The world of glaucoma management in 2012 is feeling the impact of not only a variety of challenges, but also new opportunities,
said Dr Andrew G. Iwach, at Glaucoma Symposium 2012.
Dr Iwach, associate clinical professor of ophthalmology, University of California, San Francisco, California, USA, presented
a snapshot of current medical, surgical and practice management issues pertaining to glaucoma patient care. The symposium
was held at Glaucoma 360°, which was presented in association with Ophthalmology Times.
In 2012, new chemical entities for treatment of glaucoma are showing promise, but most are in phase II clinical trials or
earlier stages of development and so are not expected to come to market for at least several more years. Prostaglandin analogues
are still the leading class of ocular hypotensive agents used in the medical management of glaucoma, and the number of prostaglandin
analogue prescriptions written continues to rise.
Meanwhile, generic medications, which now include latanoprost, are taking on a more prominent role, causing an increasing
burden on physician practices because of the time spent communicating with pharmacies and insurance companies, as well as
a potential confusion for patients. Dr Iwach cautioned that generics manufactured in other countries may not be equivalent
to the products manufactured in the US. In addition, there is an increasing problem with look-alike packaging for generic
ophthalmic drops that can cause confusion for the patient who is being treated with a multi-medication regimen.
"These issues are creating new challenges. Therefore, I always ask my patients to bring in their bottles when they come in
for a follow-up visit because I want to see what they are using and where it is from," said Dr Iwach.
He added that he is particularly concerned if there seems to be a sudden loss of IOP control or the patient has developed
side effects that can't readily be explained. If tolerability is an issue, clinicians should consider the possibility of a
"In my experience, the preservative used in the formulation can make a difference for certain patients. Fortunately, there
are a number of alternatives to choose from, including products containing preservatives other than benzalkonium chloride
or that are preservative-free," Dr Iwach said.
Data on glaucoma surgical procedures show a continued rise in the number of laser trabeculoplasty and tube procedures as trabeculectomy
"I think these numbers reflect acknowledgement that the outcomes of trabeculectomy are really not what we would like them
to be and indicate perhaps we should be reexamining how we define success when evaluating new glaucoma surgical procedures.
Maybe we should be looking at outcomes from the patient's perspective because we treat individuals, not averages," Dr Iwach
Although newer techniques may not lower IOP as much as trabeculectomy, that needs to be balanced against the risks of each
procedure in context of a specific patient's situation.
"If we focus on judiciously choosing an intervention based on who is having the surgery, having different methods available
becomes very important," said Dr Iwach.
Another recent development has been the introduction of new ICD-9-CM glaucoma diagnosis codes. Dr Iwach acknowledged that
while he first reacted to the information about new staging severity codes by thinking it was just an added nuisance, he recognizes
"With these new codes, we can identify patients with severe disease [that is] more difficult to manage and will require more
surgery and more testing. Thus, there will be a way to parse out resource use data that will ensure patients get appropriate
care and that we have the right infrastructure to provide it," Dr Iwach said.
Treating glaucoma in today's world also requires that practitioners pay attention to themselves. Growing demand for eyecare
services in the population requires strategies for increasing office efficiency, but practitioners also need to consider how
it will affect their risk of occupational injuries from performing repetitive activities, said Dr Iwach.
"When you are busy and focused on the patient, ergonomics can be overlooked. However, a simple manoeuver, like adjusting the
angle of the operating microscope, can make a huge difference over time for physical well-being and enable us to meet the
future challenge of handling an increasing volume of patients," he explained.