COMMENTARY

As Glaucoma Management Evolves, New Surgical and Therapeutic Options Abound

Christina M. Sorenson, OD

Disclosures

September 07, 2016

Out With the Old, In With the New

The algorithm for treating glaucoma used to be fairly straightforward: Begin with drops, add drops, add more drops, adjust drops, add oral medications, try laser, and then do the surgery, trabeculectomy. This methodology, like many of the drops we used to use, has fallen by the wayside. Management remains our only avenue of "treatment" with this group of diseases as a cure continues to be elusive. Our management scheme is now increasingly varied—much more an ecosystem than a food chain.

Drop therapy enriched our management pool over the past two decades. We have benefitted from the addition of once-daily prostaglandin analogues. The topical carbonic anhydrase inhibitors and alpha agonists have augmented intraocular pressure control, while combination medications have made patient compliance one step easier.

New classes of medications for clinical treatment, which target the trabecular meshwork and are suspected to have multiple mechanisms of action, are close to being available. They promise to have greater efficacy with less frequent dosing. Once readily available, these medications hold the promise of bringing us closer to the ideal of "few drops, great results" in our quest for intraocular pressure control.

New Surgical Options

In addition to advances in topical therapy, surgical intervention now occurs earlier, is less invasive, and has the potential to leave the appropriate patient drop-free.

The cornerstone of excellent long-term successful glaucoma management is timely referral when surgery is indicated. Waiting until all topical management has failed is no longer the standard of care. Surgical intervention, whether laser or incisional, is seen in early or moderate stages of the disease and is best performed before progressive visual field loss has been established.

A solid relationship with a glaucoma surgical specialist will enhance your patient care, compliance, and co-management outcomes. It behooves all co-managing doctors to understand what surgeries are available and when they are appropriate. The more we understand this, the better our patient care will be.

Surgical options with lasers include those that treat the trabecular meshwork to increase outflow, such as argon laser trabeculotomy, selective laser trabeculotomy, excimer laser trabeculotomy, and MicroPulse laser trabeculoplasty. They also include those that decrease aqueous production via destruction of the ciliary body, such as MicroPulse transscleral diode cytophotocoagulation or endoscopic cyclophotocoagulation.

Surgical options that involve placement of a device to assist in outflow include iStent and CyPass Micro-Stent (as part of microinvasive glaucoma surgery), the Ex-PRESS glaucoma shunt, and the more traditional tube shunt devices. Canaloplasty, with its lasso suture that is left in place, might also be included in this category.

All surgeries will alter anatomy, but there are several used in the management of glaucoma that will change it to bypass impediments to outflow. These include, among others, Trabectome, gonioscopy-assisted transluminal trabeculotomy, and goniosynechialysis.

Enhancing Patient Care and Outcomes

Glaucoma management is evolving, with newer medications and early and more varied surgical options.

The care of our patients with glaucoma remains a long-term commitment to slow the progressive vision loss that may occur despite the best therapy. Understanding the changing treatments with earlier surgical intervention and co-management responsibilities will enhance patient care and outcomes.

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