What ocular disease causes the greatest problems for patients? Although cataracts are the leading global cause of blindness in patients aged 50 and older, followed by glaucoma,1 examining the number of cases alone may not tell the full story. “In America, things aren’t even close,” says Matt Jensen, MBA. “Glaucoma is a real threat to vision among the aging population, and we can’t possibly combat it with the number of providers we have, in the way we have. Cataract patients don’t necessarily have this problem.” But what does cataract practice have that glaucoma currently doesn’t?
Late in the game
According to Arkadiy Yadgarov, MD, a comprehensive glaucoma and advanced cataract surgeon at Omni Eye Atlanta, the answer may be the interventional infrastructure that exists for cataract practice, but doesn’t exist for glaucoma. “In my experience, patients are only referred to a glaucoma surgeon when things are really awry,” he says. “The typical patient walking into an optometrist’s office with mild-to-moderate glaucoma is offered a prostaglandin drop as first-line treatment.” Although this may initially reduce IOP, some patients experience further problems. “With time, as these patients’ visual fields get worse, they’re offered a second drop, then a switch in medication, and then a third and maybe even a fourth drop. It’s only at this point that, in the vast majority of offices nationwide, patients would be referred to me. As interventional glaucoma specialists, we work to either stabilize glaucoma progression or offer an alternative to drops—so can we intervene sooner?”
Omni Eye Atlanta has been at the forefront of facilitating earlier surgical glaucoma intervention by emulating what’s worked elsewhere. “We looked to work together to take care of patients without competition—many high-volume cataract surgeons already rely on the collaborative efforts of optometrists sending patients over for surgery and then following up in-office post-operation,” Dr. Yadgarov says. “The collaborative interventional glaucoma model we employ at our center is the same: optometrists communicate with surgeons like myself to send over patients who would benefit from earlier surgical intervention.”
Identifying when to intervene
Early intervention requires optometrists to identify who is most suitable for early intervention and at what point during management they should consider making a specialist referral. Early intervention options include selective laser trabeculoplasty (SLT) and procedural pharmaceuticals, such as the iDose TR (travoprost intracameral implant) 75 mcg. Dr. Yadgarov first suggests considering SLT as the first-line treatment for everyone. “We have good data evidencing first-line SLT to be a good option for glaucoma,” he explains.2 “Because of this, we don’t really have to think about who are or aren’t good candidates for SLT; it should be offered as a first-line treatment to any glaucoma patient.”
But what about those for whom SLT isn’t an option? There are three main patient populations Dr. Yadgarov advises optometrists to look out for. The first are those struggling with compliance. “The area where optometrists will be most successful—both in converting to an interventional mindset and making referrals—is identifying and working off patients’ compliance and history of present illness,” he says. Intervening here can prevent the pathway of progression outlined earlier.
However, in the case of patients who are fully compliant it doesn’t mean there aren’t problems to solve—such as tolerance issues. “Glaucoma medication, especially preserved medication, is the number one cause of dry eye in ocular surface for glaucoma patients,”3 Dr. Yadgarov explains. “When patients adhere to medications but complain of burning and stinging, the reflex most practitioners will have is to add something—however this may not be the best approach. We have data highlighting that instead of additive therapy, subtractive therapy, i.e., taking treatments like benzalkonium chloride (BAK)-preserved drops away, is a better approach.” In these cases, intervention can provide a non-additive solution to tolerance issues, elevating patient quality of life.
The third group in which interventional treatment can make the biggest impact are those struggling to administer their drops, for example, those with dexterity issues, arthritis, tremors, or limitations the result of old age. “Before, when patients expressed that they were having difficulties squeezing their bottles, we could do little more than apologize,” Dr. Yadgarov recalls. “But now we have solutions, and because they’re such natural steps, it’s an easy conversation to have.” Alongside SLT and minimally invasive glaucoma surgery (MIGS), the emergence of procedural pharmaceuticals means that when optometrists do identify suitable candidates for interventional surgery, they have increasing options to present and to tailor to patients’ specific needs.
“Currently the two procedural pharmaceuticals we have are Durysta, intracameral bimatoprost; and iDose TR (travoprost intracameral implant) 75 mcg, slow-release,” explains Dr. Yadgarov. “Both have their advantages; Durysta can be performed in-office and is dispensed over a period of 3–5 months, whereas iDose TR is longer-lasting, being slowly released up to 3 years. In terms of efficacy, safety, and overall experience, it’s fantastic—patients love it. I’m very big on procedural pharmaceuticals; they’re going to be a big part of our future.”
Building a collaborative framework
How can eyecare professionals take an interventional glaucoma approach to practice? “I think the first thing to realize is that it’s a collaborative effort,” Dr. Yadgarov advises. “The reason I’ve enjoyed my work for the past eight years—and that I’m still doing it—is because everybody has to be on the same page. To start, talk to your optometrists and team to determine how exactly you can build such a system and the specifics of achieving this. How will you identify suitable patients, and which interventions will you perform? It’s here that you can then consider the industry reps within your network, [whom] you can rely on to help set up such interventions. Once you start building with this mindset, things will move in the right direction.”
Although creating such a framework will take time and effort from multiple parties, Dr. Yadgarov says that in the end, everyone benefits. “Ophthalmology and optometry really go hand-in-hand; when you work together to intervene, it’s good for the practice, and it’s good for the patient.”
PM-US-2922
Dr. Yadgarov was compensated for his time by Glaukos.
