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A Day In the Clinic With Yvonne Ou, BrightFocus Expert on Glaucoma

Glaucoma is a complicated disease, and solutions to treatment issues aren’t always obvious. In other words, the answer might not be “yes,” or “no,” but “it depends.” To reach the right decision, a patient and his/her doctor have to weigh the risks and benefits in each individual’s situation.

Probing the complexities of glaucoma care, “A Day In The Clinic” session was held during the 2015 American Academy of Ophthalmology annual meeting. At the popular debate-style event, experts were assigned to debate a “pro” or “con” point of view on such topics as the use of generic vs. branded medications; combining or separating glaucoma and cataract surgeries; the treatment of advanced glaucoma initially with medications or surgery; and when to perform a laser iridotomy.

Debaters were asked to highlight the evidence, or lack thereof, for their viewpoints. Then attendees voted for the most convincing management approach, based on scientific evidence.

Experts Debate Medical vs. Surgical Treatment for Glaucoma

Yvonne Ou, MD
Yvonne Ou, MD
Taking part in the AAO debate was one of BrightFocus’ own experts, Yvonne Ou, MD, Associate Professor of Ophthalmology at the University of California, San Francisco. She is a regular contributor to the BrightFocus Insights series, and her bio appears on our website.

Dr. Ou spoke to whether newly diagnosed advanced glaucoma should be treated first with a trial of medications, or directly with surgery. She argued for first giving medications a try, adhering to the principle that physicians, above all, must “first, do no harm.” Complications from surgery, while rare, tend to be more serious than those from medication, and therefore present a greater risk of harm to the average patient.

In this test case, which involved an elderly patient whose glaucoma was diagnosed at an advanced stage and is severe, Dr. Ou advocated for the standard approach, ie, an initial trial to see if this patient could use eye drops comfortably and whether they would lower intraocular pressure (IOP) sufficiently. However, if the patient's eye pressure did not sufficiently respond, she advocated moving on to surgery quickly.

Her opponent in the debate, Brian Francis, MD, argued that there was no time to waste in bringing this patient’s severely elevated IOP under control.  Given the patient’s advanced age, the training and skill required to use eye drops correctly could present an obstacle. Thus, he felt that surgery might be warranted as an initial treatment approach, in order to achieve immediate results with no worries about whether the patient could manage eye drops. Dr. Francis is an Associate Professor of Ophthalmology at the Doheny Eye Institute, University of California, Los Angeles.

The bottom line is that both approaches can be reasonable first steps depending on each patient's specific situation. These approaches are spelled out in the new BrightFocus brochure, Glaucoma: Treatment Options.

[Please click the link above to obtain a pdf of the new BrightFocus brochure, Glaucoma: Treatment Options, or you can request a print copy, free-of-charge, by calling 1-855-345-6647.]

Although the debate was not set up to address this question, another very reasonable first-line treatment for glaucoma patients is selective laser trabeculoplasty (SLT). Several years ago, the AAO website featured a discussion of this topic. It described a clinical trial in which SLT had similar efficacy to eye drops at one-year follow-up (Katz et al, J Glaucoma, 2011).

On the BrightFocus website, you’ll find an entire series of articles by Dr. Ou on various surgical techniques used to treat glaucoma (see links above). In the interview that follows, we asked Dr. Ou to elaborate on the debate question, including whether laser procedures may evolve as an initial treatment.

Q and A with Yvonne Ou, MD, On Glaucoma Treatment Options

Q.  Dr. Ou, it’s a pleasure to talk to you! How long have you been treating glaucoma patients in San Francisco, and have you experienced situations when the choice of initial treatment wasn’t obvious?

A.  I have been treating glaucoma patients for almost 10 years in San Francisco. I definitely experience situations where the choice of a medical vs. surgical approach isn't always obvious. What I try to do with my patients is to describe the risks and benefits of both options, and help guide the patient to what most suits their preferences and specific home situation. Of course, sometimes the choice is more obvious, in which case I will let patients know my own recommendation. A good question to ask your ophthalmologist is: "If I were your relative, what treatment would you recommend?"

Q.  The field seems aligned with your viewpoint in the debate—that surgery for glaucoma is a last resort rather than a first-line therapy. Why is that?

A.  As you know, we were assigned the position we were defending, and actually, for the specific situation of advanced glaucoma, I will often move to surgery fairly quickly. However, there are obviously mitigating reasons why surgery sometimes is or is not the better option. For early and moderate forms of glaucoma, we will often try medical or laser treatment first, because the risks of these treatments is lower than for surgery. And sometimes the benefit can be tremendous — even with high eye pressures, sometimes patients respond exceedingly well to medications or laser. However, there are some patients for whom instilling eyedrops daily is too difficult, too expensive, or causes too many side effects. In that case, laser or incisional surgery can certainly make more sense

In addition, for patients with early to moderate glaucoma, minimally invasive glaucoma surgeries (MIGS) combined with or without cataract surgery, may be a great option. Surgery doesn’t always have to be the “last resort” if we have safe and effective options for patients. The area of MIGS Is rapidly evolving, however, so it is also important for patients to recognize that these newer procedures don’t all have the long track record of our more traditional surgeries such as trabeculectomy or tube shunt surgeries.

Q.  To treat open angle glaucoma (the most common type), isn’t the main goal to get the eye to drain more effectively? Can both medications and surgery do this?

A.  The main goal is to lower eye pressure because all of our current treatments, medication, laser, and surgery, are designed to achieve this goal. All three approaches can lower eye pressure in different ways, either by decreasing the amount of fluid the eye produces, or by increasing the drainage of the eye, or "outflow." 

Q.  Do laser procedures hold promise? Are they safer and quicker to heal than microsurgery (ie, conventional surgical incisions)?

A.  Laser procedures, such as SLT, are generally safer and quicker to heal than surgical incisions. There is no risk of infection with SLT because no openings are made into the eyes. SLT usually creates less inflammation and scarring than other types of glaucoma surgery. The main risk is a temporary eye pressure elevation, so typically patients are asked to wait 30 minutes to an hour after the procedure so that the eye pressure can be rechecked. If there is an elevation, eye drops are used to lower the pressure. There are some other less common risks too, and these should be discussed with your ophthalmologist.

  Q.  Were you trained in both laser and conventional eye surgery during your residency? Is it important to take “refresher” courses to stay up to date?

A.  Yes, I was trained in both laser and conventional eye surgery during my residency at UCLA. However, I also received additional glaucoma laser and surgery training while performing a glaucoma fellowship at Duke University. While there are no formal requirements to take "refresher" courses, all board-certified ophthalmologists must participate in continuing medical education and maintain their board certification through continued lifelong learning.

Q.  If  SLT is safe and about as effective as medication (ie, lowering eye pressure by about 20 percent), do you see it poised to become a first-line therapy? What are its possible drawbacks?

A.  In some countries, SLT is indeed first line treatment. Indeed, the NIH-funded Glaucoma Laser Trial, completed over 20 years ago, demonstrated that laser was just as effective as medications in the treatment of newly diagnosed open-angle glaucoma. The laser and medications used in the trial are not the current ones we typically employ now, but more recent research (SLT/MED study) using more current technology and medications confirmed the Glaucoma Laser Trial's findings.

In some patients, SLT is effective enough that eye drops do not have to be used at all. However, some drawbacks include the fact that the laser is not a "cure" and the effect does wear off over time. Sometimes the procedure can be repeated with good results.

The laser also has the risk of the temporary eye pressure elevation I described above. However, medications also have side effects, and these side effects may worsen over time. Furthermore, one has to remember to take the drop (or drops) every day (or multiple times each day) in order for the treatment to be effective.

In my practice, depending on the patient’s preference, SLT may indeed be first-line therapy, and patients can do very well with this approach.

Q.  One of your research interests is to “elucidate diagnostic and therapeutic targets earlier in the course of the disease.” Could you elaborate?

A.  I do think the field is in need of having treatments that are not just based upon eye pressure lowering, and much of my research is dedicated to understanding how glaucoma affects the retinal ganglion cells that compose the optic nerve. It would be wonderful if we had treatments that protected the optic nerve or enhanced its function when injured.

A lot of my patients are "glaucoma suspects"and deciding when to start treatment is a big decision. I like to make the decision with the patients, taking into consideration not only the status of their eyes, but also their tolerance for treatment vs. careful observation. Generally speaking, open-angle glaucoma does not rob one of vision overnight, so there is some time to determine whether a patient's eyes are getting worse. This depends, however, on a patient's willingness to be very vigilant with follow-up. 

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This content was first posted on: January 29, 2016

The information provided in this section is a public service of BrightFocus Foundation, and should not in any way substitute for the advice of a qualified healthcare professional, and is not intended to constitute medical advice. Although we take efforts to keep the medical information on our website updated, we cannot guarantee that the information on our website reflects the most up-to-date research. Please consult your physician for personalized medical advice; all medications and supplements should only be taken under medical supervision. BrightFocus Foundation does not endorse any medical product or therapy.

Some of the content in this section is adapted from other sources, which are clearly identified within each individual item of information.

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