As optometrists take on a larger role in medical eye care, it becomes increasingly important that they stay informed on how they can help manage glaucoma. Elizabeth Muckley, OD, FAAO, director of optometric services at Northeast Ohio Eye Surgeons says that she is dedicated to building ODs’ confidence in doing so. “Glaucoma initially is almost all medical management. There are laser as well as minimally invasive surgical interventions that can be co-managed, but most mild to moderate cases are managed with medications,” she says.
Even as organized optometry has been advocating for expanded scope, optometry has traditionally been a conservative profession, “Fewer primary care optometrists want to manage glaucoma. The reasons vary from taking on risk of a potentially blinding disease to many optometrists are signed up with only vision plans and also can’t get on medical panels,” she says. However, since optometrists are skilled in diagnosing glaucoma and initiating IOP lowering treatment, this can be a great way to retain your medical patients and decrease the disease burden on specialists.
EDUCATING THE PUBLIC, TOO
There is also an element of public education needed, she says, but the cycle of referring patients to specialists for mild to moderate glaucoma has a negative impact and reinforces the erroneous perception that optometrists only provide routine vision care. “Optometrists are educated to manage all medical diseases of the eye, including glaucoma. Referring our patients to specialists for mild to moderate glaucoma when specialists are already overburdened caring for surgical and advanced patients, is unnecessary when ODs are uniquely qualified to provide medical glaucoma care. Managing glaucoma can also ensure patient retention and work to change the public’s perception of what optometrists treat,” she says.
She understands that missed glaucoma diagnoses are the root of litigation – but that doesn’t mean that optometrists should turn away from it. “If optometrists become more comfortable diagnosing and treating it before it becomes an impairment, they might not be so risk adverse to get involved,” she says. “This is such an opportunity for us to watch these patients and prevent functional vision loss over a lifetime.” Typically, doctors recall moderate glaucoma patients every three or four months and mild glaucoma patients every six months. Patients who are suspect for developing glaucoma should be monitored annually. “Optometrists have great relationships with their patients, and glaucoma management can help make those relationships even stronger.”
SPARKING AN INTEREST
Dr. Muckley’s interest in glaucoma management came during her residency in ocular disease 25 years ago. At that time, only about 10 percent of ODs completed a disease residency, but she was determined. She worked with a glaucoma specialist who empowered her to take on cases under his guidance during her training. She then went onto work with a progressive ophthalmology practice, but the practice focused more on anterior segment and corneal disease. “I wanted to do glaucoma, so all those cases came to me,” providing her even greater experience. “I was in a practice where we needed a medical glaucoma optometrist, and I had an interest and fell into it. We eventually recruited a glaucoma surgeon, and he was thrilled I was there because that freed him up from the medical glaucoma cases. We could leverage his full surgical skills.”
The Optometric Glaucoma Society is also a terrific resource for optometrists, she says. Industry has also been an advocate, supporting meetings and providing optometrists with the tools and samples need to build their glaucoma management practices.
COMMIT TO IT
Glaucoma management is not something to tiptoe into. “You can’t dabble in it. Optometrists need to feel confident as they are striving to lower baseline intraocular pressure 20% to 30%. Target the pressure goal and make sure patients are responding. If they are not, change or add further medication,” she says.
That last point can be a tripping point for some ODs who are willing to try one medication but choose to refer if that doesn’t work.
Here are some guidelines.
- For mild glaucoma, try to maintain the pressure under 18 mmHg where the likelihood of progression is lower.
- For moderate glaucoma, set the pressure targets at 14 mmHg to 16mm Hg.
- For advanced glaucoma, the target is 10-12 mmHg or even lower.
“You cannot diagnose without gonioscopy,” says Dr. Muckley. As an extern site supervisor, she has externs from The Ohio State University College of Optometry perform gonioscopy on four contact lens patients per day. “These patients are used to having something on their eyes, so they’re good candidates. Once these externs see a lot of open angles, they can recognize abnormal angles. They’re more confident,” she says.
Get to know your pharmaceutical rep or the services they provide. “These representatives generally do not have the bandwidth to call on ODs outside of the MD/OD setting, but they do support us at meetings, providing educational tools, helping us get prior authorization and assisting in getting patients covered for branded medications that might work better,” she says.
As a first line therapy, Dr. Muckley says patients can opt for selective laser trabeculoplasty (SLT) or pharmacological management. “I will pick a prostaglandin, which are great choices because they are easy in terms of compliance and they’re easy on the ocular surface. I like LUMIGAN® (bimatoprost ophthalmic solution) 0.01% because I find it to the most potent of the prostaglandins on the market. It works very well; it’s established, and most insurance plans cover it.”
One important tip is to check patients at different times of day. It’s important to check the diurnal curve at all time points. I’ve seen medications wear off, and we’ve had to change meds. But if you’re always seeing them in the morning, you might not know that.”
THE TIME IS NOW
Finally, Dr. Muckley encourages ODs to step up to manage glaucoma now. “Baby boomers are retiring, and the population is aging. There is a decreasing supply of glaucoma specialists as more ophthalmologists want to be cataract and cornea specialists. So they need ODs to see the patients who can be managed.”
Want to know more? Dr. Muckley is a contributing author for the glaucoma section of the 3rd edition of Catania’s Primary Care of the Anterior Segment. At by Lou Catania, OD, FAAO, DSc, and Brian Armitage, OD, MS, FAAO. That volume has just been released, and readers can order it here. Through the end of June, enter promo code AFL01 at checkout for a 20% discount.
Read this related story form WO: Stretch Your Glaucoma Management Comfort Zone