Interventional glaucoma management: The art and science

Lee Peplinski, OD, FAAO

Lee Peplinski, OD, FAAO, from Focal Point Vision, San Antonio, emphasized the importance of interventional care in patients with glaucoma—sooner rather than later is advantageous in the disease process. He described the rationale for interventional rather than passive treatment.

Traditional glaucoma care can be associated with obstacles such as medication toxicity to the ocular surface, cost, patient compliance with drug instillation, and treatment fatigue associated with chronic care.

The art of glaucoma care

In this scenario, the care is patient centered, patient specific, and individualized, he explained, and outlined 4 objectives to embrace interventional glaucoma management.

Objective 1 for clinicians is to identify the differences between passive and interventional glaucoma management. Engaging in passive glaucoma treatment, according to Dr. Peplinski, involves reacting to outside influences such as insurance formularies and/or following a cookie-cutter approach to treatment; yielding control as in compliance failures; lethargy on the part of the patient (or the clinician); and finally failure to take an active role in treatment.

In contrast, interventional treatment exerts 3 actions: interference with the course and outcome of glaucoma; for example, performing selective laser trabeculoplasty (SLT) or stent placement that stops progressive obstruction of the trabecular meshwork and more visual loss; modifications that hinder the natural disease progression, such as lifestyle changes that improve circulation and perfusion; and promotion or prevention of an action that initiates lowering of the intraocular pressure (IOP).

Objective 2 involves recognizing the advantages of early intervention in the glaucoma disease process. “Early intervention decreases visual field loss, functional visual loss, blindness, and the need for more invasive surgical procedures,” Dr. Peplinski enumerated.

Objective 3 is gaining an understanding of the various interventional methods and when to use or recommend them.

Dr. Peplinski suggests lifestyle counseling that may include promoting moderate exercise, with the goals of improving circulation and perfusion, specifically 30 minutes of cardio exercise 3 times weekly; preventing nocturnal hypotension by avoiding the use of systemic hypertension medications before bedtime; being aware of the effects on the IOP of weight-lifting and head down yoga positioning, which can cause significant transient pressure elevations; and recognizing the benefits of yogic breathing, which has been associated with lowering IOP.

Alternative therapies such as ginkgo biloba, mirtogenol, black currant, and other non-allopathic drugs may have a supportive place in glaucoma management.

He also suggests minimally invasive procedural care that carries the following advantages: less or no impact on the ocular surface, decreased long-term cost, less or no reliance on compliance, less patient burn-out, and while not achieving a cure or eliminating patient monitoring, buys time until the next best procedure is needed.

Optometrists can perform some procedures, such as SLT and insertion of intracameral medical implants, i.e., Durysta (bimatoprost 10 mcg, Allergan) in some states. Optometrists can engage in co-management of these procedures in every state.

Other interventions that ease the patient burden are implantation of the iStent (Glaukos) and Hydrus Microstent (Ivantis) during cataract surgery. Stand-alone devices include the Xen Gel stent (Allergan) and the Express Mini Glaucoma Shunt (Optonol Ltd.).

Minimally invasive glaucoma surgeries that do not involves device implantation include the Kahook DualBlade (New World Medical), the Trabectome (NeoMedix) and OMNI (Sight Sciences), all of which enhance aqueous outflow. Procedures that suppress aqueous are endocyclophotocoagulation, and diode cyclophotocoagulation.

Objective 4 involves developing a mindset and an approach to providing interventional care.

Dr. Peplinski emphasized that there is no one approach that fits all patients. “Knowledge is power and provides options. Be a patient advocate. Listen to your patients and they will help guide your intervention,” he concluded.