ODs: Redefine your role in glaucoma collaborative care

By the year 2050, 45.6 million Americans will need some type of ocular surgery. Some 6.3 million of these patients will require care for glaucoma. As these numbers climb, ODs will see a need for better collaboration with their surgical partners.

Experts like John Berdahl, MD, and Justin Schweitzer, OD, FAAO, of Sioux Falls, SD, predict these new collaborations to come with a few growing pains.
Dr. Berdahl and Dr. Schweitzer challenged optometrists to rethink how they deliver glaucoma care in a presentation at Vision West Expo 2019 in Las Vegas.

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With demand increasing for surgical eyecare services, ODs will need to pick up the slack and embrace new collaborative care strategies with ophthalmologists to help meet their patients’ needs, says Dr. Schweitzer.

The role of ODs in collaborative care
“Is there a missing link in that communication?” Dr. Schweitzer asks of the typical relationship between ODs and ophthalmologists.
Comanaging glaucoma patient care requires different strategies that are not always obvious to one side or the other. Communication is key, Dr. Schweitzer says.

ODs remain responsible for discussing options, suggesting procedures, and caring for patients across the operative spectrum. But in collaborative care, ODs and ophthalmologists need to support one another.

“Help ophthalmologists keep their options open,” Dr. Berdahl says.

He suggests that ODs think long term about what type of care the patient will receive on both sides of the referral. For example, if an OD suspects a patient might need minimally invasive glaucoma surgery (MIGS), she may decide to put the patient on a drop ahead of time. Such a treatment plan makes it easier for the ophthalmologist to prescribe a follow-up treatment, if needed.

As optometrists refer, they should try to leverage their longstanding patient relationships, Dr. Berdahl says. Patients may have more confidence in their trusted clinicians than with new ophthalmologists.

“You can really help us with your 15-year relationship that we can’t get in our 15-minute interaction,” he says.

MIGS and glaucoma compliance
A key aspect of modern glaucoma management is leveraging MIGS alongside traditional methodologies. MIGS formed a bridge between conservative treatments and more aggressive filtration surgeries, Dr. Schweitzer says. In addition, MIGS offers an easier way for patients to adhere to their medication regimens-a known challenge in glaucoma management.

“Patients are not using medication regimens correctly, no matter what they tell you,” Dr. Schweitzer says.

MIGS offers an alternative that reduces the burden of medication. “When we take compliance out of our patients’ hands, it is usually a win for the patients,” Dr. Berdahl says.

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Long-term glaucoma management
Among the other tools used to manage glaucoma, selective laser trabeculoplasty (SLT) offers a successful first-line treatment. This approach selectively targets pigmented trabecular meshwork (TM) cells, with research showing successful decreases in mean intraocular pressure (IOP). Other methodologies involve the use of stents, subconjunctival devices, and trabecular meshwork procedures that offer glaucoma relief. Among the treatments mentioned were original iStent (Glaukos), Hydrus Microstent (Ivantis), Kahook Dual Blade (New World Medical), Omni Glaucoma Treatment System (Sight Sciences), and Xen Gel Stent (Allergan).

“To me, minimally-invasive glaucoma procedures are really a no-brainer,” Dr. Schweitzer says.

However, ODs need to be careful when deploying newer technologies.

“The right thing for the patient may not be the right thing for the eye,” Dr. Berdahl says.
Certain therapies may not be covered by a patient’s health insurance. In those cases, the OD needs to balance the patient’s personal needs with the best medical approach.

“What I usually believe the right thing for the eye is to try a trabecular bypass approach first,” Dr. Schweitzer says.

This approach can produce dramatic results without the need to resort to more invasive implantations, he says.

Stopping glaucoma medications
A common concern for glaucoma patients is the type of daily management they will need to maintain after their surgery. “When do you take a patient off a medication after a MIGS procedure?” Dr. Schweitzer asks. Dr. Berdahl suggests keeping patients on medications for at least a week prior to the procedure, then decreasing medications, as needed, based on IOP.

Again, ODs must keep the patient’s expectations in mind during these discussions. “A lot of times patients want to know if they will get off their drops after surgery,” Dr. Berdahl says.

As the stewards of the patient’s postoperative care, ODs will need to make sure they are coordinating with their surgical partners to come up with the right answers for the best patient management.

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