Published in Glaucoma

Tales from the Trenches: The Newly Diagnosed to the Advanced Glaucoma Patient

This is editorially independent content
8 min read
In this session from Eyes On Glaucoma 2022, join Dr. James Thimons and Dr. Robert Noecker as they discuss the diagnosis and management of a variety of unique patient presentations from both a medical and surgical perspective.

On June 10-11, eyecare practitioners from all over the world gathered online for Eyes On Glaucoma 2022, a two-day educational event all about glaucoma disease diagnosis, treatment, and management.

With so much fantastic education happening at once, we knew that people had to choose which sessions to attend. So over the next few months, we'll be releasing much of the excellent content from Eyes On Glaucoma for you to watch at your leisure—whether for the first time or to review important learnings!

Please note that these videos are provided for review only.

In this session from Eyes On Glaucoma, James Thimons, OD, FAOO and Robert Noecker, MD, walked through a series of glaucoma cases. Glaucoma is a disease that involves a range of clinical variations.
This presentation covers the diagnosis and management of six unique patient presentations from both a medical and surgical perspective. Watch now.

Case one: The case of one more thing

  • 68 YO Hispanic Male
  • VCDR 0.65
  • HVF PSD 1.7
  • R5 year risk of progression = 30%
This patient’s initial presentation could be described as marginal across the board. However, with patients like this, there’s a significant opportunity to decrease the rate of progression earlier.
Over 5 years, this patient had a significant shift in their imaging. This gets into the concept of pre-perimetric glaucoma, where glaucoma can be seen and treated before visual field loss occurs. The data shows that 40-50% of nerve fibers can be lost before the loss shows on the visual field.
For early glaucoma suspects, imaging and OCT is the way to go, particularly for doctors wishing to be more aggressive in their approach, or doctors who wish to take the approach of preventing onset and not just progression.

Case two: I was fine yesterday

  • FIRST EYE EXAM @ 33 y/o with baseline IOP of 18 mmHg.
  • VA: 20/25 OD, OS
  • Patient has no family Hx of glaucoma
  • IOPs: OD 8.4 and OS 14.7
  • VF presents with defect
  • OCT GCC: wiper effect inferotemporal to macula
  • Referred for MRI of neck and face w/ and w/o contrast
    • MRI detailed large size of optic nerve OD (no other abnormal findings)
In the initial exam, the patient was referred to OCC for a second opinion on what his optometrist believed was end-stage glaucoma in the right eye only. He was being treated with travoprost QHS OD. When the patient returned for follow-up—still taking travoprost QHS OD—he presented with the complaint, “My right eye doesn’t look like my left.”
This was an interesting case of an unusual form of early glaucoma. The patient presented with both functional and structural damage to the nerve. The question became, is this glaucoma, or a hereditary disease he had for his whole life? If the disease is well-known, should clinicians still treat the visual field loss when a patient has already lost half of the nerve fibers?
It’s arguably worth treating MS patients and optic neuritis patients as (at minimum) glaucoma suspects, since patients have atypical patterns of field loss and inherently weaker nerves. In the long term, the goal is to minimize deformation and treat both eyes as preventative measures to prevent further loss of vision.

Case three: How low can you go?

  • SM a 40 y/o white female was referred for evaluation of glaucoma. Current Tx was beta blocker and brimonidine.
  • VA 20/20 OD/OS
  • Ta 12/12 @ 10
  • SLE: wnl
  • DFE: 0.7 OD / 0.9 OS
  • VF: Early near fixation loss OS
  • Gonioscopy: CB 360 OU
  • Medical Hx: LBP ( 100/65), pulse 54, Raynaud’s, Migraine HA
    • Family Hx: Negative
In this case of an abnormal tension glaucoma patient with a longstanding history of low blood pressure, the patient initially presented with no field loss and normal OCT in the right eye, but an optic pit developed in the left eye associated with a wedge defect.
Optic pits are more common than you’d think; data has shown that incidence rates in patients with normal tension is fairly high, though less common in open-angle and elevated pressure patients.
This patient then presented with Ta 14/15 and a drance hemorrhage.
At this point, you worry that this patient is progressing. There are many reasons patients can develop drance hemorrhages, but when your patient has glaucoma, you can always assume that the glaucoma is progressing until proven otherwise. If visual field loss has not already occurred, you can give it 6 months before it appears. That said, however, if the patient already has some form of visual field loss, you have to assume that whatever you’re doing is not enough.
With younger patients, Dr. Noecker notes that his goal is to have their pressure under 10 at all times. Dr. Thimons prescribed Latanoprost for this patient, which brought her pressure down to 11; however, she experienced an increase in the severity of her migraines and even bouts of syncopy—a clear case of a systemic disease manifesting as an ocular problem.
Here is where you want to turn to gonioscopy and differential diagnosis. Gonioscopy not done as frequently as it should be; if you use your OCT and angle assessment you’ll be really impressed in how they illuminate the disease state.
Another thing to keep an eye out for is nocturnal hypotension and its role in visual field progression. Patients with nocturnal dips are more likely to show visual field loss even with good IOP control, leading to increased risk of disc hemorrhages. Their pressure drops 10-20% at night, and the damage is being done during sleep. Vein occlusion and other vascular AIONs will occur in the morning; the disease hits in the morning because of the imbalance between IOP and hypovolemic supply to the optic nerve. For these patients, SLT can be an excellent option.
Glaucoma patients, because of their compromised facility of outflow, fluctuate a lot more, and we have to have a healthy index of suspicion, especially when patients are getting worse.

For the rest of the cases, make sure to watch the full session recording!

The value of MIGS and combining procedures

When it comes to MIGS, the question is not whether to do it, but how to do it. Currently, there are many, many of options for less invasive procedures that are highly effective, including:
  • Trabecular Bypass/Canal Enhancement
  • Goniotomy
  • Canal Expansion
  • Suprachoroidal Space
  • Entire Outflow System Bypass
    • Subconjunctival stent
  • Cycclophotocoagulation

The combination model

One of Dr. Thimons’s favorite conversations to have with a patient is when they have glaucoma and develop a cataract, because that opens the door to so many treatment options for them. When he starts with any glaucoma patient, his first comment to them is to say, “We’re going to use a combination of medicine and surgery over your lifetime to control your pressure so you’ll have good vision for the rest of your life.”
If you treat glaucoma long enough, even with patients who respond well to glaucoma eye drops, he adds, it’s an absolutely true statement: at some point you will have to reach out to the surgical arm of eyecare.
This is the best opportunity: cataract surgery not only addresses the cataract, but provides a solid reduction of IOP. Furthermore, it’s the only opportunity to be reimbursed for stents, as their on-label use is restricted to combination with cataract surgery.
Patients embrace the opportunity to address both problems at once. Medications have their place and always will, but minimizing it offers massive benefits for patients in terms of compliance, the long-term economics, and the health of their ocular surface.
It’s an interesting time: we’re working through optimizing therapeutic choices, but we have so many choices. It’s just about optimizing the risk/benefit of each for our patients.


Consider visual outcomes when making decisions on treatment options. There are many options available now and in the near future for patients needing surgical IOP lowering. Newer MIGS procedures are aimed at maintaining low risk profiles while providing used friendly techniques that produce good efficacy. These procedures appear to be reasonable options for patients with earlier and less severe disease.
James Thimons, OD, FAOO
About James Thimons, OD, FAOO

Dr. Thimons serves as the medical director at Ophthalmic Consultants of Connecticut. Prior to co-founding Ophthalmic Consultants of Connecticut, Dr. Thimons held the position of Center Director at Omni Eye Services, Fairfax, Virginia and served in that role until 1989 when he became Chairman, Department of Clinical Sciences at the State University of New York. While there, he developed The Glaucoma Institute, a clinical research center, and served as its first Director.

In 1998, he accepted the position of Executive Director of TLC and served in that role until 2002 when he started Ophthalmic Consultants of Connecticut. In 2002 he also founded the National Glaucoma Society, a NFP with executive offices in Andover, Massachusetts, that provides educational and clinical development services to primary care clinicians worldwide in the area of glaucoma management.

Dr. Thimons has written articles for over two hundred publications on glaucoma, dry eye, cornea and external disease as well as refractive surgery and new technologies and has received numerous awards for his service to the optometric profession. He is a nationally and internationally acclaimed speaker and educator and an acknowledged leader in ophthalmic clinical education.

James Thimons, OD, FAOO
Robert Noecker, MD
About Robert Noecker, MD

Dr. Robert J. Noecker is a leading ophthalmologist specializing in the medical, laser and surgical management of glaucoma and cataracts. He specializes in MIGs (micro-invasive glaucoma surgery) procedures for the treatment of glaucoma and femto-laser assisted surgery for the treatment of cataracts.

He is currently an Assistant Professor of Ophthalmology at Yale University School of Medicine and Professor of Surgery at the Frank Netter School of Medicine of Quinnipiac University. He teaches courses and lectures to fellow ophthalmologists, optometrists, residents and medical students locally and around the country and the world every year.

Dr. Noecker has more than 20 years of experience in developing innovations in cataract and glaucoma surgery. He has conducted numerous trials on the pharmacologic and surgical treatment of glaucoma, macular degeneration and dry eyes. He has also helped to develop and apply novel materials and surgical techniques to the treatment of glaucoma. He currently has several on-going clinical studies evaluating new medications, laser treatments and surgical devices for glaucoma.

Robert Noecker, MD
Eyes On Eyecare Editorial Team
About Eyes On Eyecare Editorial Team

Led by Editor-in-Chief Eleanor Gold, PhD, Eyes On Eyecare is a digital publication that provides clinical and career education to the young generation of optometrists and ophthalmologists. We work with eyecare professionals to create compelling, educational content available for free to all those in the eyecare industry. To learn more about our team, values, and other projects, visit our About page.

Eyes On Eyecare Editorial Team
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