When caring for glaucoma patients, one of the toughest jobs can be accurately communicating the patient’s disease stage, velocity, and prognosis in a way that allows them to achieve the best outcome. For us to be successful in glaucoma, getting this right is essential. However, for many reasons, it isn’t as easy as it sounds.
I attribute George Spaeth, MD, as the one who said that for the glaucoma patient, the single greatest decrease in quality of life on a single day will be the day that they take their first topical eye drop. This begins the routine of having to worry enough to take drops every day, not to mention a potential lifetime of side effects to topical therapy. Patients are often and quite easily lured into using topical medication, because it makes them feel like their disease is benign and easily controlled. They may also like the fact that when they take the drops, they are personally doing something to stop their disease.
The paradox is that, while we want to preserve our patients’ quality of life, we also aim to avoid overburdening them with concern or worry. Because the medical field generally follows a treatment model that prioritizes oral medications, it is reasonable for patients to expect that medicine should be tried before other interventions.
This is the central challenge—and opportunity—facing interventional glaucoma. We now have interventions, such as MIGS and sustained delivery, that can comfortably replace topical therapy, and others, such as SLT, that may even be superior. These options work well as initial treatments or very early in the disease process. The challenge is motivating patients to accept these therapies during the asymptomatic phase of the disease.
I believe that our best hope of doing this is to entirely reset the way we introduce patients to the disease of glaucoma, and to our treatment options. To begin with, our discussion of the side effects and pitfalls of long-term, or lifelong, topical therapy should place greater emphasis on downsides such as cataract formation, dry eye, and the nearly universal challenges with compliance.
We may also do well to tailor our explanations of glaucoma towards the outflow system and how we have therapies that directly treat the diseased meshwork right at the site where the disease begins.
Advances in diagnostics could also be incredibly beneficial here. Just imagine being able to detect the pressure range at which the ganglion cells stop dying for each individual patient.
As you read through the fall issue of Glaucoma Physician, you will appreciate a wide variety of articles that cover different aspects of modern glaucoma management. I am hopeful that our articles will stimulate conversations and discussions within the glaucoma community on how we can present the disease and its treatments to our patients in a manner that helps them achieve the best outcomes. GP
