Create a Comprehensive Practice With Multiuse Technologies

Meet patients’ needs by managing glaucoma under same roof as retina, cataract patients.

By Ahmad A. Aref, MD

Although it is still possible for new ophthalmic training graduates to pursue solo glaucoma practices, health care laws have created formidable challenges for these endeavors. For this reason, there is now growing trend toward the formation of larger multi-subspecialty practices, and glaucoma centers must critically assess their investments in new technology to maximize the benefit for all members. One way to achieve this is to purchase diagnostic and therapeutic technologies capable of serving patients suffering from a wide range of ophthalmic pathologies.

GLAUCOMA ASSOCIATED WITH INTRAVITREAL INJECTIONS

More and more research suggests an increased risk of glaucoma with various retinal therapies.1,2 It is imperative that retina subspecialists make a diagnosis of glaucoma in a timely manner to allow for early therapy and a better overall prognosis. Becoming adept at using and interpreting the optic nerve head protocol for optical coherence tomography is key.

OCULAR SURFACE DISEASE

A large proportion of any practice’s cataract and glaucoma patients will have some degree of ocular surface disease (OSD) which can have a negative impact on the final visual acuity achieved with otherwise successful cataract surgery. Additionally, OSD may become exacerbated with the use of glaucoma medications and may therefore hinder patient compliance with a prescribed intraocular pressure (IOP)-lowering regimen. OSD and inflammation may also affect glaucoma surgical outcomes by increasing the risk of postoperative episcleral and subconjunctival scarring, limiting IOP-lowering efficacy.3

To enhance my protocol for diagnosing and treating OSD patients, I recently incorporated osmolarity testing with the TearLab Osmolarity System (TearLab Corporation). Research on the effects of various glaucoma therapies on tear film osmolarity has shown that benzalkonium chloride, the most commonly used preservative in eye drops, can induce symptoms of ocular irritation in patients treatment for long periods of time.4 Investigators found increased cytotoxic effects of benzalkonium chloride in hyperosmotic conditions, such as caspase-dependent and independent apoptosis and oxidative stress.5

This is further evidence that many of the glaucoma medical therapies used routinely in a majority of patients have a negative impact on the ocular surface by increasing tear film osmolarity. There may be differences in terms of how various agents affect the ocular surface, and awareness can allow ophthalmologists to tailor treatment approaches to minimize any adverse impact of treatment on the ocular surface.

COMBINATION THERAPY

Posterior capsular opacification remains the most common complication of modern cataract surgery, and it degrades postoperative visual acuity and visual functioning.6 The Lumenis Selecta Trio system (Lumenis) can perform YAG laser capsulotomy. The 532/argon portion of the laser can be used for simple suture lysis or can be upgraded to include pattern scanning with array. The Trio offers argon and selective laser trabeculoplasty laser modalities in a single unit for patients with open-angle glaucoma and/or retinal pathology. These conditions are likely to occur at an increasing rate due to the aging US population. Physicians’ ability to treat the various conditions in an effective and efficient manner will best prepare practices for a higher volume of patients

Figure 1. Macular edema persisted.

Figure 2. The patient required an aqueous shunt implant.

Figure 3. The patient’s cornea was diffusely opacified.

Figure 4. Surgery included combined procedures.

INTEGRATED CARE: CASE EXAMPLES

Case 1

This case is one commonly seen in private and academic practices. A 76-year-old woman presented with decreased vision in her right eye. She was diagnosed with a branch retinal vein occlusion and associated macular edema. Despite treatment with antivascular endothelial growth factor injections, her macular edema persisted as noted on optical coherence tomography (Figure 1). She was subsequently treated with an intravitreal steroid injection. One month later, her IOP was 40 mm Hg. Despite treatment with topical IOP-lowering drops, the patient’s pressure remained elevated, and she required an aqueous shunt implant (Figure 2). Postoperatively, her IOP has remained well controlled and the retina surgeon has been able to give additional steroid injections without causing an IOP elevation. This case required frequent communication between the retinal and glaucoma subspecialists. The patient’s macular edema was monitored with the same spectral-domain optical coherence tomography device that was used to diagnose and monitor the patient’s secondary glaucoma.

 

Case 2

In a more complicated case, a 62-year-old man with a history of chemical injury presented with long-standing decreased vision and uncontrolled IOP. The examination revealed a visual acuity reduced to hand motion and an IOP of 20 mm Hg. The patient’s cornea was diffusely opacified (Figure 3). After consultation with cornea, glaucoma, and vitreoretinal surgeons, a plan was made to proceed with combined glaucoma drainage implant, keratoprosthesis, and pars plana vitrectomy surgery. The patient had an excellent outcome (Figure 4) as a result of strategic planning and communication among the three ophthalmic subspecialty surgeons. Strategic planning involved the preoperative review of multimodal imaging study results among the three ophthalmic subspecialist surgeons.

Case 3

In a final case, a 73-year-old Asian man presented by referral from a local optometrist for evaluation of possible anterior chamber angle narrowing. Gonioscopic evaluation revealed a convex iris configuration in each eye and an inability to view structures posterior to Schwalbe line. With compression gonioscopy, I visualized scleral spur in all quadrants and discrete areas of peripheral anterior synechaie. IOP measured 19 mm Hg in each eye, and an undilated funduscopic examination in each eye revealed a cup:disc ratio of 0.4 and 0.5 in the right and left eyes respectively. Automated visual field studies were unremarkable. A diagnosis of primary angle-closure was made.

After informed consent, the patient underwent laser peripheral iridotomy in each eye, using the Trio, which allowed for pretreatment of the iris with the argon laser prior to full-thickness iris penetration with the YAG laser. This decreased the risk of hyphema while minimizing the need for extensive YAG laser energy. The patient tolerated the procedures quite well. Postoperative gonioscopy, without compression, revealed opening to scleral spur in each eye.

CONCLUSION

The aging US patient population will require ophthalmologists to consider all aspects of the aging eye when delivering care. In many cases, this will require collaboration among various ophthalmic subspecialists. Innovative, multimodal diagnostic and therapeutic equipment will undoubtedly serve as valuable tools for the delivery of efficient and effective eye care.

1. Aref AA, Scott IU, Oden NL, et al. Incidence, risk factors, and timing of elevated intraocular pressure after intravitreal triamcinolone acetonide injection for macular edema secondary to retinal vein occlusion: SCORE study report 15. JAMA Ophthalmol. doi: 10.1001/jamaophthalmol.2015.1823.

2. Aref AA. Management of immediate and sustained intraocular pressure rise associated with intravitreal antivascular endothelial growth factor injection therapy. Curr Opin Ophthalmol 2012;23:105-110.

3. Broadway DC, Grierson I, O’Brien C, Hitchings RA. Adverse effects of topical antiglaucoma medication. II. The outcome of filtration surgery. Arch Ophthalmol 1994;112:1446-1454.

4. Anwar Z, Wellik SR, Galor A. Glaucoma therapy and ocular surface disease: current literature and recommendations. Curr Opin Ophthalmol 2013;24:136-143.

5. Clouzeau C, Godefroy D, Riancho L, Rostène W, Baudouin C, Brignole-Baudouin F. Hyperosmolarity potentiates toxic effects of benzalkonium chloride on conjunctival epithelial cells in vitro. Mol Vis. 2012;18:851-63.

6. Nibourg LM, Gelens E, Kuijer R, et al. Prevention of posterior capsular opacification. Exp Eye Res 2015;136:100-115.

Ahmad A. Aref, MD
• Assistant professor of ophthalmology and glaucoma service at Illinois Eye and Ear Infirmary, Chicago
aaref@uic.edu
• Financial disclosure: consultant to New World Medical