44.211.239.1
dgid:
enl:
npi:0
-Advertisement-
-Advertisement-
Glaucoma
Optometry
Video

The Growing Glaucoma Burden: Issues Associated with Treatment

Posted on

Mark Dlugoss:

Glaucoma affects about 64 million people worldwide, and is projected to affect more than 100 million people by 2040. Since January is Glaucoma Awareness Month, the editors of Ophthalmology 360, thought we’d sit down with a leading KOL and optometry to discuss some issues associated with glaucoma and its treatment. This is Mark Dlugoss, senior contributing editor of Ophthalmology 360, and joining me for this discussion is Jessica Steen, OD. Dr. Steen is an assistant professor at Nova Southeastern University’s College of Optometry in Fort Lauderdale, Florida. Dr. Steen, welcome.

Dr. Jessica Steen:

Mark, thank you for having me. This is a wonderful collaborative effort for a very good reason, so it’s a pleasure to be with you today.

Mark Dlugoss:

Okay. Great. Before we start, I’d like to get a little brief bio of yourself, your clinical background, your clinical interests, et cetera.

Dr. Jessica Steen:

Sure. I’m originally from Canada. I studied optometry at the University of Waterloo School of Optometry and Vision Science and moved to Fort Lauderdale, to Nova Southeastern University College of Optometry to complete my residency. After residency, I stayed as a faculty member where I currently serve as director of the eyecare institute’s glaucoma service. I teach the course in glaucoma. I teach the course in ocular pharmacology. And then, outside, within our community, I’m also very involved in our optometric and eyecare practice, and communities.

Mark Dlugoss:

Oh, that’s great. Great to hear. Okay. Let’s start with best practices in glaucoma. As you know, glaucoma, with open-angle glaucoma as the most common form, is a multifaceted disease. And it’s treated in a multifaceted approach. In treating glaucoma patients, clinicians need some sort of guidelines or best practices to treat the disease. Can you outline some of the best practices in early glaucoma detection and its treatment in general?

Dr. Jessica Steen:

It really starts with that very large picture approach, that we’re truly examining a patient as part of a comprehensive eye examination. And there may be historical features, whether that’s a family history of disease, or systemic risk factors that start to trigger that question to say, what is this individual’s overall risk? Really, it stems directly into evaluating the optic nerve. Now, clinical evaluation of the optic nerve, even in a time where we have excellent technology and continued development of technology, is truly that central, central clinical ability to evaluate the structure to determine whether or not an optic nerve may be suspicious of disease or not. It’s later features, additional risk factors, including intraocular pressure, that then impact that patient’s overall risk. But I think starting to think about early disease detection really centers on a very thorough clinical evaluation that truly starts with optic disc evaluation and assessment of, then, additional risk factors.

Mark Dlugoss:

How important is the role of progression analysis in treating glaucoma?

Dr. Jessica Steen:

That is our central, most important feature. Once disease is diagnosed, to ask ourselves at every continued follow-up visit, is this patient’s disease progressing? Are there early signs that may even increase the risk of disease progression, which, certainly, center on intraocular pressure, slight elevation, detection of fluctuation, understanding barriers that the patient may have to returning to care, identifying those patients that have been lost to follow up, or have had difficulty with adherence in medical therapy, or previous follow up of surgical care as well. So detection of progression is that secondary big question that we certainly do ask and assess at every visit, which really does incorporate every piece of ancillary testing and clinical evaluation at every visit.

Mark Dlugoss:

Is there best practices in regard to progression analysis?

Dr. Jessica Steen:

It’s putting the pieces together. So we’re thinking about visual field functional change and early detection that may flag for concern of progression with functional change, and then taking it a step earlier with serial OCT imaging. Are there early changes detectable in retinal nerve fiber layer change, or ganglion cell complex change that may be the red flag that may signal further future functional progression as well? So it’s about putting these pieces together that I think is really our most important best practice, that we can’t focus on just one test, one risk factor, or one measurement loan, but really looking at a lot of data holistically. That makes it, really, our biggest puzzle and challenge in that single, short clinical visit that we may have with a patient.

Mark Dlugoss:

How about long-term management of glaucoma? What are some of the best practices involving that segment of the diagnosis?

Dr. Jessica Steen:

We know that when we diagnose a patient with primary open-angle glaucoma, it’s a lifelong disease. So this is a long-term discussion. I think it really starts with trying to get across the key features that we are concerned about to have that patient really involved in their care, to understand why we, as a team, may be doing what we’re doing, ultimately, to prevent that long-term functional vision loss for the individual that we’re treating. So it’s not a short-term disease process. And certainly, there are challenges in chronic disease management, especially when we’re talking about, often, asymptomatic chronic disease management. Keeping that patient engaged in their care, aware and involved, I think, is really the long-term key to success.

Mark Dlugoss:

That’s great. I’ve been doing some research. I’ve been finding out that the ophthalmic associations that are doing this as well, but the optometric associations are reviewing and updating the best practices for glaucoma. If so, do you have any insight at what areas they will be updating, or what new or old practices will be added or deleted?

Dr. Jessica Steen:

Certainly, we know that updating clinical practice guidelines is a very onerous, difficult task, but certainly, such an important task. Now, leaders within the optometric space, the Optometric Glaucoma Society, the American Optometric Association and the American Academy of Optometry are truly driven to continue not just research efforts, but bringing that to the clinician in clinical practice through the use of education events, as well as clinical practice guidelines. Certainly, glaucoma, as a growing concern from a primary care optometry perspective, nevermind a specialty, optometry and ophthalmology perspective, is something that truly, truly is central. And I can’t imagine that an update to our current clinical practice guidelines would not be considered here.

Mark Dlugoss:

Okay. Do you have any idea how far along they are, or where they’re going?

Dr. Jessica Steen:

At this point in time, I don’t. I often see this as an ongoing continued effort rather than an isolated update. But we were just, actually, speaking about this yesterday to say, how long does it take for a change that exists, or a change that we identify from a clinical side, to really be incorporated into core clinical practice? And we’ve had so many technological advancements and treatment advancements in glaucoma that, from a clinical practice guideline perspective, we know that we’re always just a little bit behind in updating and keeping those guidelines current, because of the continued efforts and continued research.

Mark Dlugoss:

It’s a good observation, Doctor. It’s very good, because the new technology comes through. It changes all over again. Let’s talk about ocular surface disease and glaucoma. Now, past 10 years, the ophthalmic researchers have found that dry eye and other ocular surface diseases have been making impact on the outcomes in every subspecialty of eyecare, including glaucoma. What’s the clinical association between ocular surface disease and glaucoma?

Dr. Jessica Steen:

If we take it, really, from the beginning, we’ve got to understand that the prevalence of dry eye disease in, generally, an older population is very significant, even without treatment of medication, or incisional or interventional procedures for the management of glaucoma. If we’re considering a new glaucoma diagnosis, we really have to take a step back and, number one, think about whether the procedure or the treatment that we are going to recommend or employ is going to tip that previously asymptomatic dry eye disease patient over the edge in becoming symptomatic. So I think taking a really aggressive stance early on, with additional dry eye therapy understanding and treatment is really focal and central to improving success.

Because we know that that asymptomatic dry eye patient, once they’re on a topical therapy, is certainly going to become symptomatic. So if we get ahead of that symptomatology early and treat the ocular surface aggressively… And that’s not just artificial tears. We certainly have therapeutic options, whether they’re topical, oral or, for example, a nasal spray, as well as lid hygiene in office procedures that are truly becoming much more advanced and able to well manage, not just the surface, but the eyelids as well here.

Mark Dlugoss:

Now, as a literature, not only optometric literature, are they telling clinicians about how to address this problem of ocular surface disease and glaucoma?

Dr. Jessica Steen:

Yeah. Dry eye disease has really been embraced by the optometric community. And when we think about the number, the sheer volume of patients that do have glaucoma, that are managed in an optometric setting, certainly, there is that significant overlap. So I think our community has really become so welcoming of managing, aggressively, dry eye disease to optimize the ocular surface for long-term glaucoma treatment positive outcome. Now, I think it’s something to always remind patients and our colleagues about that once, for example, if we switched from a topical preserved agent to a non-preserved topical agent that… Now we, very recently, have a new option in the United States that our colleagues in Canada and Europe have had for years. But switching that patient from a preserved to a non-preserved agent is not going to cure that patient’s ocular surface disease. We truly still have to treat the underlying disease process.

Mark Dlugoss:

Speaking of which, similar to other areas in eyecare, clinicians are… For the most part, what I’ve been learning is, before they address the actual disease, they’ll treat the ocular surface disease first. Are clinicians in optometry addressing the two diseases simultaneously as well in glaucoma?

Dr. Jessica Steen:

Absolutely. That truly is… From my personal practice setting, I typically have a referral-based practice, that these are patients that are referred from other eye care providers. In that case, it really is about working hand-in-hand with the referring physician, in this case, to understand what treatments may have been employed, and then, from our glaucoma treatment perspective, to ensure that our recommendations really do fit in line and support with that, co-managing physician’s treatment as well.

Mark Dlugoss:

Okay. In relation to ocular surface disease and glaucoma, what best practices can optometrists incorporate in treating these two diseases?

Dr. Jessica Steen:

I think it starts with treating the surface early, before consideration of a topical therapy or a procedure-based treatment, address the surface issues that exist to try to minimize the symptomatology of the patient once they begin a treatment. I think it’s also important to recognize that, for individuals that undergo procedure-based events, this is not going to cure the patient’s surface disease. And we do have to understand that every patient’s treatment and every patient’s response to treatment, and lifestyle will support a different dry eye regimen.

So whether that is in-office procedure, whether that is in addition to, for example, not another eyedrop, but something like a nasal spray or long-term anti-inflammatory low-dose medication, we have additional options. And it’s about thinking about which combination of options of management of the surface is going to be most effective. Incorporating other tools into clinical practice outside of the exam room to really have an understanding of that patient’s true symptomatology is also important. Incorporating questionnaires into intake forms or periodic check-ins to really find out how your patient is truly feeling really helps the clinician to understand, maybe, how they can adjust treatment for that patient to have a more positive outcome.

Mark Dlugoss:

Let’s move on to diagnosis and treatment of glaucoma. And we were just discussing earlier about the best practices. And they all move into developing the plan, treating follow up, et cetera, even getting compliance with patients. Are new treatment options needed in treating glaucoma?

Dr. Jessica Steen:

Our biggest challenge in the management of glaucoma is that every treatment option that we have focuses on management or lowering of intraocular pressure. When we know that that, of course, is the key risk factor for the development and progression of disease. It really doesn’t hit home to that gap that exists in glaucoma pathophysiology and understanding, where is it? Where is that tipping point that causes glaucoma development and progression? So really hitting the key underlying disease… Underlying process, central process is certainly the gap that we have. And that really is the core of glaucoma pathophysiology. And understanding that pathophysiology to, then, develop a treatment that really does stop, reverse, or potentially, directly address the underlying true feature that causes progression and development of disease.

Mark Dlugoss:

Now, you see a paradigm shift in regard to the diagnosis into treatment of glaucoma?

Dr. Jessica Steen:

I think we’re all incorporating the technology that we have in very effective ways. Certainly, the incorporation of OCT is something that is so central, especially in the management of early diagnosis, and early to, really, moderate disease progression. It’s something to remind ourselves not to get carried away, that it’s not… A single device can never diagnose disease. It is truly that clinician’s understanding, incorporation and interpretation of the data that’s most central. But the incorporation of biomarkers for disease development and progression, and identifying risk factors for future progression that really are very important here. I think one of our challenges right now, as a clinician, is that we have so many data points. And how do we incorporate those data points to understand that patient’s, maybe, risk of development of disease, as well as risk of disease progression into a short clinical visit? And I think, truly, that’s where the concept of artificial intelligence is really going to help us to best understand risk and incorporation of the many metrics that we have right now.

Mark Dlugoss:

Will clinicians and optometrists see new diagnostic options moving forward?

Dr. Jessica Steen:

If the past is any reflection of what is to come, I think the answer is, absolutely. And it’s a very exciting time to be so centrally involved in the management and development of understanding of what these new technologies may be. So even in the last, at this point, really, six to seven years, the commercial availability of the development of OCT geography, I think, has really shaped our understanding very well in retinal disease. And we’re still trying to understand how these biomarkers may be most relevantly applied to the detection, and detection of development, and detection of progression in the management of glaucoma, but we are seeing new points, new metrics, new technologies. And it’s about how we can incorporate them practically.

 

-Advertisement-
-Advertisement-
-Advertisement-
-Advertisement-
-Advertisement-
-Advertisement-