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Managing glaucoma means managing the odds


Optimal management of glaucoma requires an individualized approach in which treatment is tailored based on multiple considerations. Developments in therapeutic options are adding new layers to the complexity of care decisions.

The goal in glaucoma care is not just to lower IOP, but rather involves maintaining vision throughout the patient’s lifetime, while causing minimal compromise to quality of life. Successful management, therefore, requires gauging the risks and managing the odds on multiple levels, said Andrew G. Iwach, MD, in his presentation “Glaucoma: Managing the Odds.”

Dr. Iwach, clinical professor of ophthalmology, University of California San Francisco, discussed how the charge to ophthalmologists is to collect all of the necessary information and then apply their training to determine the best management approach for individual patients. He also reviewed how an expanding array of tools for managing glaucoma provides new solutions and creates new challenges.

“Our treatment algorithms and risk calculators that are derived from large studies are important guides,” Dr. Iwach said. “However, we must not forget that we are treating individuals and not population means.”

One of the most fundamental considerations is the need to assess the trend of progression as it varies between patients as well as in individuals over time. Clinical decisions need to take into account the pace of progression, while factoring in patient age, patient preferences, and disease severity.

“We can always try to lower the IOP, but we must consider what the cost to the patient will be,” added Dr. Iwach. “Getting a sense of the trend of progression will help us to grade our therapy to a level appropriate for each eye.”

Managing odds

Assessing progression is analogous to obtaining a video rather than a snapshot of the case, and delaying decisions based on progression is rational for most patients because glaucoma tends to progress slowly.

To illustrate the value of this approach to “managing the odds” for glaucoma patients, Dr. Iwach used an analogy of placing a bet on the Super Bowl. If gamblers can choose to place their wager either before the game starts or after the first, second, or third quarters, but are always given the same odds, it is clear that it is better to delay the decision until the most information is available.

He also highlighted his point by describing the case of a 62-year-old flight attendant who was intolerant to medications and underwent trabeculectomy to treat her progressive glaucoma. Although the surgery was judged successful because it reduced the IOP and resulted in visual field stabilization, the patient was miserable having a bleb, bothersome ocular symptoms, and the inability to continue with the scuba diving, which she loved.

With this case as background, Dr. Iwach noted that new glaucoma surgical techniques bring new options for glaucoma care. He acknowledged they have more modest IOP-lowering effects than filtering surgery. Nevertheless, the new procedures can be a preferred alternative in appropriate patients. Here, Dr. Iwach used an analogy involving cars.

“We can zip to achieving a lower IOP with trabeculectomy, but sometimes the brakes don’t work and the patient ends up with bleb problems or endophthalmitis,” he said. “In some patients, we may not need to be so aggressive with lowering IOP and instead can choose a vehicle that provides a smoother ride that will buy us time as we see how the patient’s status evolves.”

Managing medication

Medication compliance continues to be a major concern in successful glaucoma care, and poor tolerability is one issue that can prevent patients from using their medications as directed. As preservative-related reactions are sometimes a cause for intolerance, new formulations containing novel preservatives, or that are preservative-free, are offering new solutions to this problem.

Looking ahead, investigational sustained-release medication delivery systems hold promise for addressing compliance issues, but also for opening the avenue to new therapies. Dr. Iwach explained that by delivering lower doses of medication, the prolonged release systems might enable treatment with molecules that were too toxic to use when delivered as a conventional drop.

Dr. Iwach noted that generic medications are presenting a double-edged sword. While they make treatment more affordable for many patients, they may not provide the same treatment benefit or quality packaging.

Additionally, they create a time-consuming burden for ophthalmologists, who increasingly need to be in contact with the pharmacy and insurers. Furthermore, as pharmacies’ stock constantly shifts between generic providers, it is difficult to know if a change in a patient’s IOP control might be due to use of a different generic product.

Dr. Iwach mentioned a situation he recently encountered when a patient, who received a generic IOP-lowering medication, complained that the medication seemed to dispense as a stream rather than as a drop. After investigating, Dr. Iwach determined that the tip came closed and was to be punctured using a prong on the covering cap. Unfamiliar with this type of packaging, the patient had cut off the tip with a scissors.

“There are some excellent generic products, but we don’t know what our patients are getting,” Dr. Iwach said. “We need to keep that in mind as we try to ask the proper questions when we are investigating compliance and treatment responses.”


Andrew Iwach, MD, is a consultant to or receives lecture fees from several companies that market products used in glaucoma patient care.

e. ai@glaucomasf.com



‘We can always try to lower the IOP, but we must consider what the cost to the patient will be.’

Andrew G. Iwach, MD


Optimal management of glaucoma requires an individualized approach in which treatment is tailored based on multiple considerations. Developments in therapeutic options are adding new layers to the complexity of care decisions.



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