Transcript
Speaker 1:Glaucoma is a group of conditions that lead to deterioration of the peripheral visual field and irreversible vision loss. Although it is the leading cause of irreversible blindness, the only modifiable risk factor currently supported by clinical trials is IOP control. As a result, timely treatment to lower IOP [00:00:30] is imperative to slow the rate of vision loss from glaucoma with common methods including topical medication, sustained release drug delivery, laser treatment, and surgery. As the landscape of glaucoma treatment evolves and minimally invasive options are integrated into clinical practice, early stage disease management represents a pivotal therapeutic window to which timely intervention may prevent lifelong visual disability. In recent years, advancements [00:01:00] in both procedural and pharmacologic modalities have transformed clinician's approach to managing this phase of the disease.
The early stage glaucoma consensus group reflects the perspectives of experienced glaucoma specialists and comprehensive ophthalmologists, uncovering a harmonized view of how selective laser trabeculoplasty and sustained release drug delivery systems may function as a complimentary tool in the early stage [00:01:30] glaucoma treatment algorithm. The consensus group participated in an online survey and follow-up interviews to address prevailing practice gaps and establish current practice patterns in attempt to advance the care of patients with early stage glaucoma.
Emily M. Schehl...:[00:02:00] What I talk to my patients about is I say glaucoma is a chronic disease, and this is what we're going to start with, which is usually SLT. And then we have all these different things in our toolbox that we can choose from over this journey. And my hope is that we'll do something and then we will be able [00:02:30] to just monitor you for a couple of years, but it's really difficult. Everybody's disease progression is different. So if I see that a patient is progressing either on their visual field, or again, we have OCT, so if I see pre-parametric progression, I'm also going to treat them. But I also will set an IOP goal. And if, for example, they have a great response to SLT and then a year later, it wears off, then we're either going to repeat the SLT or we're going to move to [00:03:00] it probably something like eye dose or a standalone minimally invasive glaucoma surgery option.
Speaker 1:67% of the early stage glaucoma expert consensus group believe lack of perceived disease severity and the asymptomatic nature of the disease is the biggest barrier to patient adherence in early stage glaucoma. Side effects of treatment is another barrier seen by 33% of the consensus group.
Emily M. Schehl...:There's [00:03:30] no appreciation for this sort of invisible disease, and then also side effects. You're trying to explain to patients that they have this invisible disease that you're trying to treat before it gets to a part where it's actually going to impact their vision, but then you also have to make them intervene on it. And they're like, "What? I don't have any problems. You're giving me problems by putting me on drops." I also have a lot of patients, so that's really hard. I think that's where [00:04:00] a lot of people struggle being interventional because patients, if your knee hurts, the patient's going to be like, "Well, yeah, I need knee surgery." But if you have pre-parametric glaucoma and you're trying to be more aggressive, I think it's really hard for them to wrap their mind around. So I've worked really hard to figure out how to explain things to patients in a way that they will understand so that they're more comfortable doing an SLT or doing a drug delivery or going to the operating room prior to cataract surgery to do standalone MIGS.
And I think that I've developed [00:04:30] a lot of tools that many of my patients are on board. But I also think that there's a lot of patients who are non-adherent if they're on eye drops because of ocular surface disease, but I think there's even more patients who are not adherent and they don't even know they have ocular surface disease. It's this sort of unconscious thing where they're like, "I don't know that my eye drop is causing my eye to feel bad, but I'm not going to take it just because something's going [00:05:00] on." So I think there's so many patients who come into me and they're not complaining of ocular surface disease, but then I'll do something interventional, get them off their drops, and they're like, "Oh my gosh, I feel so much better. I didn't even realize that I was uncomfortable." And that happens all the time. So I think the patients that report ocular surface disease in a lot of these studies that we cite are probably way under-reporting the side effects in the real world from glaucoma drops.
Manjool Shah:When you have a disease that you don't feel, it's really [00:05:30] hard to buy into chronic lifelong therapy that's going to not be fun and not help you in any way as far as you can tell. So that's definitely number one for sure. I think all the other things you mentioned, cost, just remembering to take the thing, the tactile skill of putting a drop in the eye, these are all real issues that need to be dealt with. But I think for early stage glaucoma, undeniably, problem number one is like, [00:06:00] there's nothing wrong with me. I see great. And now you're making me do this thing that makes me not feel great and not see great. It doesn't make sense.
Inder Paul Sing...:If you're going to give someone a drop, especially for the first time, give them an artificial tear and have them take it in front of you, see how bad it is. It is scary. Very few people can actually take a drop the correct way. And there's been data sets out there videotaping [00:06:30] people, giving them instruction sheets, and then showing that even with the video instruction and it telling them how important it is to take the drops correctly, that about 80% of patients don't take their medications correctly, whether they touch the lid, they don't get it in their eye itself, it gets on their cheek, they contaminate. So I do think the physical attributes and the ability to actually physically take a drop, let alone the knowledge, let alone the kind of forgetfulness and all the other things that happen, that just the physical ability to take is not easy.
I'm one of those people who can't take, I cannot take a drop. [00:07:00] It takes forever for me to get a drop in my eye. I can put drops in anybody's eye but my own. So I think it's a real issue. And I don't think we spend enough time really figuring out can this person take this drop, especially if they live alone. And I think it's a serious issue that we sometimes minimize or forget to even ask about.
Lorraine M. Pro...:I tell patients that there's no cure [00:07:30] and that no matter what treatment we do, there's always a chance that we could have to do more down the road and that it could continue to progress. So I say, "Just because we're doing this and you don't have to do a drop at home, that doesn't mean that it's gone and that you don't have to have follow-ups." So we still talk about regular follow-up. I co-manage a ton, so I'm usually not keeping them in my clinic, but what I do is I think part of my job as a specialist is to guide the [00:08:00] primary eye doctor on how often they need to be seen.
So I'll put that in the note, recommend interval of follow-up every six months or every three to four months or something like that. I say that to the patient as well so they can kind of help own that. But I don't scare them, but I set the story that this is a lifelong journey and that we're going to have to do multiple things over the course of their lifetime.
Speaker 1:[00:08:30] The early stage glaucoma consensus expert group lists several factors that influence their decision to escalate treatment in early stage glaucoma, including progressive structural changes on OCT, progression of visual field loss, lack of adherence to current treatment regimens, poor IOP control, and patient-specific risk factors.
Zarmeena Vendal:[00:09:00] So a few factors right off the bat I can name, the aggressiveness of the condition, so strong family history, super thin corneal thickness. If I see a lifestyle, which is often the case in my Austin patients, quality of life, lifestyle issues which I know right away show me that there's a good chance the patient will have trouble being compliant. Ocular surface disease, that's a big one.
Speaker 1:The top three most [00:09:30] critical missing elements in current early stage glaucoma management guidelines, as identified by the early stage glaucoma expert consensus group, are more emphasis on SLT as first line therapy, clear guidelines on when to initiate treatment, and a shift toward precision medicine and personalized treatment algorithms.
Zarmeena Vendal:The most critical element that we're missing right now is a general consensus on how we as [00:10:00] clinicians should approach this condition. We have a toolbox, we have a very expanded toolbox now, thankfully. We have a condition we have to deal with for the rest of the patient's life, so we need an expanded toolbox, but I would say that we as clinicians, unfortunately, are still the number one rate-limiting step. We haven't quite made the leap yet to take all of the data that we now have in our hands and make recommendations proactively. And [00:10:30] so in the world of early stage glaucoma, I would say we as clinicians are really at the rate-limiting step still, that we do not all strongly proactively recommend things like laser therapy, for example, unanimously.
Swarup S. Swami...:I think precision medicine is a sexy terms to throw around in healthcare. And to be clear, I think especially in oncology and some other areas, I think we do have some evidence of personalized therapy when we can characterize a tumor and [00:11:00] kind of get targeted immunotherapy. So there's some evidence of that, but I think it's still a ways away for us in ophthalmology, but I think it kind of gets at what we're talking about, which is what clinicians do ultimately, and I think what AI is striving to do, which is to take the entire picture of this patient to figure out how should I initiate treatment.
Manjool Shah:So I think the two things that I'd like to see us as a community do better at is, again, leaning a little bit harder on [00:11:30] SLT and doing good quality gonioscopy.
Zarmeena Vendal:And in Texas, certainly in Austin, we have a lot of people walking around with either environmental issues related to ocular surface disease to begin with or computer use, and so a lot of meibomian gland dysfunction. And so that's another big one for us.
Swarup S. Swami...:These medications are not without adverse effects. And [00:12:00] I think in some ways, I tell patients it almost causes a slow burn of your ocular surface. You don't notice it today, you don't notice it next week, but over years, and we see these patients that come through our clinic who've been on medications for 20, 30, 40 years of putting a drop in every day. I mean, if you think about that, even if you use a medication once a day for 10 years, that's over 3,600 drops that you've been putting on your ocular surface. [00:12:30] It's a lot. You multiply it by the volume, and then you can calculate how much you're pouring into your eye of chemicals.
So these patients, what I try to tell them who are often either early disease or they have a little bit of meibomian gland dysfunction, dry eye, I say, "Look, this stuff has the potential of making this worse as you kind of get older, and so I really think this is a great option for you to consider." So I think the older patient, the patient with some [00:13:00] underlying surface dysfunction, the patient who's got the arthritis that just prevents them from being able to squeeze the bottle, those are also common.
Speaker 1:To read the consensus statement in its entirety and complete the related CME activity, scan the QR code on this screen.
