In this episode of Inside Intrepid, Mitch Ibach, OD, FAAO, an associate with Vance Thompson Vision in Sioux Falls, South Dakota, and Jessica Steen, OD, FAAO, Dipl. ABO, the director of the glaucoma service at Nova Southeastern University in Fort Lauderdale, Florida, discuss how to meet this growing glaucoma demand and overcome the biggest challenges in the diagnostics and treatment.
Glaucoma as a growing concern
Glaucoma is the second leading cause of blindness worldwide. As of 2020, 76 million people across the globe were affected. By 2040, that number is expected to rise to 111 million.1 In the US, that number in 2020 was 4.2 million adults, based on meta-analysis of multiple national databases. With the aging population, optometrists are destined to see even greater prevalence.2
“And so, very quickly, we're going to have 5 million patients in the US diagnosed with glaucoma that we're going to have to manage,” said Dr. Ibach. “I think you can view glaucoma in your practice either as an opportunity or as a burden. Either way, the patients are there.”
An overview of the top challenges
Both clinicians identified the primary challenges impacting glaucoma care today, including:
- Avoiding data overload
- Balancing effectiveness and efficiency
- Battling patient non-compliance
Avoiding data overload
The rapid development and adoption of new diagnostic tools is delivering more data than ever for glaucoma care. Dr. Steen explained, “We are gathering so much high-quality information, and then we're incorporating, analyzing, evaluating that information, and then applying it to the patient's overall progression analysis.”
Beyond the diagnostic data, clinicians must also integrate a wide range of additional factors, including disease severity, life expectancy, systemic conditions, medications, prior experience with topical therapies and procedures, and lifestyle as well as patient preferences.
“With the incredible diagnostic tools, our improved understanding of disease development, and of risk factors for development and progression, we’re reaching this tipping point of near data overload,” explained Dr. Steen.
Balancing efficiency and effectiveness
With the escalating number of glaucoma patients, one question is top of mind for Dr. Ibach: “How do we get these patients through our practice efficiently, yet give a super high-quality exam?”
When seeing up to 50+ patients in a day, it is imperative to put in place a workflow in which a five-minute visit is so thorough, it feels like a 30-minute minute visit to the patient in which they are not only accurately assessed, but have their concerns addressed and questions answered.
Utilizing advanced technologies such as integrated imaging platforms, AI-enhanced diagnostics, and digital surgical planning tools can go a long way toward streamlining workflows and improving monitoring.3 However, once the data is gathered, the monumental task of explaining these findings and their implications to the patient.
According to Dr. Steen, “We're putting that all together in a short visit. We're coming up with a management plan. We're explaining it to the patient in a way they can really understand.” At this point, the patient may accept the course of treatment or choose to ask for changes in the plan to more fully accommodate their preferences and expectations.
This, in turn, requires the clinician to pivot, reevaluate their approach, and devise an alternative management plan—all in the relatively brief time allotted for most appointments.
Battling with patient non-compliance in glaucoma care
Many factors lead to non-adherence to treatment plans—which has reported rates of 30 to 80%—including cost, forgetfulness, manual dexterity, an overly complex regimen, and flat-out denial.4 Regardless of the cause, patient non-compliance with topical glaucoma drops can result in irreversible nerve damage and vision loss that is caused by a rise in uncontrolled intraocular pressure (IOP).1 This presents an ongoing challenge to optometrists.
For Dr. Ibach, the dilemma hits very close to home, as his own grandmother, who suffers from “full-spectrum” glaucoma and has already undergone MIGS, struggles with drop compliance and complaints of drop discomfort. “I don't ever say that medications aren't a great option for a patient. It's just, ‘how do I get my patients to be more compliant with the medications that I'm prescribing?’”
Dr. Steen believes the key to increasing compliance is by increasing trust and building positive, open relationships with patients, which includes “understanding preferences that can’t be documented on a chart.”
Positive prognosis for the future of glaucoma care
Following a long lapse in management options, new treatments have emerged in the form of rho kinase inhibitors, prostaglandin analog (PGA) combined with nitric oxide, Dr. Ibach referred to this as a “mini renaissance in pharmaceutical options.” This in combination with two new FDA-approved drug delivery devices and the more frequent use of early intervention via MIGS is changing the treatment landscape.
Dr. Steen sees the goal as using all the tools in the armamentarium to alter the long-term course of the disease by hitting the target tissue at the level of the disease—the trabecular meshwork.
Wrapping it up
In closing, Dr. Ibach sums up the reward of taking on and tackling this ever-expanding patient population: “If you're the provider who is able to stop glaucoma, stop the train on the tracks for that patient, keep it from progressing, then these are the patients that send you cards at Christmas and they bake cookies for you and are very loyal in general.”
