The practice of ophthalmology has evolved tremendously over the last decade. Technology, pharmaceutical advances and the growth of social media have led to several trends in our field that are steadily gaining momentum. Millennial, Generation Z (and even some Generation X) ophthalmologists are spearheading many of these new developments, ultimately changing the landscape of modern-day practice. In 2022, we have more tools, devices and technology than ever before. As a result, practice patterns are beginning to evolve.

Many of these solutions have taken flight during the pandemic, when physicians began to turn to technology and social media to keep in touch with colleagues. Coincidentally, the first sustained-release drug in the glaucoma space received FDA-approval just days before the AAO recommended that ophthalmologists provide only urgent or emergent patient care.

Nearly 2 years into the COVID-19 pandemic, I have found myself turning to these trends more than ever.

SUSTAINED-RELEASE OPTIONS

In March 2020, bimatoprost SR (Durysta, Allergan) became the first implantable, sustained-release treatment for the reduction of IOP in patients with open-angle glaucoma or ocular hypertension to receive FDA approval. This was groundbreaking for several reasons. While most ophthalmologists would agree that topical drops are here to stay, some of the most common reasons that they may not be optimal for all patients include compliance, effectiveness, cost and tolerance.¹

As a glaucoma specialist, I have several daily conversations with patients stressing drop compliance. Many are on numerous medications, which further decreases their ability to adhere to a strict drop regimen. If I am concerned that compliance is a key factor in the inadequate management of a patient’s glaucoma, I offer more “autopilot” options such as laser trabeculoplasty and, now, sustained-release medications. Having an implantable medication removes the barrier of non-compliance. The retina space has already seen the success and improved outcomes that extended-release anti-VEGF and steroid medications can offer. It’s exciting that comprehensive ophthalmologists and glaucoma specialists can now partake as well.²

Tolerance of medications is tied to compliance. Patients with severe ocular surface disease who are unable to tolerate topical medications tend to be ideal candidates for sustained-release options. Several patients in whom I have administered Durysta have told me they feel like their eyes finally have a “break” from the daily grind of topical drops. They spend less on monthly medications because we have been able to stop one or two of their glaucoma medications. The patients who are most grateful are those with low vision, arthritis, tremors, cervical spine problems, Parkinson’s disease or other medical comorbidities that increase the difficulty of taking drops multiple times a day. They are finally achieving target pressures with less worry than before.

While there are still limitations to these sustained-release options, I believe we must embrace these options as another tool in the armamentarium. Other sustained-release options are being tested as well. For example, Travoprost XR (Envisia Therapeutics), a biodegradable anterior chamber travoprost implant, is currently in Phase 2 clinical trials. Another option coming down the pipeline with expected FDA approval in 2023 is the iDose TR (Glaukos). This implant contains a novel formulation of travoprost through a design that continuously releases therapeutic levels of medication for at least 1 year. Once all the travoprost is released, the implant can be removed surgically and replaced with a new iDose TR. I believe that sustained-release therapy will one day become as common as traditional topical medications.³

TELEMEDICINE

There was a time when telemedicine was not integrated into the practice of medicine and ophthalmology. Prior to 2015, physicians were reluctant to begin the process due largely to the lack of guidance from the state and federal governments. Reimbursement rates were relatively low compared to in-person examinations, which further deterred physicians from adopting it into their practices.

Since the onset of the COVID-19 pandemic, the US health-care landscape has changed dramatically. Telemedicine has finally become more commonplace, thanks to a loosening of once rigid regulations and the allowance of reimbursement for these “visits.”⁴

In glaucoma, telemedicine has a special role to play. While it may not allow for the assessment of objective measures of the ocular examination (eg, IOP measurement, gonioscopy, pachymetry, etc.), many other important aspects of the glaucoma visit can be addressed thoroughly from the comfort of the patient’s own home. This includes, but is not limited to, clarification of drop regimens, explanation of diagnostic testing and surgical consenting.

Telemedicine’s entry into ophthalmology has further opened doors for advancement in certain technologies and artificial intelligence, all geared towards improved disease detection, monitoring and remote management. Examples include mobile apps, smart devices, software and artificial intelligence to examine and monitor patients.

For instance, smart contact lenses that provide patients and physicians with 24-hour IOP monitoring could be game changers for patients who may otherwise be missed to follow up. Virtual reality visual field testing would free up office space, improve flow and allow patients to perform testing from the comfort of their own homes. This is only the beginning.⁵

Technology and telemedicine are not without their challenges. Patient engagement, the need for information technology personnel to help troubleshoot problems and the processing of patient data will all inevitably place roadblocks in their full integration. The biggest challenge of all, however, may be the physician’s acceptance and willingness to adapt their practice patterns to the future of medicine.⁵

Current and future generations of ophthalmologists are beginning their careers in a world where technology and telemedicine are becoming ever more accepted — even the norm. Though it will never replace an in-person examination, telemedicine’s integration may provide patients with an alternative (and more convenient) approach to the management of their ocular health.

SOCIAL MEDIA

As a millennial, being on social media is second nature. Along with numerous colleagues, I have found myself gravitating towards social media for the growth of my professional name locally, nationally and internationally, as well as for the ability to connect with colleagues and friends from all over the world.

Since starting my personal account, I have shared content relating to surgical techniques, disease management strategies and use of new technology and drugs. I have also shared non-clinical and personal content occasionally to further make my platform more relatable to my audience. Social media has allowed me to grow my network and provided me with opportunities that I may not have otherwise had.

It can be daunting to consider starting your own account. My advice is to ask yourself what your passions are and build an audience from there. Perhaps you are looking to create a more educational account geared towards medical students, residents and fellows. Or you may be looking to grow your own personal brand by connecting and engaging with industry. By knowing your “why,” you can govern yourself as to what content to create and post.

When creating content and posting online, it is even more important to present yourself in a professional and ethical manner. It is easy to forget that while we are behind a screen, our content is on display for the world to see. Therefore, reviewing each post for any potential medico-legal implications is necessary. Putting in appropriate disclaimers, removing patient identifiers and obtaining the appropriate informed consent are all ways in which to protect yourself and your patients. Furthermore, taking the responsibility for your own content, as opposed to hiring a third party, tends to be a more authentic representation of yourself and your “why.”

CONCLUSION

These ongoing trends in glaucoma and the practice of ophthalmology have presented younger physicians with more ways to practice, educate, network and provide their patients a more personalized approach to the management of their ocular health.

My advice to my residents — and any newly minted ophthalmologists — is to be open to innovation and new technology. While there may be times when what is tried and true is better for the patient, having access to new drug therapeutics and technology can enable us to provide our patients with a personalized approach to their ophthalmic care. OM

REFERENCES

1. Sustained-Release Glaucoma Medications. The Glaucoma Foundation. Available at https://glaucomafoundation.org/sustained-release-glaucoma-medications/ . Published July 6, 2021. Accessed January 21, 2022.
2. Camp A., Ganapathy P. Glaucoma Point-Counterpoint: Sustained-release Devices vs. Traditional Drug Regimens. Review of Ophthalmology. https://www.reviewofophthalmology.com/article/sustainedrelease-devices-vs-traditional-drug-regimens . Published January 15, 2021. Accessed January 21, 2022.
3. Whooley S. Glaukos completes enrollment in Phase 3 trials for iDose TR drug-eluting implant. Drug Delivery Business News. https://www.drugdeliverybusiness.com/glaukos-completes-enrollment-in-phase-3-trials-for-idose-tr-drug-eluting-implant/ . Published June 10, 2021. Accessed January 21, 2022.
4. Charters L. Future looks promising for telemedicine. Ophthalmology Times. https://www.ophthalmologytimes.com/view/future-looks-promising-for-telemedicine . Published June 13, 2021. Accessed January 21, 2022.
5. Al-Aswad L. Telemedicine: Promising Future for Glaucoma Management. Glaucoma Research Foundation. https://www.glaucoma.org/news/blog/telemedicine-promising-future-for-glaucoma-management.php?gclid=CjwKCAiAz--OBhBIEiwAG1rIOk4wU1GK_g1Dw97vFScb2azBBQrKm10AMVu7rojq6VKUBqR7YYLhixoCtG4QAvD_BwE . Published June 19, 2020. Accessed January 21, 2022.

Monisha M. Vora, MD, specializes in the medical and surgical treatment of glaucoma and cataract surgery. She practices at Northern Ophthalmic Associates in Jenkintown, Pa., and is a clinical instructor of the Glaucoma Service at Wills Eye Hospital in Philadelphia. She is a member of the American Glaucoma Society, AAO and Women in Ophthalmology. E-mail her at mandalmv@gmail.com and find her on instagram at @drmonishavora. Dr. Vora reports no financial disclosures.