Why individualized glaucoma care remains essential amid uneven patient awareness

Patient awareness of glaucoma differs markedly depending on urban and rural locations and the patient population, and that awareness or lack thereof impacts diagnosis, treatment, and monitoring.

James Tsai, MD, MBA, discussed with Ophthalmology Times his approaches given the wide diversity of patients in a major urban setting when awareness of glaucoma can run the gamut from highly educated patients to uninformed individuals.

He is president of the New York Eye and Ear Infirmary of Mount Sinai, the Delafield-Rodgers Professor of Ophthalmology at the Icahn School of Medicine at Mount Sinai, and chair of the Department of Ophthalmology at the Mount Sinai Health System, all in New York.

Implementing individualized patient care in practice

Tsai favors individualized treatment of his glaucoma patients. “My advice is based on their knowledge and interest level, and this is a great pitch for individualizing the treatment plan. It is incumbent on the physician and his or her team to understand the type of information that each patient and the family need to ensure the best possible care,” he commented.

He pointed to the implementation of artificial intelligence (AI) as a great opportunity to individualize treatment with the increasing presence of the technology in clinical practice. AI applications can aid in image analysis,¹ risk prediction,² prediction of treatment response,³ surgical planning,⁴ and treatments tailored to patient needs.⁵

Another new focus in glaucoma treatment, according to Tsai, over and above that rendered in the doctor’s office, is health coaching. Patients can access support groups and other organizations that can provide vision rehabilitation and social support; in addition, the Centers for Medicare and Medicaid Services is beginning to explore payment for health coaching that includes reimbursement for staff services to enhance overall glaucoma management.⁶

In his practice, Tsai does not adhere to a specific treatment step plan; rather, he addresses the challenges of patient medication adherence directly and encourages patients to link instillation of drugs to an activity such as tooth brushing. For patients for whom instilling drops is especially difficult, such as in the presence of arthritis or the potential for ocular irritation, he suggested that selective laser trabeculoplasty may be a good first-line treatment.

For patients for whom surgery is indicated but who are opposed to undergoing glaucoma surgery, he may suggest a different therapeutic route, including consideration of cataract surgery, which has been shown to effectively lower intraocular pressure (IOP) long term.

Outside of the practice setting within the community, the long-established Glaucoma Support and Education Group at the New York Eye and Ear Infirmary invites local glaucoma specialists to lecture to patients looking for more information about glaucoma. The Glaucoma Foundation and the Glaucoma Research Foundation also provide patient informational sessions and materials for interested individuals.

Current unmet patient needs

Despite the advances in technology to diagnose/treat glaucoma, gaps still exist, according to Tsai.

IOP fluctuations

He pointed out that one of the biggest gaps in managing glaucoma is ascertaining fluctuations in IOPs when a patient is not in the office. While follow-up office evaluations occur two to three times annually, those are the only occasions when the IOP is actually measured in patients with this blinding disease.

This realization has resulted in a great deal of interest in smart contact lenses, which are manufactured by a number of companies and incorporate technologies over and above vision correction. “There is a great deal of interest in smart contact lenses that measure IOP. It is illogical to think that we can manage glaucoma effectively when we don’t know how the IOPs fluctuate during the day,” he said (see sidebar).

Patient education

He also cited a gap in patients’ understanding of how glaucoma works. “Patients don’t understand that treating glaucoma is more than just controlling the IOP. There are risk factors for glaucoma that do not involve the IOP, such as low perfusion pressure (from too low a blood pressure), and patients are shocked by this. All of these other factors may be increasing their risk of progression,” he explained.

MIGS procedures

MIGS offer a less invasive alternative to traditional glaucoma surgeries, primarily aimed at reducing IOP, minimizing tissue trauma, and providing a safer profile.⁷

Drug-eluting MIGS are billed as a “significant” advance in the technology. They can both perform surgical interventions and deliver medications directly to the target tissues.⁸ This dual functionality aims to enhance IOP control while reducing the dependence on topical medications. The potential of this innovation lies in its ability to increase the efficacy of MIGS and improve patient adherence to treatment plans.⁷

However, the MIGS do not always reach the target IOPs, according to Dr. Tsai, and patients may need to undergo trabeculectomy with releasable sutures. There remains a need for glaucoma specialists to know how to perform some of these “old-fashioned’ surgeries.

Genetics and glaucoma

Tsai described work that is currently ongoing at Mount Sinai Health System by Louis R. Pasquale, MD, and colleagues. The study focus is on assessing the diagnosis of glaucoma in patients with a high genetic risk for glaucoma. Not surprisingly, those patients are more likely to be diagnosed as having glaucoma. “In the future, based on their genetic profiles, patients may be told to see an ophthalmologist given a high genetic predisposition for glaucoma,” he said.

AI will be instrumental in helping clinicians decipher the sea of data that will be collected, with which gaining a clear picture would be impossible.

Treatment options under study

Neuroprotection revisited

Neuroprotection⁹ in glaucoma is an area that is starting to regain attention, Dr. Tsai said. With advances in imaging, the physiologic, structural, or functional changes seen on images may provide more information about which therapies could provide neuroprotection in the future,” he explained.

Drug-eluting contact lenses

These are of particular interest to Tsai because, unlike some treatments such as implants, contact lenses do not require implantation. “This form of drug delivery is an interesting way of dealing with nonadherence to medical therapy,” he said. Challenges associated with this type of treatment are the length of time the lens can remain on the eye and the risk of corneal infection. The contacts are not yet approved for use in the US.

Glaucoma implants

Some companies are evaluating subconjunctival implants and anterior chamber implants to provide sustained drug release. Two such devices are currently available (Durysta, bimatoprost, Allergan; iDose, travoprost, Glaukos) and they have been instrumental in decreasing the treatment burden attached to drop instillation.

While Durysta provides sustained drug release, only a single administration per eye is currently permitted by the FDA; Tsai anticipates future implants that can be injected more than once.

Neural regeneration

“This is the final frontier in glaucoma,” he said. The end goal for patients is beyond simply controlling IOP and preserving vision; they want to regain lost vision. He views regeneration as possible ultimately and sees the role of AI as indispensable in developing a treatment strategy to deliver biologics or other therapies that could stimulate the body’s intrinsic regeneration capacity, he explained.

The Nogo receptors, present throughout the eye, actively inhibit regeneration of axons through an inhibitory cascade in the central nervous system. “Figuring out how to safely inhibit Nogo can potentially unleash some regenerative capacities in the central nervous system. This may offer some hope in the future.”

James C. Tsai, MD, MBA

Tsai is on the scientific advisory board of AI Nexus Healthcare, Eyenovia, Ophthalmic Therapeutic Innovation, and Smartlens. He is also a consultant for Thea Pharma.

References

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