Dr. Andrew Rixon, OD, FAAO, is the Residency Coordinator and an attending Optometrist at the Memphis VA Medical Center in Memphis, TN.

Dr Rixon is on the executive committee of AAO’s Glaucoma section and a member of the Optometric Glaucoma Society and a Contributing Editor, CRO Journal. 

A few years ago I had a conversation with one of our ophthalmology residents, who went on to do a retinal fellowship. He observed that I was working on a lecture. The conversation proceeded as follows.

Resident: Hey Drew. What are you working on?

Me: A lecture discussing updates in the field of Glaucoma.

Resident: That should be easy enough, glaucoma is pretty much the same as it was 30 years ago.

Me (initially speechless): I’ll send you this when I’m done and you’ll be surprised how radically different the landscape of glaucoma IS in contrast to 30 years ago.

Unfortunately, such inaccurate perceptions about glaucoma still exist amongst eye care practitioners which may preclude them from appropriately managing glaucoma. Industry data suggests that 20% of ODs prescribe 80% of glaucoma medications written by our profession. The reality is that with a rapidly aging population, who will have a substantially increased ocular disease incidence, and a static production of practicing ophthalmologists (per San Francisco match data over the last decade), glaucoma needs optometry more than ever.1,2

Thankfully, this is an extremely exciting time to be involved in glaucoma care, with recent and impending advances that will reduce the burden on both patient and practitioner. Fortunately, I was able to attend both the annual Optometric Glaucoma Society and AAO meetings in Orlando a few weeks ago. These meetings are the highlight of my CE year as they perfectly blend cutting edge research with updated clinical care. So, what’s happening in glaucoma?

Recent clinical trials LIGHT (Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma) and ZAP (Zhongshan Angle Closure Prevention Trial) have challenged the status quo on first-line management of patients with open-angle glaucoma and those classified as angle closure suspects respectively. Although, the debate of when to do SLT first-line and when to perform or withhold LPI in Primary Angle Closure Suspect (PACS) rages on.3,4

Importantly, both trials assessed patient’s health-related quality of life. This is a positive holistic direction that may shift the paradigm of outcome assessments in future trials to become more patient-centric. Look for the results of Phase III of OHTS (Ocular Hypertension Treatment Study) to be available soon. The OHTS investigators were able to ascertain 66% of the study’s initial 1636 patients and further evaluate their outcomes from 2016-2019 with the goal of describing visual function over the life expectancy of individuals with OHT over 55 years of age.4 With the inclusion of Phase III, 20 years of data on patients with OHT is accessible and will provide additional guidance on the management of patients with OHT, furthering the impact of this study.

Patient adherence and burden of treatment are at the forefront of any glaucoma discussion with a growing shift toward guided administration of pharmaceuticals and earlier interventional surgical management. Multiple sustained release drug delivery mechanisms are in Phase III trials and should be available soon, bypassing current patient related barriers to successful treatment. On the surgical side, MIGS (Microinvasive Glaucoma Surgeries) continue to evolve with newer devices and techniques becoming available to provide our surgeons with a greater arsenal to combat the many types of glaucoma.

Researchers are working to modify and advance existing technology so that we may ultimately have alignment between structure and function (which is currently limited by, among other things, discordant units of measurement between visual field and OCT technologies), as well as better visualize the structures of the conventional outflow mechanism in vivo.

When I hear about the umbrella of Artificial Intelligence that has exploded over the last few years, I irrationally worry about job security. However, the purpose of AI, specifically deep learning (DL) algorithms, is to enhance our abilities as clinicians to improve early detection and subsequent care, not replace us. Recently a DL algorithm trained by humans on fundus images was able to detect referable glaucomatous optic neuropathy with greater sensitivity and comparable specificity to eye care experts, demonstrating the promise of DL, especially in underserved areas where tele-imaging may be the only initial eye care access for patients.5 Of note, at present there exists no FDA-approved AI for glaucoma use.

Lastly, BAK continues to prey upon the ocular surfaces of our glaucoma patients. More non-preserved options exist but the major issue may be recognition of this comorbidity by the eye care community. Industry data shows only 21% of ODs are managing DED by the use of prescribed pharmaceutical agents. It’s critical that we are cognizant of that fact that by initiating ocular hypotensive treatment we often worsen our patient’s quality of life by inducing or worsening ocular surface disease. We as a community have to do better.

In short, although there are many remaining challenges, the future of glaucoma care is bright and will provide us the opportunity to maximize functional vision, which at the root of things is our principle objective as Optometrists.

Andrew Rixon, OD, FAAO, Contributing Editor, CRO Journal

1. Varma R, Vajaranant TS, Burkemper B, Wu S, Torres M, Hsu C, Choudjury F, McKean-Cowdin R. JAMA Ophthalmol. 2016;134(7):802-9.
2. https://www.sfmatch.org/PDFFilesDisplay/Ophthalmology_Residency_Stats_2019.pdf
3. Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M; LiGHT Trial. Lancet. 2019;393(10180):1505-1516.
4. He M, Jiang Y, Huang S, Chang DS, Munoz B, Aung T, Foster PJ, Friedman DS. Lancet. 2019;393(10181):1609-1618.
5. Phene S, Dunn RC, Hammel N, Liu Y, Krause J, Kitade N, Schaekermann M, Sayres R, Wu DJ, Bora A, Semturs C, Misra A, Huang AE, Spitze A, Medeiros FA, Maa AY, Gandhi M, Corrado GS, Peng L, Webster DR. Ophthalmology. 2019;S0161-6420(19)31875-5.