surgery is necessary. We are very excited about that. Most MIGS are covered by insurance, so, patients now have the choices of drops, lasers, and MIGS. In the pipeline, there are companies working on some drops with new mechanisms of action, new MIGS procedures, and newer lasers that may affect areas of the eye — like the trabecular meshwork — that impact glaucoma.
Of course, if a patient is diagnosed with end stage glaucoma, or near end stage glaucoma, then the options are limited. Perhaps the first-line drops, the laser, and some of the MIGS won’t work as well, and more traditional incisional surgery, such as a trabeculectomy, or tubes for draining the eyes are necessary. This is why it’s so important to get diagnosed early.
Getting diagnosed
I’m very bullish about the therapies for glaucoma overall. Eye pressure is still the only way we can diagnose glaucoma. With a newly diagnosed patient, we check eye pressure a couple of times per year in the morning and a couple of times per year in the afternoon due to variations based on the time of day. We then very often start them off on a drop. If patients do not want to take drops, we can start them off with an SLT laser procedure — that’s a conversation between the doctor and patient. We also do visual field tests, OCT imaging, and sometimes an ERG retina/glaucoma test. At the beginning we may do these tests more frequently to chart the progression of the glaucoma.
If the tests show the glaucoma is stable, we’re good to go. If not, we add a drop or do a laser, or sometimes a stand-alone MIG. What’s most important is to talk to your eye care provider about your options.
Understand what your options are for where you are. The journey of glaucoma can last for decades if you’re diagnosed early. It’s not a one-shot deal; it’s like any other disease. If you are going to have heart disease, don’t you want to know earlier? Don’t you want to know earlier if you have diabetes? Glaucoma is no different in that respect.