Christine Funke, MD, of Barnet Dulaney Perkins Eye Center, spoke with Ophthalmology 360 about the current state of glaucoma care in celebration of Glaucoma Awareness Month. She talks about the importance of early detection and treatment for this “silent vision stealer.” Dr. Funke also talks about the growing adoption of more interventional glaucoma care among ophthalmology practices.
Question:
Can you talk about the growing national and global burden of glaucoma? Why is the prevalence of this condition increasing, and what factors are impacting this?
Christine Funke, MD:
We are now in a place where we know that the burden of glaucoma is just continuing to get larger and larger. We have at least 12 to 13 million people just in the United States alone who have been diagnosed with the disease of glaucoma, so that means the prevalence is probably even higher than that. Why we’re seeing this enlarging portion of the population with glaucoma is we have an aging population, one, and we know that this is a condition that we see more commonly as people get older in life, and that might just be due to the natural wear and tear of their eye, their drainage structure being used, and there’s also a genetic component that is associated with that.
Then we also know that there’s other comorbidities that may fall into that category, so as people have other disease states, hypertension, diabetes, we know that there’s an indirect correlation with those kinds of things too, which we’re seeing increase in prevalence as well. Then there’s certain subsets of the population where we can see glaucoma as more prevalent, again genetically, in especially the African American community. In the native community, especially where I am, we can see that we are seeing more of an uptick of the disease there, and of course, that’s important because we want to recognize this disease so that we can start managing and treating it so people don’t have negative consequences to their lifestyle.
Question:
Why is early detection and intervention crucial for these patients? How can a lack of access to regular eye exams impact overall prognosis?
Christine Funke, MD:
The big key we are learning with glaucoma really is detecting this disease early on and then treating it early on with intervention. The reason we are finding that is because early disease is much more modifiable, and we have a lot of options now where we can actually do disease modification with lasers and minor incisional surgeries, and those just work better when this disease is young. When we’re waiting until the disease has progressed, a lot of the area of the eye that gets disease, specifically the drainage structure in the eye, it becomes less moldable or remoldable, and that becomes then less effective in terms of a lot of our treatments that are low-risk procedure.
If we can get people in to see their doctors at least annually and have checks for glaucoma, then we can find the glaucoma early. If we can find the glaucoma early, perfect, that means that we can treat it early, which means that we’re going to have a much higher rate of success with our treatments, but then also we’re going to slow down the potential for the very large burden that can happen to people when this disease progresses to something where they have severe amounts of vision loss and potential blindness. The earlier we can detect, the earlier we can treat, the better the prognosis just generally is for people.
This then means access to care is really important, so being able to get in and see your eye care specialists, ophthalmologists, optometrists, all very important, because they’re going to be the key to being able to detect if there is or isn’t glaucoma, because it’s a silent disease. You’re not going to feel this disease. You’re not going to be able to notice changes until you’re very far along in the disease spectrum, so really this is something that’s a silent vision stealer. What we want to try and do is again, have professionals being able to see large swaths of the population to do general testing, to find the people who really need access to care and treatment early.
Question:
What are the typical treatment options for glaucoma? What are the pros and cons of each from both a clinical and business or practice perspective?
Christine Funke, MD:
Typical treatment in the past was really talking about topical therapy, meaning eye drops. We did a lot of drops, and now we’re really changing the entire paradigm of how we want to treat and manage glaucoma, and that’s for several reasons. One is that we are finding, and have known actually very honestly for a long time through all of our clinical trials, that doing intervention, and that means something that’s non-pharmaceutical, whether it’s laser treatment, drug delivery, or minimally invasive glaucoma surgery, tends to be more effective at lowering pressure 24 hours a day. There’s a very important component to 24-hour-a-day control and management of pressure, and so we’re finding that that’s very important as opposed to the traditional paradigm of just drop therapy.
The other things that’s important is people don’t take their drops. No one can blame them. I probably wouldn’t be particularly great at being asked to take some form of a medication at least once a day, if not multiple times a day, for the remainder of my life. Putting that burden on people is a lot to ask. A lot of these medications have negative side effects, on top of the fact that people don’t remember their medications. We have to find a better way to deliver our treatment that’s just as effective, low risk, and also isn’t burdening people’s lifestyle, which we’ve really gotten to a really very good place of being able to do with interventional glaucoma.
Those are the things that we’re kind of trying to do now in terms of treatment. Again, like we had talked about before, we also have to remember early treatment, especially with these new modalities, is going to be very, very effective compared to waiting. Traditionally also, we waited until we did any kind of interventional procedure, and now we’re finding that actually we need to do that early in the disease in order to be more effective at treatment and management for patients.
Then you also can think about the burden not only on the patients of what we’re trying to do if we’re doing topical therapy, which we’re trying to avoid, but also there’s a large burden on all of us as providers from our clinic perspective. When we look at how we provide care, when we’re doing topical therapy, you are going to have a lot of the burden of unfortunately drop therapy causing patients to have to call in because they are uncomfortable with the medications, or maybe they’re too expensive, or then there’s the prior [authorizations], the refills, all the things that are taking up a lot of mindshare and time of a lot of our staff, more than maybe us personally, that we can also mitigate by doing other interventions. It’s kind of a nice win-win, which we don’t often see in medicine, which is better for patient care to be doing interventional treatment, but then also, it’s really much nicer for all of us who are doing the treatment because it lessens a lot of burden for the staff around us.
Question:
Interventional glaucoma has become a treatment theme. How do you describe interventional glaucoma? How can more practices adopt an interventional approach to provide optimal patient care?
Christine Funke, MD:
Interventional glaucoma is just a terminology, but really it’s a mindset, which is a very large shift in how we look at glaucoma management and practice. What we’re talking about with interventional glaucoma is saying eye drop therapy should only be used as a supplement or bridge in between other procedural options. We are looking more now at taking the burden of treatment and disease management on ourselves as the providers, and off of the plates of those who are taking care of, and all of our patients. The reason for this is because we just know that our current and past way of doing glaucoma therapy was just not as effective, and it’s because patients just aren’t taking their medications. They don’t also follow up with us, which is a big problem. We’re also starting to understand that those patients who are treated topically have about a two times more likely chance that they’re not going to follow up to see us, as opposed to those who are treated in some sort of interventional way. They actually do much better at coming back to see us.
Because this is a chronic progressive disease, we need to keep seeing people, because this is going to change, this is going to evolve, and we’re going to have to keep changing our management. If we’re not seeing patients, we’re going to miss vision loss, worsening of disease, and disease burden. Then if we don’t see the patients, we don’t see this change, well, then we’re not going to be able to treat them appropriately. We really need to understand globally why interventional glaucoma is so very important for patients, and those are some of the things that we’re looking at. We’re realizing that if we can take this burden off of patient’s plates in terms of treatment, they follow up with us more frequently. They are definitely more controlled, especially 24 hours, as opposed to the original treatments that we had done topically.
We’re finding a lot of patients just generally much more satisfied with their care than we had ever previously known, so it’s a big shift. It’s a mindset change, but I think it’s a really important one, because we are really doing a very large service to all of our community and patients who have the burden of this disease, and hopefully we can manage to a place where they are going to have less vision loss and less change in quality of life by doing it this way.
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