Are Glaucoma Treatment Paradigms Changing?

American Academy of Ophthalmology 2011

Douglas J. Rhee, MD; Shuchi B. Patel, MD


November 03, 2011

This feature requires the newest version of Flash. You can download it here.

Talking Glaucoma at AAO 2011

Douglas J. Rhee, MD: Welcome to Medscape Ophthalmology Insights. My name is Douglas Rhee. I am an associate professor of ophthalmology at the Massachusetts Eye and Ear Infirmary and Harvard Medical School. Joining me today is Dr. Shuchi Patel, director of glaucoma at Loyola University in Chicago. We are here today at the American Academy of Ophthalmology (AAO) meeting in Orlando to discuss the latest developments in glaucoma.

Dr. Patel, can you bring me up-to-date on what is happening at the meeting? What was the most impressive finding, paper, or discussion that you heard that you think will have an impact on your practice? What have you heard that you can apply starting on Monday?

A New Paradigm in Selective Laser Trabeculoplasty

Shuchi B. Patel, MD: Many great points came from the meeting. The one that was most applicable to my practice and to practitioners of glaucoma is what we heard about selective laser trabeculoplasty (SLT). SLT has often been used in the treatment of glaucoma; it is often reserved for patients who may be on maximal medical therapy, patients who need a slight drop in pressure, but in whom you may not want to add a second agent, or in patients with noncompliance issues.

Dr. Rhee: Further down our paradigm -- we are talking about marching down therapy -- maybe starting with medications and proceeding to laser and then to surgery. That has been the traditional paradigm. Would you agree with that?

Dr. Patel: Exactly, and that is how most practitioners look at laser in the spectrum of treatment.

Dr. Rhee: What did you find different at this meeting?

Dr. Patel: At this meeting, the issue was raised that SLT could perhaps be used as first-line treatment and offered to patients earlier in their treatment course. I found that quite interesting because many clinicians reserve SLT for later in the paradigm for treatment. It was noted that SLT could also be used in younger patients. Previously, it was believed, and literature showed, that SLT worked better in elderly patients or in patients with pseudoexfoliation or pigmentary glaucoma. Many patients waited until they were on maximal medical therapy; therefore, they were also a little older. However, it was shown that SLT could also work in younger patients.

Dr. Rhee: When you are talking about laser trabeculoplasty, do you think that this also applies to argon laser trabeculoplasty (ALT) or only SLT?

Dr. Patel: According to the material that was presented and what I have found in my practice, this is more applicable toward SLT.

Dr. Rhee: Is SLT your preferred therapy?

Dr. Patel: More and more ophthalmologists and glaucoma specialists are converting to SLT as their first-line treatment as opposed to ALT, although SLT can be effective after ALT.

Tips for Performing SLT

Dr. Rhee: Can you share with me and our viewers how you perform the procedure?

Dr. Patel: I prefer to do SLT at 360 degrees, so after giving appropriate anesthetic treatment and checking that the patient does have an open angle and that it would be appropriate for doing SLT, I start the laser settings at about 0.8 mJ and then titrate up or down accordingly. I look for "champagne bubbles" and I like to see them at least 50% of the time. From there, I treat the entire 360 degrees.

Dr. Rhee: Very good. What if you have a patient in whom you see too many champagne bubbles or none at all? How do you handle that?

Dr. Patel: If I see too many champagne bubbles, I try to titrate the power down. Having too much power is a higher risk for having postoperative spikes in intraocular pressure (IOP) and a higher rate of inflammation. I would titrate the power down. If I see too few bubbles, I would titrate the power up, but be a little bit cautious past about 1.3 mJ. Patients with lighter pigmentation tend to need a higher power.

Dr. Rhee: After the procedure is done, what is your postoperative management? It has been fairly controversial whether to use topical corticosteroids, nonsteroidal anti-inflammatory (NSAID) drops, or nothing at all. What is your preference?

Dr. Patel: The standard has been to use either an NSAID or nothing at all. The literature has said that using a steroid may actually diminish the effectiveness of the laser because inflammation was thought to be part of the process for lowering the IOP. That was another interesting point brought up in this meeting. It has been found that using a steroid does not reduce the efficacy of the SLT, but it may increase the patient's comfort. That may be something that I will change because currently I am using just a nonsteroidal agent in patients who have inflammation or photophobia. Otherwise, I don't add any medication at all to their regimen.

Dr. Rhee: It is certainly great to hear that we have a range of options for postoperative management.

The Effect of Cataract Surgery on IOP

I am going to switch to a different topic, and I want to ask for your perspective. There was some discussion about the effect of phacoemulsification cataract surgery on IOP. There has been some discussion and a movement toward considering that as a glaucoma procedure. What are your thoughts on that?

Dr. Patel: This topic has been around and discussed for many years. Given that cataract surgery is the most commonly performed ophthalmic procedure, is relatively safe, and has the benefit of increasing and improving vision for patients, that as a first-line treatment for reducing pressure it is becoming more popular. Patients who have severe glaucoma are at risk for having a postoperative IOP spike. No one knows the exact numbers, but it is 5%-10%. Physicians should be ready to do an emergency procedure such as a filtering procedure trabeculectomy should a patient need that following cataract surgery.

Dr. Rhee: What I am hearing is that for earlier-stage disease, for patients who need a modest reduction of pressure, cataract surgery alone might be beneficial.

Dr. Patel: I would agree, and in my own practice I am offering that as first-line treatment more often before jumping directly to a glaucoma procedure or even a combined procedure.

Dr. Rhee: In terms of your [patients with] severe glaucoma, how would you handle them?

Dr. Patel: In [patients with] severe glaucoma, the literature has shown a modest drop in pressure after cataract surgery in patients with primary open-angle glaucoma as opposed to chronic angle closure glaucoma. Therefore, I would still proceed with a combined procedure, knowing that the reduction in pressure that may be required may not be achievable with cataract surgery alone, or that the risk for a postoperative IOP spike may be more detrimental to the patient.

Dr. Rhee: That is what scares me -- the postoperative spike. I agree with you that a combined cataract infiltration procedure is often the way to go for patients with advanced disease.

A Global Perspective on Glaucoma

I happened to be at the subspecialty day put on by the American Glaucoma Society in conjunction with the AO and I was very impressed that they had a section on global health. I thought it was a different take. What did you think of the session?

Dr. Patel: This was a very different view than previous talks on international medicine, especially international glaucoma. What was really interesting about the talks this year was the inclusion of how to set up infrastructure in these areas so that there can be maintenance and continuity of care for these patients, as well as how to build further glaucoma care for the patients and what is more appropriate therapy in places that may not have the resources available.

Dr. Rhee: The focus on how we can get involved as physicians and help build the infrastructure for the on-site practitioners and sustain their ability to take better care of their patients was fantastic. That was a new perspective.

Surgical Decision-Making in Glaucoma

Who wouldn't enjoy Dr. Heuer?[1] He was the keynote speaker and the honoree and also gave a lecture about surgery. Did you happen to see that? What did you think of his lecture?

Dr. Patel: His lecture was very enlightening. It brought up so many salient points about how physicians, especially glaucoma specialists, have approached surgery, whether they do early surgery or late surgery. It was very interesting to see how his practice has changed. He said that early in his career he would have waited to do surgery on patients so that he was not the initiator of any poor outcomes, and it was interesting to see that now, with his experience, he would proceed with surgery earlier so that there could be better outcomes. It was really interesting to see that because, as a young physician, I am going through the same fluctuations in my decision-making.

Dr. Rhee: Plus he has such depth of experience, and he is a great critical thinker. Thank you, Dr. Patel. We covered some great topics and I know I learned some things. This is Douglas Rhee and Shuchi Patel for Medscape Ophthalmology Insights.