By Dr. David Anderson – We have all heard the statistics about undiagnosed glaucoma, the aging population, and the opportunity that exists in our practices because optometrists provide nearly 75 percent of all primary care eye exams to our communities. I agree that we will have the biggest impact in diagnosing glaucoma, but also in the treatment of glaucoma.
Many optometrists have been treating glaucoma for years; we all are well trained in the diagnosing skills for glaucoma, and most of us have amazing technology to help us find the disease many years prior to any vision damage. We also know that the treatment options that are available are highly effective. But what percent of our patients are compliant? What does compliance mean to our patients? Does following our instructions most of the time mean compliance? More than 50 percent of patients are non-compliant in all of health care, so what do we do with this? How do we treat a painless, asymptomatic disease in a non-compliant world?
This leads to the reason I love treating and managing patients with glaucoma. Our treatments have varying degrees of success, carry side effects and are not fully understood by our patients. And in glaucoma care, treatment is rarely black and white. Most often we are managing patients who may have several options for the next step in care. In fact, it is rare that 100 percent of doctors would choose the same follow-up care, diagnostic test frequency and medication for first and second line treatment.
We all have different ideas for each patient encounter. What I love about glaucoma is not the gray area, but that the gray area gives us an opportunity to discuss the condition with the patient and involve them in the care plan while discussing the various options. Following Woody Hayes’ comments about passing the football, I tell every patient there are four things that happen when I prescribe a medication for a long-term condition, and three are bad:
1. We provide a vision benefit.
2. We introduce potential side effects.
3. We change a patient’s lifestyle and routine.
4. We add to their health care costs.
Those negatives are potential barriers to compliance and, therefore, successful treatment and vision preservation. So for each glaucoma patient, when considering a medication, I always discuss surgical options, especially SLT.
During the last 10 years, SLT has been shown to be as effective as all of our first and second line medications. SLT shows similar pressure-reducing effects with minimal side effects, while drastically reducing compliance issues for most patients. The way I have incorporated SLT in to my practice is much the same way we have all incorporated cataract care into our practices. A few years ago, I spoke with my favorite cataract surgeon about SLT. I asked him how many he has done, what his success rate was, and what type of follow up he usually does. I also asked if he was willing to co-manage SLT surgery for my glaucoma patients, and how best to coordinate this. Over time, we have developed the best set of record sharing and follow-up strategies for my patients, much like we did for cataract surgery patients.
In the few years that I have done this, I have learned a few things about SLT co-management, including the best patients for the procedure, and the things my surgeon does on each patient before, during and after the procedure.
The best candidates are ocular hypertensives who have other risk factors like family history or thin corneas but little to no visual field loss. Another great candidate is a patient on multiple medications who may have suspect compliance or admits to frustration with using drops or their side effects. The last patient that tends to do well with SLT is someone who is currently progressing. I offer it to this last group primarily to buy some time until better medications are available or more research could give us different perspective. With SLT having up to five years of pressure control, time can be a huge asset for many of our patients.
Of course, many optometrists may wonder, why would an ophthalmologist want to co-manage a disease patient? The answer is two-fold and very simple: they have worked with our cataract patients for years and have seen the quality of care we provide to our patients, and they are surgeons and would rather do surgery than check pressures and discuss field loss with a patient every few months.
Reach out to your ophthalmologist and present them with an opportunity to do more for your patients. Most would love to partner with you to provide the best care for your glaucoma patients.