On this episode of Interventional Mindset, Preeya K. Gupta, MD, is joined by Deborah Gess Ristvedt, DO, to discuss a recent study that outlined a new, consensus-based treatment protocol for glaucoma that factors in the efficacy of modern procedure-based interventions.
Dr. Ristvedt is an ophthalmologist at Vance Thomas Vision in Alexandria, Minnesota, who specializes in advanced cataract surgery, glaucoma care, and oculoplastic surgery.
What ophthalmologists need to know about interventional glaucoma
While topical medications are an often-prescribed treatment for glaucoma, there are a number of significant limitations in their long-term utility and sustainability for patients that require a paradigm shift in glaucoma management.1
Some of the limitations of topical therapies include:1
- Intraocular pressure (IOP) fluctuations
- Visual field deterioration
- Local and systemic side effects
- Tissue deterioration impacting future surgery
- Non-adherence with subsequent glaucomatous progression
- Emotional ramifications for patients, such as depression and loss of confidence
- Diminished quality of life
This shift away from topical glaucoma medications as a first-line therapy has been called interventional glaucoma to describe the transition to embracing more procedural treatments.
Over the past three decades, multiple procedure-based interventions have gained traction, including:
- Laser trabeculoplasty
- Selective laser trabeculoplasty (SLT)
- Micropulse laser trabeculoplasty (MLT)
- Direct SLT (DSLT)
- Minimally invasive glaucoma surgery (MIGS) with or without cataract surgery
- Tissue-sparing procedures
- Trabecular microbypass
- Canaloplasty
- Non-tissue-sparing procedures
- Goniotomy
- Trabeculotomy
- Tissue-sparing procedures
- Filtering surgery
- Trabeculectomy
- Tube shunts
- XEN gel stent
- Sustained-release drug delivery systems
- Travoprost intracameral implant (iDose TR)
- Bimatoprost intracameral implant (Durysta)
These therapies allow ophthalmologists to proactively intervene in the disease course at earlier stages, often with equal or even improved efficacy compared to topical medications.2 Dr. Ristvedt added that in her practice, interventional glaucoma treatments have allowed for streamlined and effective care that considers and mitigates the impact of glaucoma drops on patients’ quality of life.
Watch the interview to hear Dr. Ristvedt’s pearls for getting started with interventional glaucoma!
Interventional glaucoma consensus-based protocol
Dr. Ristvedt contributed to a paper published in Expert Review of Ophthalmology that described a consensus-based protocol wherein each glaucoma stage has its own stepwise logical procession of treatments, with a rationale behind each step.1
She noted that the resulting framework is intended to be a practical guide or starting point for providers seeking to incorporate interventional glaucoma principles into their practices. She also emphasized that this paradigm shift does not seek to remove glaucoma drops as a treatment option, but instead utilizes them as a bridge or supplemental therapy.
The protocols were developed by a working group of 10 glaucoma specialists and listed how to manage ocular hypertension (OHT) and mild, moderate, and severe glaucoma while delivering care that maximizes safety and quality of life for patients without compromising efficacy.1 Of note, the protocols assumed the patient was previously undiagnosed and untreated, with no other significant ocular comorbidities.
As glaucoma treatment is a lifelong process requiring continuous adjustments to management to prevent progression and preserve vision, no treatment is a “one size fits all” solution, remarked Dr. Ristvedt. Instead, given its progressive nature, a staged approach with multiple interventions and adjustments is likely needed, as shown below.
Figure 1: Consensus-based treatment protocols for OHT and mild, moderate, and severe glaucoma. *In certain severe cases, according to the surgeons’ discretion, interventions may be completed “out of sequence” compared to the above diagram.
Figure 1: Courtesy of Funke et al.
To learn more about how the protocols were developed, watch the full interview!
Final thoughts
As glaucoma management is evolving in treatment algorithms and mindset, now is a great time to adopt new technologies to improve the patient experience by using earlier minimally invasive surgical, laser, or procedural pharmaceutical treatments instead of prolonged topical medications.
In Dr. Ristvedt’s opinion, it is a disservice to patients not to educate them on the many available treatment options and explain the limitations of topical glaucoma medications.
Further, due to the prevalence of glaucoma in patients presenting for cataract consults, Dr. Gupta recommended that cataract surgeons take on the challenge of learning and incorporating some aspect of interventional glaucoma care into their practice. She added that she recently began offering DSLT at her practice, and has found great success with it.
