While medicated eye drops that lower eye pressure continue to be the first-line choice of many ophthalmologists, laser therapy, minimally invasive procedures, and surgical treatments are also available. How do eye doctors decide which treatments to prescribe for any given patient, and in what order? In a recent article, Janet B. Serle, MD, professor emeritus of ophthalmology, Icahn School of Medicine at Mount Sinai, New York, offers some guidelines for clinicians.

Considerations for Clinicians

The main question facing clinicians with glaucoma patients is which treatment(s) can achieve and sustain the desired level of intraocular pressure (IOP) and prevent both disease progression and further vision loss. 

The most common treatments include:

• Medicated eye drops, which are Self-administered by patients at home
• Selective laser trabeculoplasty (SLT), which causes chemical and biological changes in the eye that improve drainage
• Minimally invasive glaucoma surgeries (MIGS) such as implants (performed in-office) that perform time-release administration of medication into the eye 
• Trabeculectomy, an operation in which a small trap door is fashioned out of the wall of the eye so that fluids made inside the eye have an easier path outwards.
• Tube shunt implantation, involving a small plastic tube that redirects fluid away from the eye’s natural drainage system that has been blocked or damaged 

Currently, even surgical treatments require some post-operative medication therapy.

Clinical Challenges

All existing glaucoma treatments have their benefits and drawbacks. In addition to individual potential side effects, some challenges include:

• Although medicated eye drops are highly effective and the least invasive, they must be administered on a fairly rigid daily schedule, so their effectiveness is dependent on patient adherence, which can be inconsistent.
• Many of the newer MIGS, such as implants, reduce the dependency on patient adherence, but their newness means that their long-term safety and efficacy are not yet known.
• Identifying and diagnosing glaucoma patients early in the disease process can be difficult since noticeable symptoms often don’t manifest until considerable damage has been done. When it is caught early, the question is how aggressively to treat it, particularly in younger patients who are likely to live with the disease for a longer period of time.

Recommendations

Serle suggests that ophthalmologists consider therapies besides eye drops as a first-line treatment is in order to reduce the burden on patients, regardless of how advanced the disease. 

“For each patient, it is important to assess the risk parameters in addition to the stage of the disease,” she said. She also emphasized the need to devise ways to identify, diagnose, and treat glaucoma earlier.

“In some patients, we can hopefully get ahead of progression by treating glaucoma aggressively, and in other patients, we may be able to step back, accept higher target IOPs, and carefully assess the most appropriate therapies.”

This article was reviewed and edited for accuracy by Alan Robin, M.D., a Responsum Health Advisory Council member, ophthalmologist, glaucoma treatment specialist, and leader in the clinical management and scientific study of the disease.

*Charters, L., (2021, June 15). Dropless Glaucoma Treatment an Elusive Path to Ease Burden. Ophthalmology Times. https://www.ophthalmologytimes.com/view/dropless-glaucoma-treatment-an-elusive-path-to-ease-burden