Advanced Surgical and Medical Treatments in Glaucoma

Defocus Media Podcast Network

Alexander S. Barsam, MD, MBA, NC ENT at Duke

In the dynamic field of eye care, staying at the forefront of medical advancements is crucial for ensuring patients receive the best possible treatments. Glaucoma, a progressive and often silent disease, is one of the most challenging conditions eye care professionals manage. With the rise in glaucoma cases, particularly as the population ages, it becomes increasingly important for optometrists and ophthalmologists to work together to provide seamless, comprehensive care. This article delves into advanced surgical and medical treatments in glaucoma management, drawing insights from Dr. Darryl Glover and his podcast discussion with Dr. Alexander Barsam, a comprehensive ophthalmologist and glaucoma expert.

What’s Covered:

Understanding Glaucoma: A Silent Threat

Drops vs. Surgical Interventions: A Shift in Treatment Philosophy

Selective Laser Trabeculoplasty (SLT)

Micro-Invasive Glaucoma Surgery (MIGS): Bridging the Gap

Setting the Stage for Glaucoma Surgery: Partnering with Glaucoma Experts

Understanding Glaucoma: A Silent Threat

Glaucoma is often called the “silent thief of sight” because it can progress without noticeable symptoms until significant vision loss occurs. The condition is characterized by damage to the optic nerve, primarily due to elevated intraocular pressure (IOP). Early detection and intervention are critical to preserving vision, but many patients remain undiagnosed until the disease is in its advanced stages. As Dr. Glover highlights, “I’m blown away by how many patients walk into my door with severe glaucoma.” This underscores the need for increased awareness and better diagnostic tools to catch the disease earlier, ideally before irreversible damage.

Drops vs. Surgical Interventions: A Shift in Treatment Philosophy

Traditional Management:

• Topical medications like prostaglandins and beta-blockers have historically been the first line of treatment for glaucoma.
• These medications effectively lower intraocular pressure (IOP) but come with challenges. Patients often struggle with side effects such as ocular surface irritation, redness, and the burden of adhering to a daily regimen.
• Compliance remains a significant hurdle, with studies showing that adherence rates for once-daily drops hover around 70%, similar to more complex regimens from decades ago. This stagnation in compliance highlights the need for better treatment options that address both efficacy and patient quality of life.

Emerging Approach:

• In response to these challenges, eye care professionals are shifting towards more proactive and interventional treatments. This approach includes surgical options that intervene earlier in the disease process, reducing dependence on drops.
• Dr. Alexander Barsam emphasizes the benefits of this shift, stating, “SLT offers a way to restore the natural drainage system of the eye,” making it a valuable alternative or complement to traditional medical management.

Selective Laser Trabeculoplasty (SLT)

Selective Laser Trabeculoplasty (SLT) is a less invasive option that has gained prominence as both a first-line treatment and a complementary option to drops. Dr. Barsam explains that SLT offers a way to “restore the natural drainage system of the eye” by improving outflow through the trabecular meshwork. It’s a minimally invasive procedure with a favorable safety profile, making it an attractive option for patients who struggle with drop compliance or experience adverse effects.

SLT can be an effective first-line treatment, and many glaucoma specialists are now offering it alongside the more traditional option of topical medications. Dr. Barsam shares that “SLT provides a chance to intervene earlier in the disease process without waiting for the more invasive surgeries.”

One challenge with SLT is managing patient expectations. Some patients believe that once they have the procedure, they no longer need to worry about glaucoma. Dr. Glover points out, “When patients come back and say, ‘I got the laser, so I don’t need to worry anymore,’ it’s important to clarify that glaucoma is a lifelong condition that requires continuous monitoring.

This shift from drops to surgical interventions like SLT marks a new era in glaucoma care, focusing on improving patient outcomes and quality of life while addressing the limitations of traditional medical management.

Micro-Invasive Glaucoma Surgery (MIGS): Bridging the Gap

Micro-invasive glaucoma Surgery (MIGS) represents a significant advancement in glaucoma treatment. It offers a middle ground between medication and more invasive surgeries like trabeculectomy or tube shunt procedures. MIGS procedures involve using tiny stents or devices to improve fluid outflow and reduce IOP with fewer risks and a faster recovery time compared to traditional glaucoma surgeries.

MIGS is often performed with cataract surgery, offering a dual benefit for patients with both conditions. Dr. Barsam emphasizes that “MIGS provides an option to intervene during cataract surgery, allowing us to lower pressure without adding more medications.”

For optometrists, understanding the indications for MIGS is critical when referring patients to glaucoma specialists. Knowing when to recommend surgical intervention versus continuing with medications can be pivotal in the patient’s long-term outcome. Dr. Barsam advises that the key is “early intervention and setting realistic expectations about what MIGS can and cannot achieve.”

Setting the Stage for Glaucoma Surgery: Partnering with Glaucoma Experts

The relationship between optometrists and ophthalmologists is crucial in managing glaucoma. Transitioning from medical management to surgical intervention requires careful coordination to ensure patients feel supported throughout their treatment journey. Dr. Glover highlights the importance of provider communication: “Teamwork makes the dream work. If we can start together, the transfer of trust from optometrist to ophthalmologist can be life-changing.”

For new graduates or optometrists just starting their careers, understanding when to refer a patient for surgery can be daunting. Dr. Barsam recommends keeping an open line of communication with glaucoma specialists to determine the best course of action based on the patient’s disease severity and response to treatment. “We’re here to support our optometry partners and help guide patients through the decision-making process,” he says.