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

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.

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.