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    5 things about glaucoma care that frustrate me


    3. Ocular surface disease (OSD) is prevalent among glaucoma patients and is one of the biggest reasons for noncompliance

    It just so happens that the very same patients who often require topical glaucoma drops either already have OSD or latent OSD, which is made manifest by the preservatives (often benzalkonium chloride [BAK]), active ingredients, or drug vehicles in topical glaucoma medications.

    Fortunately, non-preserved glaucoma medications and others with “soft preservatives” have come online. I have personally used many of these to great effect to improve compliance and maintain IOP lowering without scorching the ocular surface.

    Still, you’ll almost always end up treating two chronic, frustrating diseases at the same time, especially as patients age.

    “But Doc, I was fine until you put me on those pressure drops.  I stopped them because my eyes feel so much better without them.”

    Related: Riding out conjunctivitis like a bad storm

    Are we having fun yet? Do you still think this is sexy?

    4. Glaucoma surgery is better and safer—but not always available when and where you need it

    Improvements in glaucoma surgery have been a welcome relief for eyecare practitioners in the trenches and for patients.

    In particular, selective laser trabeculoplasty (SLT), improved filtering/shunting techniques, and minimally invasive glaucoma surgery (MIGS) are enabling many patients to reduce the number of their topical meds, and in some cases, eliminate them all together.

    But this happens far less often than it should. Among the many reasons are a lack of accessibility to glaucoma surgeons performing state-of-the-art procedures, cost, and a persistent culture in the U.S. of saving surgery as a “last resort.”

    This needs to change. Here’s hoping the emerging generation of glaucoma specialists will be able to provide the full array of surgical options earlier and more often than in the past.

    All I know is that at this point in my career, if I could refer all my glaucoma patients out to “get fixed” once and for all, they’d leap for joy—and I would, too.

    5. People are living longer

    But wait, that’s a good thing, right?

    Generally speaking, sure. But with increased longevity comes the fact that even patients who have been followed closely and managed as well as possible will be more likely to continue to suffer glaucomatous vision loss as they age.

    Related: It's not easy seeing green

    I’ve seen patients with low IOPs in their 70s and 80s who have suddenly progressed, as if programmed cell death was a fait accompli all along.

    My clinic is becoming increasingly full of older patients with fragile optic nerves and severe visual field loss who nobody wants to touch surgically (and I understand that for many, there is the possibility of more harm than good in such cases).

    “As long as the IOP stays in the low teens, just follow them in your office,” my consultants will often say.

    Thanks a lot. So we wait, cross our fingers, and hope that the light at the end of the tunnel will stay lit just a little longer.

    Losses stick with you

    I mentioned at the beginning that we win far more than we lose while treating glaucoma. If this were football, I’d have a winning percentage that would put me in a hall of fame.

    But the losses stick with me more than the wins.  I even remember their names and faces.

    Read more from Dr. Brown here

    Michael Brown, OD, MHS-CL, FAAO
    Dr. Brown has practiced medical optometry in a comanagement center and with the U.S. Department of Veterans Affairs Outpatient Clinic in ...


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