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SARAH DISANDRO: Hello, and welcome to today’s Glaucoma Chat, “Staying Ahead of Glaucoma: Why a Proactive Approach Matters.” My name is Sarah DiSandro, and on behalf of BrightFocus Foundation, I’m pleased to be here with you today.
Our Glaucoma Chats are a monthly program in partnership with the American Glaucoma Society designed to provide people living with glaucoma and the family and friends who support them with information straight from the experts. We would also like to thank this month’s Chat sponsor, Glaukos, for their support. The information provided in this program is for educational purposes only and should not be considered medical advice. Always consult a qualified health care professional regarding any medical concerns or conditions.
BrightFocus Foundation’s National Glaucoma Research Program is one of the world’s leading nonprofit funders of glaucoma research and has supported nearly $51 million in scientific grants exploring the root causes, prevention strategies, and treatments to end this sight-stealing disease.
Now I would like to introduce today’s guest speaker. Dr. Amy Zhang is an associate clinical professor of the Glaucoma Service at the University of Michigan Kellogg Eye Center. Her clinical interests are patient education and home tonometry. She has been part of the patient engagement subcommittee with the American Glaucoma Society and one of the co-founders of Glaucoma Chats in conjunction with BrightFocus Foundation. She is also the Well-Being Director for the Department of Ophthalmology and, most recently, a faculty associate of the Office of Well-Being at Michigan Medicine. She has an interest in improving ophthalmic ergonomics and looking into addressing drivers of burnout across the health care system. Dr. Zhang, thanks for joining me today.
AMY ZHANG: Thank you. It is a pleasure to be here.
SARAH DISANDRO: Can you start by briefly explaining what glaucoma is and how it affects our vision?
AMY ZHANG: Sure. Glaucoma is a disease where there is damage to the optic nerve. Oftentimes early in glaucoma, there may not be very noticeable effects on the vision, meaning that starting out when you have mild glaucoma it is not something that you would notice on a day-to-day basis. The type of vision loss with glaucoma usually starts out with loss of the peripheral vision, and unless there is a formal test to really check for the peripheral vision, patients sometimes may not notice these effects. High intraocular pressure is a risk factor for glaucoma.
SARAH DISANDRO: Great. Thanks so much for that introduction. So, what does it mean to take a proactive approach to glaucoma care? And how is that different from more traditional or wait-and-see approaches?
AMY ZHANG: For me and my patients, I think a proactive approach really involves being active in the care that you receive, such as making sure that you’re going to the ophthalmologist regularly to assess the status of your eyes. It also involves understanding what treatment options are available to you. In the past decade, a lot of newer medications, technology, lasers, procedures have come out in our field of glaucoma. And so, understanding that there is more than just the conventional medications—in terms of therapies with lasers, continuous drug delivery systems, and minimally invasive glaucoma surgery [MIGS]— it’s important for all of our patients to understand is available. In terms of the traditional wait-and-see approach, I think oftentimes that involves progression on the visual field before deciding to shift treatment, and this may not take into account the compliance burden or ocular side effects of some of the medications that we’re prescribing. So, I think it is really important to educate the patient on the risk and benefit profiles of any treatment and really allow the patient to be part of the conversation to best decide what may fit specific to their lifestyle or compliance or adherence to being able to receive those treatments.
SARAH DISANDRO: Great. So, you mentioned the benefits. What specific benefits do people see when they embrace a proactive approach early in their diagnosis?
AMY ZHANG: I think the specific benefits may be different for each patient, but being proactive and informed about these treatments earlier on in their diagnoses may lead to better understanding of the disease and the treatment options. For those that are struggling with compliance or medication adherence, it may be helpful to look at alternative methods, such as laser-implanted drug delivery systems or even minimally invasive glaucoma surgeries, to help regulation of intraocular pressure without the burden of daily use of medications. It may also help with reducing some of the side effects of these medications, which has a lot on the ocular surface. So for our patients who already have severe dry eye, this may be an additional burden to their ocular surface.
SARAH DISANDRO: I see. You mentioned some exciting new treatments like continuous drug delivery systems and implants. Can you walk us through these options?
AMY ZHANG: Sure. The new treatments like continuous drug delivery systems and implants are ways that the medication can be delivered through a procedure instead of using eye drops. Currently, there are only certain classes of medications that are available through this type of delivery, but the idea of this type of formulation would reduce the need for daily drops. I think it is something that is very exciting and something that our patients should know about and probably discuss with their ophthalmologist to decide what would be the best course. One of the other exciting things is that this type of therapy can be done in conjunction or in combination with cataract surgery or as a standalone.
SARAH DISANDRO: Great. We have a lot of people who contact us to ask about cataract surgery, as well. How do treatments like MIGS and laser therapy fit into this proactive ladder of care?
AMY ZHANG: For me, I like to offer laser or starting medication as the first step when treatment is indicated for a patient with glaucoma. I discuss with the patient and determine the treatment course. For some, doing a once-a-day drop is not an issue, whereas others may see it as a tremendous burden or be unable to adhere to that. And so, we talk about different other options, such as laser, which can be an alternative to ever starting eye drops. So, I counsel the patient on the risks and benefits of each, and it’s, sort of, a conversation as to what would best fit in terms of their lifestyle, as well as their own understanding of their adherence and compliance. Minimally invasive glaucoma surgery has less risks than traditional surgeries, like trabeculectomy and tube shunts, but it’s still surgery, and that would require going to the operating room. So usually, when I’m discussing with patients regarding MIGS, we start that conversation looking at the severity of the disease and also whether they’re having cataract surgery at the same time. For those that are not responding to other medications or laser, this would be something that I would move on to in terms of the latter.
SARAH DISANDRO: Okay. That’s great. Are you recommending or would you recommend all these options that you’ve just been discussing? Is this something you would recommend that patients should ask about early on, or are they typically recommended after vision changes have started? Basically, when in the course of eye care should a patient begin this conversation about these other options?
AMY ZHANG: These options are certainly something that patients can ask about, especially if they’re having issues, such as those side effects from topical medications. I think that, as I mentioned before, sometimes waiting until the vision is actually noticeably decreased may be a little bit too late. I think working with your ophthalmologists who are monitoring and assessing the status of the optic nerve is really important. And so, being able to ask those early questions—“I’m having trouble using this particular medication. My dry eye seems to have greatly gotten worse. Are there other options?”—is definitely a very valid question that I think our patients should be asking us. Just to keep in mind, not all patients may be candidates for laser or MIGS, depending on their specific anatomy, and that’s why it’s really important to have that examination, as well as that continued follow-up with your ophthalmologist.
SARAH DISANDRO: Fantastic. So, at-home eye pressure monitoring, this is something that we hear a lot about. How does that work, and who can benefit from it?
AMY ZHANG: Currently, the only available FDA-approved home tonometry unit that is available in the U.S. is the iCare HOME2 home tonometer. There are some other contact lens options that are available. However, this is not offered in the United States currently. In terms of the iCare Home tonometer, it is a type of rebound tonometer unit that patients can use on their own eye. There are specific trainings about how to use this device, and there are options to either purchase the unit or rent it. It provides a readout of their intraocular pressure, and the data is stored on the device. It can also have a capability of being stored in the cloud through this specific company. The purchase and the rental does require a practitioner with an NPI number to order the device for the patient. At the University of Michigan, I found that this type of device is the most helpful in patients in which I’m concerned about fluctuations in the pressure, especially when in the office the pressures are very consistently in a specific range, yet they’re telling me or I’m seeing on various types of testing that their vision is getting worse or that I see progression on those areas. It allows us an opportunity to see what the intraocular pressure is doing outside of the conventional office hours and offer multiple intraocular pressure measurements over the course of the day or even over many days. It also offers a chance for patients that are concerned about their eye pressures to know what is actually happening to their eye pressures when they’re outside of our office. It, however, does not replace the clinic exam but does provide additional helpful information that may be used in the management of their glaucoma.
SARAH DISANDRO: Very interesting. Now, we’re going to shift gears a little bit here. For those who struggle with daily eye drops or remembering appointments, are there proactive solutions to make adherence easier?
AMY ZHANG: I think that all of us struggle with application or remembering appointments, as well as daily eye drops. I think some of the solutions that we talked about today or some of the treatments that we discussed—such as laser, continuous drug delivery, and MIGS—can make adherence easier in the sense that once those procedures are done, there’s not really a daily need to think of what do you need to do. However, of course, the patients should still follow up in the office for those proper regular exams to ensure that all the testing is done. In terms of remembering appointments, I think it’s, sort of, setting up something that’s conducive in your calendar, either putting reminders into your phone or just a way of making sure that you’re being consistent with the follow-through of those appointments.
SARAH DISANDRO: Great. Thanks. So, August is Eye Exam Awareness Month. In that vein, why is it so important not to wait until symptoms appear before getting checked for glaucoma?
AMY ZHANG: By the time most symptoms appear, there is likely already irreversible damage to the optic nerve. I think it’s really important to have a comprehensive eye exam where the ophthalmologist can examine the vision, the intraocular pressure, the anterior chamber, the angle of the eye, which are all assessed along with looking at the appearance of the optic nerve and retina to identify some of the risk factors for glaucoma.
SARAH DISANDRO: Okay. And what should people know about family history and their risk for glaucoma?
AMY ZHANG: I think it is really important, especially for people who have a close family member diagnosed with glaucoma, because having a family member definitely increases your risk for glaucoma, and it can be as high as 10 times more likely for those family members to develop glaucoma. A project that is sponsored by the American Glaucoma Society has an actual dedicated webpage for family members of those that have been diagnosed with glaucoma, called Family Matters. We’ll make sure that the listeners have the specific link, but essentially on the bottom of that page, there is a form for patients and their families to provide their story or feedback. It also provides an excellent Q&A section in which patients and their family members can look at, and we would love to get some feedback from the patients, as well as their family members, as to what else can be done to make it be more available and more helpful.
SARAH DISANDRO: Yes, that’s an incredible resource. Wow, 10 times more likely when you have a family history. How can listeners encourage relatives, especially children and younger family members, to take vision health seriously?
AMY ZHANG: I think vision is definitely one of the greatest gifts, and while it’s easy to take it for granted when we’re children or younger when our vision is good, I think the patient can definitely relay that message a lot more strongly to their family members because it’s an active issue that’s happening to them, so making it be personal and emphasizing the importance of a regular or even a baseline eye exam is very important. As we age, the risk of cataract progression, glaucoma, and macular degeneration all increase, and we need to be aware of what the state of our eyes are doing. In order to do that, we need to have a baseline eye exam, and so I think it’s really important for those family members to say, “I know your vision is really good, but we do have this family history of X, Y, and Z, and for that reason, I think it’s even more important that even though the vision is good, to have a baseline eye exam so that an ophthalmologist can look in and say, ‘What is the current status of the optic nerve of the retina?’”
SARAH DISANDRO: That’s such excellent advice. Okay, now we are going to shift to listener questions. Our first question that we’ve received from our listeners, Dr. Zhang, is: After an implant, if a problem comes up, how difficult is it to repair or remove the implant?
AMY ZHANG: I think that’s an excellent question. While we certainly want patients to be proactive about being part of the discussion, it’s also important to understand that even though these procedures are less invasive, there are still some risks associated with that. So, understanding the type of implant and how easy would it be to reverse that or to remove that if you’re having issues is very important. I think there are many different types of implants that are out in the market these days in terms of treatment or trabecular bypass, so it’s important to understand which specific implant we’re referring to. I think for most of the minimally invasive glaucoma procedures, most of the companies have designed it where in experienced hands, the removal of the actual device should not be too complicated. However, given the anatomy of each patient being different in terms of the location and what kind of scarring properties that patient may have, it could be a little bit more challenging. But I think most of the devices have been fairly easy to remove. I think there’s also, once again, the need of continued surveillance after you’ve had a procedure to make sure that the implant is in the proper positioning, that it’s functioning well, and that there’s not side effects or issues from the surgery.
SARAH DISANDRO: Okay, thanks. We have another question that just came in, and the question is: Can you use the iCare HOME2 if you have severe dry eyes?
AMY ZHANG: That is an excellent question. There are some contraindications to the use of the iCare HOME2. I think if you have severe, severe dry eye, that is a contraindication because how the device works is through a rebound tonometer. So, much like the iCare HOME in the office, if the ocular surface is super, super dry, you are still putting a small probe that has to make contact with the eye and obtain the eye pressure. So in those cases, it would definitely have to be something that you would see your ophthalmologist for, and they really have to assess the quality of how the ocular surface looks before recommending that type of tonometer. I think for those reasons, it is why it’s important that a medical professional prescribes the order of the device rather than just getting it from a store or being able to use it or just buy it off of online.
SARAH DISANDRO: Great, thanks. We just received another question, and it’s: If my doctor is suggesting wait and see, should I seek the opinion of another doctor?
AMY ZHANG: So, I think there are a lot of different parameters to consider. It depends on where in the disease process you are, how well controlled your eye pressures are. If there’s a history of elevated eye pressures, yet your doctor is saying, “Let’s wait and see if anything else changes before we do anything,” if you don’t feel comfortable with that, that would be an opportunity where you can seek out another specialist. However, if it’s something where your eye pressures have been fairly well controlled and there’s not any disease, so it may not be that much more helpful to seek a second opinion. But if you’re concerned or you’re thinking that there’s something actively going on, you can certainly seek out a second opinion.
SARAH DISANDRO: Great, and regarding at-home eye pressure monitoring systems, what are the costs and is it covered by Medicare or other insurance?
AMY ZHANG: I think the cost of the devices, in terms of what I’ve seen, are about $3,000 per device. It is sometimes covered by insurance, but it depends on the individual insurance, and not all insurances cover it. So, I think it would be to work with the company which you’re purchasing the device from, and I’m sure they’ll assess and ask about your specific insurance and try to work with the carrier to see if they would be covered or not. I’m not sure of exactly which insurances cover it and how much it covers.
SARAH DISANDRO: Okay. Great. And regarding minimally invasive surgeries, can they be done one at a time?
AMY ZHANG: Can I ask to elaborate on that? One at a time, meaning one device at a time or one implant at a time or one eye at a time, which context? Sorry.
SARAH DISANDRO: One eye. One eye at a time.
AMY ZHANG: Okay. Yes. For all of our surgeries, we only do one eye at a time. Even for cataract surgeries, we only do surgery one eye at a time.
SARAH DISANDRO: Okay. Great. And we just received another question: Does having thin corneas preclude use of the iCare HOME2 tonometer?
AMY ZHANG: So, I think that there are certain central corneal thickness parameters to be considered. And also, the reason for that is because having thin or thick central corneal thicknesses, it may falsely elevate or underestimate the actual intraocular pressure. So, patients with especially thin corneas, it might not do as good of a job in terms of telling you what the true eye pressure may be.
SARAH DISANDRO: Great. Well, this has been incredibly informative, and that’s all the time we have for questions today. Thank you, Dr. Zhang, for the insights you shared with us. To our listeners, thank you so much for joining our Glaucoma Chat. I sincerely hope you found it helpful. Dr. Zhang, before we close, can you share what you think is the most important takeaway for someone who wants to protect their sight before it’s too late?
AMY ZHANG: Yeah. First of all, thank you so much once again. I hope the listeners know that we’re always here, and we are happy to answer any additional questions. I think the most important takeaway is to establish care with an ophthalmologist for a complete eye exam and not waiting until symptoms appear. Especially for those that know that they have a family history of glaucoma, it’s really important to get in and to see one of the ophthalmologists to do a proper full exam.
SARAH DISANDRO: Thank you so much for that incredible takeaway advice. Our next Glaucoma Chat will be on Wednesday, September 10, on the topic of optic nerve regeneration. Thanks again to everyone who joined us today, and thanks again, Dr. Zhang. This concludes today’s Glaucoma Chat.
Useful Resources and Key Terms
BrightFocus Foundation: (800) 437-2423 or visit us at www.BrightFocus.org. Available resources include—
Helpful treatment options or resources mentioned during the Chat include—
