The realm of reasonable is wide in glaucoma treatment. One of my favorite memories of glaucoma fellowship is that two mentors disagreed on nearly everything, yet both were phenomenal ophthalmologists. One sought to preserve every axon, treating early and aggressively. More attuned to risks, the other took his time with each intervention decision, often patiently repeating tests for confirmation, willing to sacrifice a few axons to decrease the risk of unnecessary treatment.

Multiple ophthalmologists may recommend different treatment — medication, laser, MIGS, or even trabeculectomy — to the same patient. None may necessarily be wrong. Our treatment biases reflect our training, practice patterns, and certainly our psychology; ie, are we more afraid of losing axons on our watch or the complications of our interventions? We try to prevent patients’ vision loss using as little intervention as we believe is necessary. Our field’s recent increase in treatment options can help deliver an individualized approach by tailoring treatment to each patient’s eye pathology and psychosocial factors. Understanding our own biases can help reach a patient-centered plan.

Shift Toward Individualized Treatment

The fields of functional and integrative medicine have led the movement toward individualized medical care. These fields take into consideration each patient’s history, genetics, environment, microbiome, lifestyle, and values to identify the root cause of disease and to determine a holistic, patient-centered treatment plan. An approach that focuses on the person rather than the disease has been shown to improve health-related quality of life, outcomes, and costs.¹

Understanding patients’ desires and psychology is instrumental in tailoring individualized glaucoma care. Do patients want to make their own informed decisions or rely more on our recommendations? Are they terrified of surgery, or blindness, or both? Numerous cultural and psychosocial factors could impact patients’ decisions to have surgery — lack of resources, trust of physicians, family history of unsuccessful surgery, etc. An individualized approach to medicine requires delving into patients’ personalities. Some patients fear lasers and others hate the idea of taking an eye drop every day. Just like in parenting, the better we understand our own psyches, the more attuned we can be to our patients’.

For newly diagnosed glaucoma patients, prostaglandin eye drops are still an excellent first-line treatment. However, the LiGHT trial has shown that selective laser trabeculoplasty (SLT) can equally lower intraocular pressure and with less cost.² Newer eye drops, including Vyzulta (Bausch + Lomb) and Rocklatan (Aerie Pharmaceuticals), are likewise reasonable. Alternatively, patients could potentially receive a prostaglandin by injection into the anterior chamber or placement within the canaliculus. For patients who struggle with eye-drop adherence, these lasers, injections, and canalicular inserts offer great promise.

Personalized medicine particularly benefits patients with poor medication adherence by finding the root of the problem. Numerous psychosocial factors can influence adherence including cost, travel, side effects, poor understanding of disease, and forgetfulness.³ Asking why patients miss their medication doses can lead to surprising answers. Eye-drop monitors, like the Devers Drop Device (Universal Adherence) and Kali Drop (Kali Care), may soon provide tracking and reminders for missed doses. Patients also struggle when self-administering drops, and eye drop aids are an underutilized resource.⁴ The Gentledrop (Bedo Solutions) was recently shown to improve eye drop delivery success, and 47 of 50 (94%) patients preferred the aid over traditional delivery (Figure 1).⁵

Timing of Treatment

Despite their differences, my mentors agreed that one of the most important decisions an ophthalmologist makes is whether to start treatment on a glaucoma suspect. Once a patient is started on eye drops, treatment often continues for life. My mentors advised me to be mindful that the easy experience for the ophthalmologist (ie, start treatment and therefore do not worry) is difficult for the patient (ie, lifetime of drops). Likewise, the difficult experience for the ophthalmologist (ie, observe and therefore worry) is easier in the short term for the patient (ie, no cost and no drop side effects). My mentors also cautioned against “reactive medicine”: making an immediate, reflexive decision in response to a sign or symptom, like automatically adding a hypotensive eye drop because a patient’s intraocular pressure rises above target. Reactive medicine seems the opposite of an individualized approach, as the nuances of patients’ pathology and psychosocial factors are ignored due to physician biases. Understanding patients’ psychology helps with individualized glaucoma care. Self-inquiry into our own fears and biases can support that understanding. GP

Robert M. Kinast, MD, is associate director of the glaucoma fellowship at Legacy Devers Eye Institute in Portland, Oregon. Dr. Kinast is the cofounder and CEO of Bedo Solutions LLC and Universal Adherence LLC. Reach Dr. Kinast at robertkinast@gmail.com.

References

1. Beidelschies M, Alejandro-Rodriguez M, Ji X, Lapin B, Hanaway P, Rothberg MB. Association of the functional medicine model of care with patient-reported health-related quality-of-life outcomes. JAMA Netw Open. 2019;2(10):e1914017. doi:10.1001/jamanetworkopen.2019.14017
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. A multicentre, randomised controlled trial: design and methodology [published correction appears in Br J Ophthalmol. 2021 Feb;105(2):e1]. Br J Ophthalmol. 2018;102(5):593-598. doi:10.1136/bjophthalmol-2017-310877
3. Friedman DS, Hahn SR, Gelb L, et al. Doctor-patient communication, health-related beliefs, and adherence in glaucoma results from the Glaucoma Adherence and Persistency Study. Ophthalmology. 2008;115(8):1320-1327.e13273. doi:10.1016/j.ophtha.2007.11.023
4. Davis SA, Sleath B, Carpenter DM, Blalock SJ, Muir KW, Budenz DL. Drop instillation and glaucoma. Curr Opin Ophthalmol. 2018;29(2):171-177. doi:10.1097/ICU.0000000000000451
5. Sanchez FG, Mansberger SL, Kung Y, et al. Novel eye drop delivery aid improves outcomes and satisfaction. Ophthalmol Glaucoma. 2021;S2589-4196(21)00011-9. doi:10.1016/j.ogla.2021.01.001