Feeling the Pressure?
This month, let’s reflect on the advances in glaucoma care. Back in the Land Before Time and iPhones, circa 1983, our optometry curriculum included extensive work in glaucoma care. Excitement was high, in anticipation of the coming therapeutic privileges. We heard from the experts, studied the pharmacology, and treated patients under the supervision of ophthalmology. Diagnostic testing was crude. The drugs were ineffective and required frequent dosing. (Epinephrine and pilocarpine, are you kidding?) Surgical interventions were crudely executed, frequent, and expected.
In the next ten years, I really wondered if glaucoma should even be treated at the primary care level, applying to both ODs and MDs. It seemed like so many cases went badly, even with pressures that seemed “ok.” Gradually, proper use of beta blockers and the introduction of prostaglandin analogues changed the playing field. We also got a better understanding of how low pressures needed to be on a personalized basis. Many patients had slowed or even arrested progression of their disease processes.
Fast forward to modern times.
Recently, a notion came out that I consider shocking. The question was, “How many optometrists are treating glaucoma?” The answer is, well, undetermined, but it’s apparently very small. A pharmaceutical rep asserted that only 4,000 ODs show up on the radar screen as prescribers of glaucoma therapy.
It was suggested on ODs on Facebook that this question might be pressuring ODs to treat glaucoma. It’s not, but it’s just unfortunate to have spent so much time in training on glaucoma studies, and leave it all behind. To me, vision therapy, low vision, and other specialties are just that……specialties.
I believe that glaucoma exists at the primary care level, and should be treated as such.
We work so hard to bond with our patients, yet there seems to be a trend to “send them out” with IOPs of 23 or cups of .6. Worse yet, the “red disease” reliance on normative databases leads to referral without comparative study. (Footnote 1) An indeterminate number of patients are lost when they are referred to the large MD practice. I know, because I work in one, and see it every day.
“Ahhh, but the instrumentation is so expensive, if we are to meet the standard of care! Won’t the OCT go to waste, if I don’t see that many glaucoma patients?”
I claim no expertise on instrument cost vs. return, but I do know that the OCT instrument can become indispensable to a primary care practice. While I am not a big fan of screening OCT, the clinical applications for Plaquenil users, macular degeneration, disc pathology, and even contact lens fitting can be amazing. As imaging has become the standard of care for Plaquenil patients (Footnote 2), the loss of these patients alone could be substantial. Dry macular degeneration could probably be managed without OCT, but I’d hate to do so. Scleral lenses? Check that lens edge with an OCT, and you may be surprised at what you thought was a good fit. Look at “combination” and pre-owned instruments to get your start.
Even if we are reluctant to treat glaucoma, we are still confronted by any number of patients who are appropriately listed as “suspects.” How do we deal with those? Do we send every .6 cup “out” to a practice that will happily run standard testing such as pachymetry, OCT, and computerized visual fields?
Will the patient return? We tend to think so, but the grim reality is that the recipient of the referral is perceived as “better” or somehow more advanced. (Why would the patient be sent there, if they weren’t?) Then there is that glitzy optical department that paves the way to the check-in desk……
It’s simply an economic necessity that primary care optometrists monitor their own glaucoma suspects, even if they aren’t going to treat.
The modern instrumentation of Humphrey VF with progression analysis, pachymetry, and OCT have been game changers. We can now detect the earliest of glaucomatous changes with confidence and reproducibility. Compare this to the analysis of stereo photographs and Goldmann visual fields, both of which had enormous subjectivity and doubt. We are simply so much better at caring for glaucoma suspects that there is no need to send most patients out for specialty care.
Circa 1983, classic teaching was that one glaucoma suspect in ten would actually suffer glaucomatous damage. Nothing in the last 35 years has persuaded me to think otherwise. Are you prepared to send ALL of these patients out for consultation? As we seem to be shifting away from materials profitability, it is imperative that we maintain the medical model as primary care, not specialty. Treat what you can, and learn and grow from the experience by interacting with specialists who treat what you can’t.