Glaucoma is an asymptomatic disease for many patients. Because of this, it is critical that we try to employ treatments that do not cause more symptoms and annoyance for our patients than the disease itself and work to optimize quality of life for our mild and moderate glaucoma patients. Unfortunately, some patients do progress to advanced and symptomatic glaucomatous disease despite treatment. For these patients, addressing quality-of-life strategies is also critically important.

In this article, I’ll discuss the treatments and strategies that we employ in our practice for these patients and how to discuss the importance of loss of vision and its impacts on their daily living.

ENSURING TREATMENT ISN’T WORSE THAN THE DISEASE

Glaucoma treatment landscape

The number of IOP-lowing therapies has grown over the last decade, as has the data supporting some of these option. We now have six categories of treatment strategies: selective laser trabeculoplasty (SLT), incisional glaucoma surgery, microinvasive glaucoma surgery (MIGS), topical eyedrops, intraocular sustained-release medications and oral IOP-lowering medications. Additionally, there are several investigational and pipeline adjuvant therapies including IOP-reducing goggles¹ and dietary supplements.²

Glaucoma and ocular surface disease

Ocular surface disease (OSD) and glaucoma frequently coexist in patients.³ Age is one reason for this. Additionally, IOP-lowering eyedrops have been implicated in causing or potentiating OSD. Histopathologic evidence shows that both active ingredient molecules and benzalkonium chloride are responsible for abnormal conjunctival and trabecular meshwork infiltration by cells expressing inflammatory and/or fibroblastic markers⁴ and can be responsible for OSD symptoms.

Importantly, OSD can have horrible effects on patients’ quality of life, with one study showing the relative impact of severe dry eye disease on patients was similar to that reported for dialysis and severe angina!⁵ With nearly 60% of glaucoma patients reporting OSD⁶ and 27% of patients reporting severe symptoms,⁶ the burden is large for patients under our care. With this in mind, addressing OSD signs and symptoms in our glaucoma patients goes a tremendously long way toward improving their quality of life.

SLT

Extremely compelling data, including the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial,^7,8 demonstrates that SLT is an outstanding option for IOP control in patients who are treatment naïve. Thus, one of the best ways to prevent glaucoma eyedrop-related OSD is to offer SLT as first-line therapy.

It is briefly reviewing the LiGHT trial data, because I have found that some skeptical patients are highly motivated to proceed with primary SLT when they hear about this trial. The LiGHT trial^7,8 randomized 718 treatment-naïve patients to SLT or topical therapy (a prostaglandin analog). At 3 years, 74.2% of patients in the SLT group required no drops to maintain IOP at their preset target pressure.⁷ Additionally, eyes having undergone SLT were within target at more visits (93.0% vs 91.3%) and required less glaucoma surgery (0 vs 11 patients).⁷ Similar results were observed in the 6-year data, which was an extension of the trial and completed by 524 patients. At 6 years, 69.8% of eyes in the SLT arm remained at or less than the target IOP without the need for medical or surgical treatment. More eyes in the drops arm experienced glaucomatous progression compared to the SLT arm (26.8% vs 19.6%, respectively; P=0.006). Importantly, trabeculectomy was performed in 32 eyes in the drops arm compared with 13 SLT arm eyes (P<0.001). Cataract surgeries were performed on 95 drops eyes and 57 SLT eyes (P=0.03). Finally, SLT proved to be extremely safe with no serious laser-related adverse events.⁹

My discussion of the LiGHT trial is tailored to specific patient questions and concerns. The cataract data is particularly noteworthy to the type of patient who presumes that eyedrops are “benign.” I explain that even eyedrops have consequences! I do try to emphasize that both drops and SLT are excellent options for glaucoma treatment and are supported by volumes and decades of data. I do not want any patient to leave the conversation feeling like they chose a “bad” option. Instead, every patient should be empowered to make the best decision for them.

Of course, SLT can also be performed in patients who are already on topical IOP-lowering therapy. I don’t typically “rock the boat” and recommend SLT in stable, happy, compliant drop users. However, I do find that I see many patients who are controlled yet unhappy on drops. In mild to moderate glaucoma patients on 1-2 drops, my success rate for getting them off drops with SLT is commensurate with the LiGHT data in treatment-naïve eyes. Patients often haven’t been offered SLT by other providers, and doing so can make a huge impact on their quality of life (and perhaps on their disease state). I often say, “Like eyedrops, laser therapy for glaucoma also works to control your eye pressure. In many patients, laser therapy can reduce or eliminate the need for eyedrops. Is that something you have heard about before? Would you be interested?”

MIGS

Like SLT, MIGS can be very successful at reducing or eliminating eyedrops for glaucoma patients. In fact, eyedrop reduction or elimination is the reason for MIGS in most of my patients. I typically perform MIGS with cataract extraction. Thus, the quality-of-life impact for patients can be quite high given the impressive combination of improved visual clarity and fewer or no glaucoma eyedrops (for more, see page 22).

The Glaucoma Outcomes Survey was recently developed to evaluate health-related quality-of-life changes for patients undergoing MIGS who have mild to moderate glaucoma.¹⁰ Analysis of results of the questionnaire (administered via the AAO Intelligent Research in Sight registry) will improve our understanding of MIGS and its impact on quality of life and OSD. This is a topic of great interest to the FDA and AAO, and our patients stand to benefit from better understanding these relationships.

Sustained-release therapies

Sustained-release intracameral bimatoprost (Durysta, Allergan) is a valuable addition to the glaucoma treatment armamentarium both with respect to OSD and with respect to compliance. This is the first intraocular sustained-release glaucoma medication among a vast pipeline. The bimatoprost intracameral implant is easy to deploy with respect to technical skill and is easy to discuss with patients given that many are already quite familiar with this active ingredient.

In my practice, the typical patient who undergoes placement of the bimatoprost intracameral implant is someone with good insight who really wants to use drops but is running into an obstacle. Examples of obstacles include severe OSD (the most common), dexterity challenges, forgetfulness, or running out of drops before the end of the month and being unable to obtain refills.

These patients are often quite grateful to be offered something they haven’t tried and are generally delighted with the ease of the procedure and the results. I generally say, “One option we haven’t tried is a pellet that goes inside the eye and releases glaucoma medication slowly over months.” Then, I connect back the obstacle we’re overcoming by implementing this strategy. For example, “Because the pellet releases the medication slowly, we don’t have to worry about you running out of drops for the last week of each month.”

STRATEGIES FOR ADVANCED GLAUCOMATOUS DISEASE

Introduce the idea of vision loss sooner

The possibilities of blindness or progressive glaucomatous visual impairment can often feel like “the elephant in the room” when patients have advanced glaucoma. Nonetheless, when possible, I have found it best to introduce the idea of vision loss from glaucoma sooner rather than later and to use clear, direct language.

One of our patients’ biggest concerns when introducing the idea of vision loss or blindness is their fear that you, their doctor, are “giving up” or abandoning them. Emphasizing the therapeutic alliance while also preparing for the future is a critical balance. In patients with fixation-threatening glaucoma or progressing severe disease, I want them to know that we are allies in doing everything possible to preserve the vision they have. But, I also want them to know that progression is a possibility and that preparation for this can start now.

These important conversations can happen incrementally over the course of many visits, and I often make a brief note of discussed topics in the patient chart. Sometimes, preparation can be as simple as discussing strategies for home safety. This includes removing or adjusting low-lying furniture that could be tripped on; minimizing flooring transitions such as rugs or elevated door thresholds; optimizing lighting; adding suction or permanent bathroom handles; and utilizing nightlights.

Explain ‘legal blindness’

I have found it extremely helpful to explain to patients what legal blindness is. Some of my patients are actually surprised to hear that they meet the criteria for legal blindness. These patients may not feel that they are “blind” because they can “see” but are comforted by having a shared language to use to describe their disability. This is important to discuss because even capable patients with tremendous social support systems may benefit from disability benefits and tax exemptions. Though definitions can vary for some disability benefits, the Social Security Administration defines blindness as:

• Central visual acuity for distance of 20/200 or less in the better seeing eye with corrective lenses, or
• Visual field of less than 20 degrees in the widest diameter

The discussion of legal blindness is an important one, because that may help to unlock resources for your patient through their State Commission for the Blind. In New York, legally blind patients can access resources for vocational rehabilitation, independent living, mobility services, mental health, etc. Generally speaking, I receive extremely positive feedback from my patients who utilize these resources. Additionally, some of my patients who are plugged in have educated me about resources they have found helpful so that I can pass along this knowledge to others who could benefit as well.

Present the option of a non-driver ID card

The question of continued driving is an incredibly challenging one. As a New York City physician, I encounter this issue far less than others because a minority of my patients drive routinely. Some patients bring me vision forms for renewing their driver’s license, yet they know they should not drive and do not want to. Nonetheless, they are concerned about being without an easy-to-use ID card. I have found it very helpful to introduce patients to the concept of a state-issued, non-driver ID card. This looks just like a driver’s license but isn’t used as authorization to operate a vehicle. Many patients are satisfied with transitioning to this option.

CONCLUSION

Patients with mild to moderate glaucoma often face quality-of-life challenges that result from OSD. Treatment strategies that incorporate SLT, MIGS and/or sustained-release medications have can reduce OSD and the daily burden of chronic illness management. Alongside these glaucoma treatment approaches, residual OSD requires management and environmental modifications, and algorithms are described elsewhere.¹¹

In addition, patients with severe glaucoma are at risk for glaucoma-related blindness, and this can manifest in various, overlapping forms including legal blindness and/or interference with daily activities. Addressing the possibility of blindness with patients is important as is tailoring your recommendations to the patient’s specific needs. When appropriate, connecting patients with resources available through your State Commission for the Blind or similar resources may be helpful. OM

REFERENCES

1. Ferguson TJ, Radcliffe NM, Van Tassel SH, et al. Overnight Safety Evaluation of a Multi-Pressure Dial in Eyes with Glaucoma: Prospective, Open-Label, Randomized Study. Clin Ophthalmol Auckl NZ. 2020;14:2739-2746. Published 2020 Sep 21.
2. De Moraes CG, John SWM, Williams PA, Blumberg DM, Cioffi GA, Liebmann JM. Nicotinamide and Pyruvate for Neuroenhancement in Open-Angle Glaucoma: A Phase 2 Randomized Clinical Trial. JAMA Ophthalmol. 2022;140(1):11-18.
3. Dana R, Bradley JL, Guerin A, Pivneva I, Evans AM, Stillman IÖ. Comorbidities and Prescribed Medications in Patients With or Without Dry Eye Disease: A Population-Based Study. Am J Ophthalmol. 2019;198:181-192.
4. Baudouin C, Pisella PJ, Fillacier K, et al. Ocular surface inflammatory changes induced by topical antiglaucoma drugs: human and animal studies. Ophthalmology. 1999;106(3):556-563.
5. Buchholz P, Steeds CS, Stern LS, et al. Utility assessment to measure the impact of dry eye disease. Ocul Surf. 2006;4(3):155-161.
6. Leung EW, Medeiros FA, Weinreb RN. Prevalence of ocular surface disease in glaucoma patients. J Glaucoma. 2008;17(5):350-355.
7. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial [published correction appears in Lancet. 2019 Jul 6;394(10192):e1]. Lancet. 2019;393(10180):1505-1516.
8. Garg A, Vickerstaff V, Nathwani N, et al. Primary Selective Laser Trabeculoplasty for Open-Angle Glaucoma and Ocular Hypertension: Clinical Outcomes, Predictors of Success, and Safety from the Laser in Glaucoma and Ocular Hypertension Trial. Ophthalmology. 2019;126(9):1238-1248.
9. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: Six-Year Results of Primary Selective Laser Trabeculoplasty versus Eye Drops for the Treatment of Glaucoma and Ocular Hypertension. Ophthalmology. 2023;130(2):139-151.
10. Cui QN, Hays RD, Tarver ME, et al. Vision-Targeted Health-Related Quality-of-Life Survey for Evaluating Minimally Invasive Glaucoma Surgery. Am J Ophthalmol. 2021;229:145-151.
11. Starr CE, Gupta PK, Farid M, et al. An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684.

Sarah H. Van Tassel, MD, is director of the Glaucoma Service and Glaucoma Fellowship at Weill Cornell Medicine Ophthalmology. Dr. Van Tassel completed her residency in ophthalmology at Weill Cornell Medical College and her fellowship in glaucoma at Duke University. Her interests include personalized glaucoma care, surgical outcomes, ophthalmic imaging, and the intersection of mental health and glaucoma. Disclosures: Dr. Van Tassel is a consultant for Abbvie, Alcon, Belkin, Glaukos and New World Medical.