How to discuss alternatives to eye drops with patients

What are the treatment options currently available to glaucoma patients?

There are numerous treatment options for the treatment of glaucoma and the chosen treatment will very much depend on patient profile and level of disease.

Medications are among the most common treatment options. Currently in our formulary we have beta-blockers, prostaglandin analogues, carbonic anhydrase inhibitors and sympathomimetics. These work by either reducing aqueous production or improving outflow. Patients can be on a maximum of four classes of medical therapies, from each of the above groups. Pilocarpine, a cholinergic agonist, which is indicated for treatment of increased IOP due to angle-closure glaucoma until surgery can be performed, is rarely used now due to the availability of other treatment options with fewer side effects like laser peripheral iridotomy (LPI).

Selective laser trabeculoplasty (SLT) lowers intraocular pressure (IOP) by inducing biological changes in the trabecular meshwork, resulting in increased aqueous outflow. The procedure is performed during an outpatient visit.

Micro or minimally invasive glaucoma surgery (MIGS) is defined by: ab interno, which means that the treatment is approached from within the eye, without dissecting the conjunctiva; minimal trauma; efficacy; high safety profile; and rapid recovery.

MIGS reduce IOP by re-establishing the natural outflow pathway for the aqueous humor from the anterior chamber angle, hence gonioscopy is important to visualise the anterior chamber anatomy. The anterior chamber needs to be fairly open with at least the trabecular meshwork (TM) visible for implanting MIGS devices.

Surgical trabeculectomy is a procedure used in the treatment of glaucoma to relieve intraocular pressure by creating a fistula from the anterior chamber and sub-conjunctival space through the creation of a “bleb.” It is currently the most common glaucoma surgery performed for uncontrolled moderate to advanced glaucoma. Early potential complications of this procedure include choroidal effusions, hypotony, bleb leak, bleb encapsulation and bleb failure from fibrosis and scarring. More serious but rare complications include blebitis, endophthalmitis and suprachoroidal haemorrhage.

Glaucoma tube devices like Ahmed, Moltino, and Baerveldt Valves are required for aggressive disease which can lower IOP significantly. Potential complications of tube valves are similar to those of trabeculectomy, with additional risks of tube obstruction or erosion and corneal decompensation.

What are the main points of consideration that optometrists should be highlighting to patients?

The aim of glaucoma treatment is to control the disease and prevent vision loss. If a patient is on medical treatment, then compliance is very important. If, however, the patient is having difficulty with drops due to various reasons like ocular surface disease, dry eye disease, arthritis, forgetfulness, the optometrist should discuss other alternative treatments that are mentioned above and should encourage the patient to have this discussion with the clinician at their next glaucoma appointment or help the patient by sending a referral to a hospital where alternative treatments are provided.

If a glaucoma patient is developing symptomatic cataracts, then a discussion on combined surgery for cataract with trabecular micro-bypass is very useful.

How should optometrists approach the discussion on treatment options?

While taking symptoms and history, check what eye drops the patient is taking, discuss compliance or any difficulties the patient might be having with the eye drops and checking that the IOP is controlled.

Patients are always interested in new developments and treatment options, and hence a discussion on trabecular micro-bypass, will be a welcome discussion.

What are your three top tips for optometrists when discussing alternatives to eye drops with patients?

1. Know your patient and their profile
2. Keep up to date with new treatments so you can discuss the benefits with your patient
3. Know where these new treatments are provided locally.