Standards of care in treating glaucoma

Standards of care are just that: standards. They are what we as clinicians are required to abide by, at the very least, with respect to our duty to care for our patients. Many of us often go above and beyond what is minimally required of us. The field of ocular surface disease is an excellent example of this notion, with many of us incorporating modern dry eye tests that haven’t yet made it into the dry eye standards of care regimen. I say “yet” because standards of care, almost by definition, change over time.

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State by state

With that being said, let us turn to standards of care with respect to glaucoma. While high intraocular pressure (IOP) is often the number-one risk factor for the development and progression of glaucoma, it also happens to be just about the only risk factor we can modify.

We can’t change race, family history, or tonic central corneal thickness, but we can lower IOP. On the medical side of IOP treatment, prostaglandin analog eye drops taken at bedtime are typically the first-line therapy of choice.

Most optometrists in the U.S. practice in areas in which they are able to prescribe glaucoma medications, such as prostaglandin analogs. However, a minority of states have laws allowing optometrists to use injectable medications as well.

This statement is somewhat skewed by the fact that some of those states allow for the use of injectable medications only in the case of anaphylaxis, such as Texas and California.

Therefore, the whole notion of which states allow what is underscored by the fact that optometry is a legislative profession. Until we can all unify in a truly “learned” sense that we should be able to practice how we were trained no matter where we live, we will remain a legislative profession-at least for the time being.

Taking the legislative approach is costly and time-consuming, but it is what we currently have as the most promising means of giving our patients the care they deserve (and we deserve to be able to give). Most other professions do not bear such a burden.

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Glaucoma standards of care

So, what does any of this have to do with glaucoma standards of care? We know that standards of care change over time as novel concepts provide for new diagnostic and therapeutic approaches. With that said, at least one company, Allergan, is working to get FDA approval for an injectable sustained release prostaglandin analog implant (Bimatoprost SR) to lower IOP.

FDA approval could happen within a few years and could have the potential to shake up the notion of defining first-line therapy. Medication compliance would essentially be a nonissue, potentially leading many patients and doctors alike to choose this route of delivery.

In the coming years and decades, eye drops may likely become less commonplace in the face of sustained release formulations, be they in the form of an injectable, a contact lens, a membrane, or some other modality which hasn’t yet been invented.

Along a similar line, new and novel glaucoma therapies that exist such as eye drops are likely to become part of our medication artillery as well.

Rho kinase inhibitors (so-called ROCK inhibitors) seem especially promising as a new means of facilitating aqueous outflow via direct targeting of the trabecular meshwork and Schlemm’s canal.¹

On the other hand, there could come a time when injectable medications such as anti-VEGFs are available in an eye drop formulation. This may be a bit more far-fetched, but it would make sense to avoid penetrating the globe with a needle.

Regarding standards of care and scope of practice, we must not think only in the present. We must continuously look and think to the future about what we do and for whom we care. It may be difficult to prevent the onset of glaucoma, even with the recent strides we have made in the area of diagnostic devices.

We currently have excellent means of therapy available to treat the “silent blinder” that is glaucoma.

However, as we look to new ways of improving patient compliance and decreasing patient burden, we, by definition, must look to new classes of medications or new delivery methods-or both.

We must, therefore, keep a pulse on our state laws and an eye out for those who want them changed. This could mean anything from looking into doing away with itemized formularies to augmenting state laws to allow for novel drug delivery mechanisms (and anything in between).

Health care is constantly evolving, and glaucoma care is no different. If we are going to remain America’s primary care eye doctors, we must evolve as well. It’s the most logical thing to do with our patients’ care in mind.

Reference

1. Kaneko Y, Ohta M, Inoue T, Mizuno K, Isobe T, Tanabe S, Tanihara H .Effects of K-115 (Ripasudil), a novel ROCK inhibitor, on trabecular meshwork and Schlemm's canal endothelial cells. Sci Rep. 2016 Jan 19;6:19640