Managing glaucoma patients as an IP optometrist

The question:

A male patient attends complaining of sore eyes and there is significant ocular surface disease on examination. He has advanced glaucoma, with sub-optimal intraocular pressure control. One week ago, at the hospital glaucoma clinic, his treatment was augmented with the addition of Betoptic (betaxolol) in both eyes. He already takes Ganfort (bimatoprost/timolol) and Trusopt (dorzolomide). The patient also has asthma. How would you manage?

OT’s panel says...

Ankur Trivedi: The use of an additional beta blocker when the patient is already using timolol (in the Ganfort) is unlikely to be helping with the intraocular pressure control (IOP). I would expect the new medication to be from a class of ocular hypotensive agent that is not currently represented.

Use of beta blockers is contraindicated in an asthmatic patient. I would want to ask about any issues they were having with their breathing before the Betoptic was started, and if the new medication has had any further impact on their asthma control.

The patient was on triple therapy before the Betoptic was started – an addition of a fourth agent has a low chance of being successful in sufficiently managing/controlling the IOP. I would expect that this may be intended as a short-term management option, as a surgical based option may be a better option for this patient.

I am in the privileged position that I work one day a week with the local trust in a Glaucoma Shared Care (GSC) clinic. Because of this, I would feel comfortable contacting the consultant ophthalmologist the patient is under to confirm and clarify the clinical management plan for this patient.

We have the award-winning Community Ophthalmic Link (COL) system in Gloucestershire, so I would access the patient’s ophthalmology notes if they give me permission to do so, to ascertain the above if needed. A conversation with the consultant, to raise my concerns and to clarify what I expect is a misunderstanding re the Betoptic, would be required.

The ocular surface disease issues are unsurprising given the topical medications being used, especially if we assume they are all preserved versions. Management of the OSD would require switching to preservative-free versions where possible. Use of preservative-free artificial tears to allow for some symptomatic relief is important – however, the patient needs careful counselling on leaving adequate time in between drops being instilled.

There is a strong prevalence of lid margin disease in glaucoma patients who are medically managed, so advice around lid hygiene and warm compresses is also very worthwhile.

Kevin Wallace: I agree with Ankur that I would want to carefully check about breathing issues with this patient – that should have been considered already by the hospital eye service (HES), as it can cause serious issues in patients.

It is also important to not interfere with what the hospital is doing. That is a theme that I have seen many times in General Optical Council complaints over the years – more commonly in something like a child who is under the HES and has their specs changed, but the principle is the same – you shouldn’t interfere with their treatment, especially when you don’t have all the information. It’s also very important to communicate clearly with them if you do change something. This case is particularly simple in that regard because they were seen very recently in the HES – so their findings would have been very similar.

It’s definitely worth checking how they are using the drops – just last week I saw a patient who was putting both of his glaucoma drops in at the same time, and the effect wasn’t what I was hoping for, so it’s worth checking even patients who have had treatment for a number of years – a bit like with contact lens compliance, people can get into bad habits without realising. They may have multiple drops, but they are not working as expected because of how they are using them – for example, all at the same time, or at the wrong time of day or in the wrong dose.

In more simple cases I would be happy to change someone to, for example, a preservative-free version of the same type of drop and then discuss that with their consultant. In this case, all drops are available in a preservative-free version, so if they’re not using those already that would be a good idea. As Ankur said, it isn’t surprising that this patient has surface issues – in my experience many patients using multiple drops, for multiple years, have a similar appearance of irritated, uncomfortable looking eyes.

Anecdotally, I have found that using a lid scrub helps – it appears to be helpful by removing the build-up you can get from all the drops, and I would definitely prescribe a preservative free lubricant – again, reminding them about not putting their drops in at the same time.

It does appear that this patient is not controlled even on multiple drops, so I would hope that other options such as Selective Laser Trabeculoplasty or drainage surgery are being considered – if I saw them in my community clinic, I would be referring back to the HES for that.

I think it is important to know the limits of your own scope and experience

Ceri Smith Jaynes: I think it is important to know the limits of your own scope and experience. Although I’m IP qualified, meddling with this case would be outside my scope of practice. My only experience of managing glaucoma has been in virtual clinics, where most of the patients had ocular hypertension or stable glaucoma, and we had oversight from an ophthalmologist. I’ve only ever prescribed a hypotensive drop for short term, when managing a steroid responder, and that was after speaking to the hospital to form a plan.

I have a friend who works in a glaucoma clinic and has the College of Optometrists’ Professional Diploma in Glaucoma. Chatting with her makes me realise how complex glaucoma management is and how little I know about it.

My role for this patient would be to provide first aid measures: check for a foreign body, protruding stitch, and improper lid closure, and supply a preservative free lubricant, if needed. I doubt the ocular surface would recover just by adding a lubricant. However, I’m not going to be giving advice on glaucoma drops, other than checking the patient is using them correctly; some patients have forgotten (or weren’t shown) how to occlude the puncta after instillation. Then, I’d write to the consultant and explain the signs and symptoms seen today and anything I had done to help. If the patient has an appointment in a couple of weeks, then I’d leave it at that, but if the follow-up is in a few months, I might ask if they wish to review the patient again sooner. In my area, the local eye secretaries can be helpful, so I would send them an NHS email.

Please contact the AOP’s clinical and regulations team via email or phone on 0207 549 2020, extension 1, for advice in any situation where you are unsure how to manage a patient.