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Creative Glaucoma Management
Treatment flexibility benefits patient outcomes.
ROBERT J. NOECKER, MD

Every patient is unique. The treatments that will be most effective for one individual may not translate as an effective treatment for another. In the art of glaucoma management, I have found the regimen that works best is often a balancing act between medication, laser treatment and surgery. Patient age and lifestyle are also a factor in determining the most effective path for minimizing visual field loss and controlling IOP.

Obviously, a patient who finds instilling drops cumbersome is less likely to be compliant. Therefore, the treatment regimen will be compromised, and success may become elusive. However, a glaucoma specialist who spends time with each patient, learns what their priorities are and understands how to measure treatment success is going to be more likely to employ the right tools to preserve that patient's sight. 

The key to effective treatment is more often than not a combination of different modalities underneath the umbrella of constructive patient/doctor communication. Ophthalmologists should be open to shifting treatments, tweaking dosing regimens, engaging surgical solutions and expanding their armamentarium to include newer technologies to find the right recipe for fighting glaucoma.

The case below demonstrates not only the long and arduous path towards treatment success, but also the importance of new treatments and strong doctor/patient communication. Additionally, the use of both outflow and inflow laser procedures such as endoscopic cyclophotocoagulation (ECP) and selective laser trabeculoplasty (SLT) expands the treatment options available to a younger patient who is going to deal with fluctuating IOP over a longer period of time.

Figure 1. Optic nerves demonstrated severe cupping and loss of temporal rims.

Case Study

In 1996, a 53-year-old male, retired military officer was referred for evaluation of primary open angle glaucoma. He had a strong family history of glaucoma, was diagnosed with increased IOP at age 40 and experienced significant optic nerve and visual field changes (Figure 1). His prognosis was guarded due to the unfortunate position of being in his 50s with visual field loss and faced with the risk of increased vision loss for potentially 40 more years. Part of what makes this a less common and complicated case is the fact that he was still actively employed and was a contact lens wearer.

His ocular history was fairly typical; he had been using a beta-blocker and a topical carbonic anhydrase inhibitor, which we changed to Alphagan (brimonidine, Allergan) due to drug-related keratopathy exacerbated by dry eyes. When Xalatan (latanoprost, Pfizer) became available, the patient was able to switch and control his pressures for a period of time. As his pressure increased after several years, he was put on Lumigan (bimatoprost, Allergan). This again reduced his pressures into the mid-teens for several years. 

As is typical of many glaucoma patients, after a few years, he needed to progress to the next line of therapy. In his case, we chose SLT. Doing a trabeculectomy or any other surgical option at this point would really limit the patient's options. At the time, I was dealing with a contact lens wearer and as such I do not want patients to wear contacts after surgical procedures due to the risk of infection.

Throughout his treatment, he experienced periods where his pressures were well controlled; SLT effectively controlled his IOP in conjunction with medications for several years. Three years after treatment, his SLT was repeated with subsequent control for another 18 months. After 7 to 8 years of active management, his IOPs began to drift into the upper teens and he developed cataracts. The patient was presented with the option of having cataract surgery alone, a combined trabeculectomy/cataract operation or combined phaco/ECP.

This patient, an active person, wanted the option of continued contact lens wear, but also understood and desired lower IOPs. We discussed taking the opportunity of lowering the IOP more while we treated the cataracts as part of a combination procedure with ECP. I believe this is the setting in which ECP works the best as access for the therapy is optimal.

We performed a combination cataract/ECP procedure and treated the patient postoperatively with steroids and NSAIDs for 4 weeks.

After surgery, the patient's vision was 20/20 OU, his ocular pressure decreased to the mid-teens without medications. Currently, the patient is still not on any medication and has experienced no progression of his disease. His IOP is now running at the mid-to-low teens, our target range. We believed this was good for an individual with some visual field loss who has many more years of glaucoma management ahead of him.

Additional Considerations

How common is it to change medical therapy?

One question is "does SLT work in patients using prostaglandin analogues?"

Some studies have shown that there is a greater drop in pressure when using SLT on patients currently using beta-blockers. However, it can be argued that because beta-blockers are not as effective as prostaglandin analogues at controlling IOP, one would see a greater drop in pressures with the SLT treatment.

Another question is "does ECP cause inflammation like transscleral cyclophotocoagulation, which can compromise post-op vision?"

If you do ECP properly, in a controlled fashion, you avoid popping the ciliary processes. Thus, the patient experiences no more inflammation than with a typical cataract surgery. The reason it is easiest to perform ECP during cataract surgery is that we are already entering the eye and can use the same incision to treat it. Also, after the cataract is removed, there is more space to work in.

For patients who are on several medications, this is a common treatment option. The benefits of doing ECP vs. a trabeculectomy is that the patient will recover much faster with ECP and will not have a permanent hole in the eye. Also, doing ECP affords the option to go back and perform surgery if need be.

Conversely, I would not advocate doing ECP as the first treatment. In this case, we exhausted several different methods such as medication and SLT before choosing ECP, but at the same time we were opportunistic at the time he had cataract surgery there was the prospect to perform ECP.

All who treat glaucoma need to have multiple treatment options available in order to effectively treat the disease over time. Different therapies are more appropriate in different phases of the treatment.

Robert J. Noecker, M.D., M.B.A., is vice chair, UPMC Eye Center, director, glaucoma service, Department of Ophthalmology, University of Pittsburgh Medical Center. He has no financial interest in the information contained in this article. He can be reached by e-mail at noeckerrj@upmc.edu.