My Patient Needs Glaucoma Surgery: Now What?

There are numerous triggers for referral.

By Murray Fingeret, OD

Involvement of optometrists in the management of glaucoma has grown over the past decades. Beginning in 1978, states have expanded optometrists’ scope of practice to include prescription of therapeutic drugs, and today 49 states allow optometrists to provide glaucoma treatment.

The level of involvement in glaucoma management varies among optometrists, depending on their training, experience, and personal inclination. In my case, I have pursued glaucoma as a specialty, as have my optometrist colleagues in the Glaucoma Section of Advanced Ocular Care. In my position at the Department of Veterans Affairs (VA) in New York, my practice includes a wide range of patients with glaucoma, some of whom have been under my care for many years.

Regardless of one’s level of training however, all optometrists care for patients with glaucoma or ocular hypertension to some degree. Some may limit their involvement to those with mild glaucoma or ocular hypertension. Others may be comfortable managing the care of those taking several antiglaucomatous medications. For those in the latter category, there will come a time when some of these glaucoma patients will need to be referred for surgery.

What happens then? Every case is different, and each patient will have his or her own path through referral, surgery, and return for continued care postoperatively. The important thing for the optometrist to remember is to keep communication lines open with the patient and the glaucoma specialist to ensure that everyone is on the same page.

TRIGGERS FOR REFERRAL

There are several triggers for referral for evaluation by a surgeon. One is an intraocular pressure (IOP) that is not well controlled, that is higher than I would like for a particular patient and cannot be reduced medically. There is no magic number, but rather an IOP that is above a patient’s target pressure. If the individual with elevated IOP is already on maximal medical therapy, or if he or she is not capable of instilling the medications for whatever reason, it may be time for referral.

Maximal medical therapy for most patients would consist of a prostaglandin and a fixed combination drop. With uncontrolled IOP despite a total of three pressure-lowering medications, that patient has pretty much exhausted his or her medical options. The more drops that are added to a medical regimen, the less likely is adherence to the regimen.

Maximal medical therapy for most patients would consist of a prostaglandin and a fixed combination drop. With uncontrolled IOP despite a total of three pressure-lowering medications, that patient has pretty much exhausted his or her medical options. The more drops that are added to a medical regimen, the less likely is adherence to the regimen.

Another trigger for referral, regardless of IOP level, is any sign of disease progression, either on visual fields or upon evaluation of the optic nerve and retina and medical options have been exhausted. If progression is noted and the patient is on one medication (and the medication is reducing the IOP and is tolerated), I would add a second agent. The IOP would be checked within a few weeks and assessment of the fields and optic nerve soon thereafter. If the condition is stabilized, I would continue to follow closely. If the IOP is not reduced to an adequate level (the target IOP needs to be reset whenever progression is discovered), the referral is indicated. Also, if further change is need after the target IOP has been lowered, a referral is also in order.

Any one of these factors is sufficient to prompt referral for a surgical evaluation. For a patient having trouble with compliance, it may be that selective laser trabeculoplasty with a relatively simple postoperative course, would be sufficient to bring the IOP into line. For patients on maximal therapy, on the other hand, a more invasive procedure such as trabeculectomy or one of the new devices may be needed.

MAKING THE REFERRAL

It is important to convey all relevant patient information to the glaucoma specialist upon referral. I practice in a VA hospital, so for referrals I record my notes in the electronic medical record, as I would at any visit including a narrative description in my assessment and plan. When we send the patient for a consult the doctor can read my notes. I make sure to highlight what the IOP is and what I feel the target pressure should be. I note whether the patient’s optic nerves or visual fields are getting worse, and any other relevant information. I also refer to any images in the electronic medical record, such as visual fields, optic nerve photos, or other diagnostic images, that will help to illuminate the patient’s condition.

Increasingly, with accountable care organizations and other networks becoming more common, practitioners will be able to share electronic records as I can with my colleagues at the VA. In the event that your practice is not connected electronically with the surgical group to which you refer, a letter of referral can convey the relevant information.

Patients who undergo laser procedures, such as selective laser trabeculoplasty or an iridotomy because of a narrow angle, are usually sent back to the referring optometrist almost immediately for postoperative management. We usually see such patients within the week to make sure there is no inflammation and check the IOP. For more invasive surgical patients, the glaucoma specialist generally handles postoperative care until the patient is stable

CONCLUSION

Every glaucoma patient is different, and every case is unique. There are numerous possible reasons to consider surgery for patients with glaucoma, as outlined above, and any one of those triggers may be sufficient to refer a patient for evaluation by a surgeon. Prompt referral and clear communication can help patients with glaucoma to maintain their visual function and preserve their quality of life over many years.

Murray Fingeret, OD, is chief of the Optometry Section, Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York. Dr. Fingeret may be reached at (718) 298-8498; murrayf@optonline.net.