The importance of glaucoma co-management
Deborah Ristvedt, DO, and Jessica Steen, OD, discuss the role of optometrists and ophthalmologists working closely to ensure glaucoma patients have access to the best care.
Deborah Ristvedt, DO:
Hi, I am Deb Ristvedt from Vance Thompson Vision in Alexandria, Minnesota. I am a comprehensive ophthalmologist who focuses on surgical anterior segment surgery, including cataract, refractive cataract, glaucoma, and oculoplastics.
Jessica Steen, OD:
I’m Jessica Steen. I’m an optometrist at Nova Southeastern University College of Optometry in Fort Lauderdale, Florida, where I serve as Director of the Glaucoma Service.
Deb, it is wonderful to join you.
Deborah Ristvedt, DO:
Thanks, Jessica, and I am so excited to spend the next half hour with you just talking about something that we’re both passionate about, and that is glaucoma. Just tell me a little bit about what you do, your practice style, and how you’ve really established a passion for interventional glaucoma.
Jessica Steen, OD:
It’s something so interesting in optometry and especially in an academic optometric environment, to be in a glaucoma service, to direct the glaucoma service. What that means in 2024, is that of course we are working closely with our ophthalmology colleagues to ensure that our patients have access to every potential therapy that can benefit them short and long-term through their glaucoma journey.
In thinking about the importance of optometric care really being at the forefront, it starts with understanding available options. That’s changed so much since really beginning practice more than 10 years ago, where we used to think about referrals as, let’s max out everything that we can possibly do with a medical portfolio. Once that patient fails, meaning that they can no longer tolerate the therapeutics they’re taking or their disease is continuing to progress despite not just maximally tolerated but true maximal medical therapy, that’s where we move on. I think it’s so valuable, especially being in an educational environment where we’re training students and residents and working with trainees in other medical fields, that it’s something that’s so valuable to truly understand what this big picture approach really means. It’s unique in our environment where I’m not only of course referring to colleagues for surgical care, but I’m receiving a large number of referrals from our community members in managing patients, so it truly is that widespread but unique environment in optometry.
Deborah Ristvedt, DO:
Yeah, and I love that. We’re all comfortable with talking about co-management, say in cataract surgery, but now with interventional glaucoma, we’re thinking about this algorithm totally different. We’re thinking about not drops as first-line therapy; we’re thinking about SLT, we’re thinking about pharmaceutical procedural medications like iDose or Durysta, we’re thinking about minimally invasive glaucoma surgery a lot earlier in the disease process. Like you said, in the past, even a decade ago, we were totally thinking about this differently. We were saying, “Okay, how can we get our patients to a good spot? How can we get their IOP under control? If I can’t, that’s when we refer.” But now, we talk about co-management being so different in the glaucoma world, but I like to think of it as collaborative care, because we truly are operating at the top of our game, both professionally and individually, when we talk about how we’re managing these patients. We couldn’t do it without each other, right? That’s what has opened my eyes.
I practice in a rural community and it took a little bit of work initially to say, “Okay, our algorithm is totally changing where now if someone is newly diagnosed with glaucoma, we’re not going to drops anymore. We’re going to maybe SLT as first line.” Now I’m starting to see that referral pattern kick in. Do you feel like that’s changed in how you’re teaching your students and how you’re practicing individually?
Jessica Steen, OD:
Certainly, both from a practice standpoint and from an educational standpoint. I think what’s still lagging is often our patient’s choice and our patient’s perception. But something that’s so core is that our patients have these choices.
When I think about first-line therapy, whether that’s an ocular hypertensive that we determine requires IOP lowering, or if this is a newly diagnosed open-angle glaucoma patient and we’re talking about therapy, no question that SLT is a part of the discussion as far as what an appropriate or reasonable first-line therapy is. But I will say, most of our patients still choose medical therapy as a first-line option and part of that truly does speak to the environment that we’re in. Often, these are patients that are really comfortable in seeing us. They may have their family members, they may have been patients of our clinic for 20, 25 years. It’s something that when we’re talking about referral networks in this collaborative care, there really are patient barriers to the understanding of, I’m going to work with a colleague to take the best care of you. Often, that requires just additional or different trust building with the patient.
Deborah Ristvedt, DO:
Yeah, and I love that. Do you feel like from your perspective with so many options being available, how have you found ophthalmologists to work with? Are you finding ophthalmologists that are kind of embracing this interventional glaucoma mindset?
Jessica Steen, OD:
That is something that in our area we have seen expand and grow and change, I will say really in the last 2 to 3 years. That’s something that has been a lot of fun for me in working with our community providers to say, “Whose preference? Who is going to intervene? Who is going to think about SLT in this particular case? Or in this particular case, who’s going to take this person and consider a standalone MIGS procedure? Or in what case may drug delivery, sustain drug delivery, may be a particular individual’s general practice pattern?”
What that has required or asked of me to do is to really talk to providers and to understand and communicate about sharing cases. Really picking their brains, and vice versa, in what, where, in which patient at which time. That’s really what building this network is really all about. It’s understanding the individual difference between providers, and that has allowed me to ensure that when we’re referring a patient, absolutely this is done in a thoughtful way in thinking about which procedure may have the greatest potential benefit for a patient and therefore, which particular provider in office may be best for that individual. That’s something that really is thoughtful in the sense of taking into account that patient’s preferences, their experience, their background, really, my relationship with that patient that’s been built often over a number of years.
Deborah Ristvedt, DO:
I love that because you talk about education, it’s so important to educate our patients so that they feel comfortable with our care. Also, we have to educate our optometric and ophthalmology networks to say, “Hey, glaucoma is changing.” We talk about this word interventional glaucoma. We’ve mentioned it a few times, and what I think of it as is a change in mindset. We’re looking at proactive instead of reactive treatment. We’re looking at catching patients sooner in the disease course to intervene earlier in a safe and effective manner and to hopefully delay visual field progression, limit the amount of drops that can cause side effects over time, we all know that. Compliance can be an issue, another reason why we’re so passionate about this field and preventing more invasive procedures over time, and we’ve seen that in the MIGS space where patients who have earlier intervention are less likely to go on to needing a trabeculectomy or a tube shunt. We couldn’t do it without each other, and that’s why I just love talking about how we’re rewiring and rethinking how we work together.
Talk about, Jessica, the patterns that you’re seeing. Are you getting your patients back in this type of approach with interventional glaucoma?
Jessica Steen, OD:
That’s something that’s so core. The answer is yes, we are getting patients back, which again, that’s the key to success is really ensuring, and that’s certainly on us as the referring optometric physician in that environment and being very clear with the reason for referral, the thought process behind it. Once again, is this to reduce topical medical therapy? Is this to lower intraocular pressure while maintaining their current topical ophthalmic therapy? Really being deliberate and clear with the reason for referral. That’s something on my end as well is every referral that I get, I make very careful, take a very careful moment, to make sure that I’m clearly addressing what the referring provider has asked of me to clearly take a look at, to make sure that I’m answering the question, number one. Then making sure that where I’m intervening, whether that’s potentially with adding an additional diagnostic technology that maybe the current managing physician doesn’t have access to and they’re not looking to transfer care but just looking for this additional diagnostic information to help them.
Really understanding that reason for referral is step one to make sure that when we’re sending the patient back, we’re sending back for the right purpose, at the right time point, and having addressed the right concern. That’s certainly something that I’m very thankful to work with providers in the area that feel the same way about that. It’s really understanding, what’s the purpose of the referral? What’s the question that I’m asking of them to potentially answer? Then, what happens next? It’s something that I will say that again as someone who is a consultative practitioner and someone who refers cases, that we certainly treat our patients in the office the same way that we hope and do see them being treated with additional consulting physicians.
Deborah Ristvedt, DO:
I love, Jessica, how thoughtful you are too, in how you take time to really know your patient and respect their wishes and also taking time to send such crucial information. I think that’s what’s been so fun on this side as a surgical referral network to receive such a thoughtful letter to say, “Hey, we’ve had Mrs. Jones on 1 or 2 medications. She’s having side effects and we would really like to see less drop dependence.” Or, “This patient is progressing and here are their visual fields.” Or, “This patient isn’t in goal range; their intraocular pressure is higher than what we would like them to be at.” I do that with cataract referrals; I do it with glaucoma referrals, where I really am mindful of looking at those referral notes because it is so important to know that patient. When you only get to spend a limited amount of time, to be able to collaborate with each other, I think really opens up the door to better patient care.
Jessica Steen, OD:
That’s something that we see our patients that are so on board with that, as setting up what the next step will look like for Mrs. Jones. This is what will happen with the next step, here’s the next approach, here’s when I will see you back. It’s that careful handoff and return and the communication through it that honestly makes our patients who may even be hesitant at first to see any other provider truly comfortable to know that this is really a mindful approach for a best purpose.
One thing that you brought up, Deb, that I think is something so valuable and something that we certainly struggle with, it truly is sharing records, sharing images in a usable form. You think about it, when I’m sharing a patient, I’m sending the thoughtful note, thankfully. I’m sending potentially their last imaging, maybe their last couple of visual fields, but at the same time, truly, how valuable is that for you?
Deborah Ristvedt, DO:
I think it’s crucial, because again, we don’t know what their visual field has been from the start of care to now. I really, when I’m making decisions along the way for glaucoma, not only am I looking at the stage of glaucoma, but I’m looking at what their pressure was before medications or before therapy. I’m looking at what their visual field was and their OCT was right at the start of treatment to where it is now. I love to look at progression analysis when it comes to visual field results, so that I can make more of a mindful decision when it comes to what that patient needs. Because you and I know that glaucoma is not a curable disease, but it’s a manageable disease, and we’re trying to do that earlier on in the disease course.
Unfortunately, two-thirds of our patients have mild to moderate glaucoma, but again, we don’t want to see them in that severe state if we can prevent visual field loss over time. Those records are so extremely important to know kind of what the steps look like. I really like to send back my thoughts to say, “Our first step is maybe SLT because this patient doesn’t want to be on drops and we need to get their pressure to an IOP goal of X, Y, and Z. But if we don’t achieve that, then I would do A, B, and C.” I kind of like to go through that algorithm in my head a little bit with the patient and then to the refer to say, “This is what I’m thinking; this is how I think they’re going to respond, but this is our next step.” Because then I just feel like patients don’t get lost in translation and we’re really able to work even more effectively in a better timeline to get the results needed, and it’s just incredible.
I was just at a meeting and they were talking about how patients kind of drop off, and it was astounding to see how many patients are lost to follow-up at a year that have glaucoma and are on drop therapy. But if you really looked at patients who had had some type of intervention, whether it was MIGS or SLT, those patients were more likely to be seen in your office. I don’t know if that’s because patients understand their disease state better if there’s some type of intervention. I’m not sure, but I thought that was so extremely interesting, and then not to mention, the compliance issue that we face.
Jessica Steen, OD:
That’s such an interesting point and when you think about it, it’s almost counterintuitive that individuals are more likely to continue with follow-up care as directed or as planned when they’re not on a topical therapy.
I wonder, I’ve been thinking about this too, and in the first time in hearing that, and I’ve been thinking about this to say, “Well, maybe that’s something that maybe that is an educational component, maybe that is.” What I’ve changed since really hearing this is to say, “Are my patients very clear with what the purpose of not just therapy is, but what each office visit is?” What’s the importance of each office visit? What’s the importance of touching base at whether that’s a 3-month, a 6-month interval, whatever is personalized to that patient and their disease process. But making sure that patients truly understand the value in, of course, the amount of work that we do on that back end.
We might be just spending a short amount of time in the room with the patient at every follow-up office visit, but of course our work is all done on the back end. Not just to evaluate the testing or ancillary imaging that was performed on that day, but to carefully evaluate, is there any trend that’s developing in looking at visual field change over time? Where is this overall guided progression analysis? Is there any early indication of progression or are we changing the rate of progression? Are there any anomalies? Is there something different? Even is there new retinal pathology that may be an incidental finding that’s picked up with a ganglion cell complex abnormality? It’s really that back-end work, but I’m trying to do a better job with patients to ensure that they understand how much care and attention goes into each visit. That really is the challenge of course in glaucoma management is we know that patients are going to get worse. We just don’t know exactly when that may be. We can have an idea based on, of course, our risk assessment, but that’s the importance of that periodic evaluation.
Deborah Ristvedt, DO:
Yeah, and that’s beautiful. Do you think that just knowing all these different options that are available, that you feel more at peace knowing that, okay, I’m not sure if my patient is taking their drops. Do you feel more a reassurance that you’re maybe taking that pressure or that compliance issue off of your patients?
Jessica Steen, OD:
It’s so challenging because I know we all feel that our patients have a better adherence rate than what’s in the literature. We know we all feel that way. Well, we know that’s what’s reported, but I know my patients do better than that. The challenge is, is that, and of course well supported in the literature, is that the patients that we often think are using their medication the way that is prescribed are sometimes not those and sometimes the ones that we may think are not using their medications as well as prescribed are actually the ones that might be surprising us in a good way. It’s difficult for us to truly or accurately determine who those perfect adherence patients truly are, despite our best efforts.
Again, that weight that’s lifted, I do think that certainly we do have some patients who truly want to be in control of their disease process, that they feel that they’re doing the right thing, that they know that they’re managing this process with their daily use of a therapeutic. That can be in addition to additional procedures that are required, but it really is something that is so unique. From my perspective, certainly it does take that stress or that weight off. We know no one’s perfect, so when you miss your drop of latanoprost, we know that there’s still coverage that is there if this is a patient who has had, for example, SLT and is on a topical therapy.
Deborah Ristvedt, DO:
Yeah, and I love that. Let’s go into other ways because I think sometimes we tend to say, “Oh, drops are bad. Let’s get rid of everything.” But drops are still needed and they work and they do bridge the gap between our new algorithm in interventional glaucoma. But also we have this whole line of drug delivery now and I think I get excited about that because you look at the data and it’s so interesting how the concentration of medication in the eye is so much higher than when you take a topical drop, or getting that 24/7 IOP reduction instead of worrying about these diurnal spikes, which I worry about a lot when patients are progressing. I just see that drug delivery is really becoming more of the future when it comes to how we take medications or how we talk about medical therapy.
Jessica Steen, OD:
No question with advances in technology and real indications for use as they hopefully do continue to enhance and develop, that will be a long-term, reasonable option with multiple strategies that may become available. Certainly, it’s something that with the first sustained-release bimatoprost agent that became available, I think we were all really trying to figure out, okay, so how many drops is this equivalent to of typical bimatoprost 0.01%? Okay, so how can that have sustained intraocular pressure lowering for that sustained period of time? Really thinking about the structural implications, the impact on the uveoscleral meshwork itself with that low concentration of consistent sustained exposure, truly is something that I think is so interesting when we think about strategies and developing strategies in lowering intraocular pressure, certainly, long-term.
Again, it’s a reminder of the good barrier of the cornea and the tear film of course, and the conjunctiva, but the challenge is that that barrier results in. That’s where again, even new technologies related to topical ophthalmic drug delivery, again, aim to improve penetration and have sustained action is something that it’s changing again not just the way we think about from a surgical standpoint or from a procedure-based standpoint, but truly from a medical standpoint as well.
Deborah Ristvedt, DO:
Yeah, and I love that because I don’t know that drug delivery will ever go away. It’s just how we’re using it. Now with a procedural pharmaceutical like iDose, we have even longer duration. They just presented the data at 3 years and it’s looking really great, and we’re seeing effect up to 3 years. When I start to think about time and the patient’s age and if they’re phakic or pseudophakic, if they’ll need cataract surgery down the road, those all play into our decisions now as far as how we’re managing each individual patient.
Lastly, what have you found from a quality of care and quality of life perspective, not only in treating your patients, but also really kind of reestablishing relationships with this referral network?
Jessica Steen, OD:
It’s been something that’s rewarding. I will say it is an additional challenge. Initially, it’s a challenge to sit down, to understand, and I love that, something that you said earlier, how you’re very, again, thoughtful in talking about the stepwise algorithmic approach that you are considering for an individual patient. That’s something that I see that back from a physician and I realize, okay, this is Deb’s pattern. Now, which other patients might be the perfect patient to fall within this pattern? Because I want to make sure that, of course, that I’m referring a patient to you, to any provider, that is going to get, again, the care that’s determined to be appropriate by you. It’s also about learning your patterns and vice versa. It’s something that, again, initially is something that can be quite challenging.
I had this conversation with our residents today that the question came up to say, “How do you choose which provider you refer which patient to?” That truly is based on the experience, the knowledge, and the communication and understanding what this patient’s next steps will be in a particular office, and really matching patients to providers and ultimately to consideration of procedures. At first, I will say it is challenging, but then it becomes rewarding. Really where our resident was coming with that question from is trying to figure this out to say, “Wow, it’s very clear that each step is made in a deliberate way. Each referral is very deliberate.” How do I learn which providers really, what that referral network will look like as this is someone who’s training to establish themselves in their own community and in practice what that will look like. At first challenging and then very quickly rewarding for myself and, of course, for our patients.
Deborah Ristvedt, DO:
Yeah, beautiful, Jess, I couldn’t have said it better. It’s just been such a wonderful adventure to be on with you and just how we manage and treat, I think is just so much more fun, rewarding, provides quality care for our patients. It’s truly fun to see these relationships grow over time and to start to really learn from each other and again, be able to have relationships not only as colleagues, but as friends too. Thank you so much for this wonderful, wonderful time together. I just appreciate you so much and what you’re doing and how you’re educating the younger generation. It’s just awesome.
Jessica Steen, OD:
Thank you. It is a pleasure to chat with you, Deb. Look forward to seeing you again.
