An Optometrist’s POV on Glaucoma Management

How can effective strategies be established to enhance glaucoma screening, treatments, and patient outcomes?

Glaucoma often leads to a significant deterioration in the patient’s quality of life—all the more so when they already have low vision. As optometrists, developing a strategy to focus on this group should help you better manage your optometry clinic and improve patient outcomes.

Glaucoma is one of the most prevalent diseases that eye care professionals encounter. Its impact can be severe, sometimes leading to vision loss. It is a silent killer, slowly yet steadily eroding the patient’s eyesight, often without immediate symptoms.

For patients affected by conditions like myopia, presbyopia, and low vision, among others, glaucoma can represent a final ‘nail in the coffin.’ It not only affects their vision specifically but their quality of life as well. As such, having a strategy in place for glaucoma patients who require prescriptions is critical.

“With over 80 million people suffering from glaucoma worldwide, and 2% of the UK population over 40 affected by glaucoma, it is impossible to avoid coming into contact with the disease in an optometric setting,” shared Mrs. Imogen R. Hawthorne, the deputy clinical lead for ophthalmology at Modality LLP (Birmingham, England).

“We have to be mindful of screening for it at every sight test for every patient, as well as making considerations for those who already have a formal diagnosis,” she added.

Look for the ‘glaringly’ obvious signs

As a member of the British College of Optometrists who is qualified to prescribe medications to her patients, Mrs. Hawthorne has witnessed the profound impact of glaucoma. Based on her experience, she has a system in place to treat glaucoma patients with compromised baseline vision. This includes taking a broad view of the patient’s overall health and medical history.

“When prescribing a glaucoma patient with either spectacles or contact lenses, it can be helpful for community optometrists to have a full patient history from their ophthalmologist, including any details of field loss. Significant field loss, particularly in the inferior field would be a contraindication to recommending bifocal or multifocal spectacles,” Mrs. Hawthorne explained.

“Certain visual field defects or poor acuity in one eye may limit the success of certain contact lens modalities, such as multifocal or monovision,” she continued. “Understanding a patient’s surgical history or any drops they may be taking will also have a bearing on what contact lenses an optometrist may recommend,” That is, if, indeed, contact lenses are suitable for the patient at all.

“Up to 70% of glaucoma patients may complain of glare for which I would suggest a photochromic lens in the spectacles. There are also various brands of tinted spectacles with a specific tint designed to block the wavelengths of light, which more commonly causes glare symptoms in glaucoma patients,” she added.

Glaucoma: It is only going to get worse

Glaucoma is an increasingly growing problem as most developed countries grapple with an aging population, highlighting the apparent strain on public health systems. The UK, well known for its National Health Service (NHS), is struggling with recruiting ophthalmologists and optometrists to deal with this challenge.

These issues will persist for a long time and, combined with growing rates of poor vision requiring prescriptions, glaucoma is a ticking time bomb. In the interim, Mrs. Hawthorne has solid recommendations for focusing on the fundamentals of glaucoma treatment, especially for those with poor vision.

“The vast majority of my clinical time is spent working in an ophthalmological setting, seeing and treating glaucoma patients. In the UK, more and more optometrists are working in glaucoma clinics to support the growing number of patients with the disease,” Mrs. Hawthorne said.

There is a deficit in NHS doctors to meet the demand. “However, we do have a nationally recognized training framework called the Ophthalmology Common Clinical Competency Framework, which guides optometrists, nurses, and orthoptists to upskill to deliver ophthalmology care, including glaucoma,” she continued.

“In the UK, we have moved towards offering Selective Laser Trabeculoplasty (SLT) laser as firstline therapy to patients with openangle disease. Not worrying about remembering to take eye drops or suffering their side effects may be life-changing for some patients. Each patient has their own unique set of circumstances, especially for those with poor quality vision,” she added.

Allies in community optometry and ophthalmology

Another piece of advice that Mrs. Hawthorne can offer for managing prescription issues related to glaucoma is community monitoring. Patients who require frequent eye exams have to be rigorously examined for signs of the disease.

According to Mrs. Hawthorne, this depends on effective communication between optometrists and ophthalmologists. If treatment is aided by community involvement and if patients who fall through the cracks are identified, then the impact of glaucoma can be mitigated.

“Community optometry plays a key role not only in identifying potential new cases or at-risk patients but also as an ally to the ophthalmology clinic. ” Mrs. Hawthorne said.

She added that optometry can flag patients whose disease may be progressing or who have been lost to hospital clinic follow-up, as well as check drop compliance and signpost to charitable organizations who may be able to offer support.

“For those who are symptomatic, the clinic plays a vital role in ensuring a patient is making the most of their remaining vision by providing practical advice tailored to their vision loss and lifestyle,” she added.

Concern for cosmesis

One of the main concerns Mrs. Hawthorne highlights from her practice is that patients with poor vision may not realize the extent of their glaucoma symptoms. This often occurs because they may mistake said symptoms for the degeneration of a pre-existing problem.

During the early to moderate stages of glaucoma, patients are often subjectively unaware of any field loss. As such, Mrs. Hawthorne does not recommend any specific spectacle or contact lenses. In advanced stages of glaucoma, her advice depends on the patient’s level of vision, lifestyle, and any other health challenges they may have.

“While magnifiers may be useful as a quick aid to pull from a pocket, many patients prefer to use magnification apps on their smartphones. Nonoptical aids may also prove useful, such as liquid level indicators, ‘bump-ons’ to help find commonly used buttons on devices in the home, and various kitchen appliances adapted for use by those with vision impairment,” Mrs. Hawthorne said.

Glare is another issue as it is one of the most common side effects experienced by patients. Mrs. Hawthorne said this often causes a diminishment in the reported quality of life of low-vision patients.

As such, Mrs. Hawthorne believes it is important to focus on lenses that match their existing prescriptions and can also offer protection against light sensitivity. However, there are two issues at play here: Finding the right tool for their problem and the aesthetics of doing so.

“Some patients may opt for a fit-over glare shield, e.g., NoIR filter. However, these do not tend to be popular due to their poor cosmesis. I haven’t been approached for prescription sunglasses very often, but I have had many more inquiries for tinted lenses, again for cosmetic reasons,” Mrs. Hawthorne shared.

“Taking prostaglandin drops over many years can lead to darkening of the skin around the eyes, and in some cases, loss of periorbital fat, giving the eyes a ‘sunken’ appearance. Some glaucoma surgeries can also leave the eyes looking ‘redder’ than before. In both cases, patients may be troubled by the cosmesis of their eyes. And I have been approached in the past for a tinted lens that hides the eyes or improves their cosmesis,” she concluded.

Editor’s Note: A version of this article was first published in COOKIE magazine Issue 16.