In honor of Glaucoma Awareness Month this January, AMSURG’s ophthalmology campaign site, YourSightMatters.com sat down with glaucoma specialist and AMSURG partner Robert J. Derick, M.D., of Columbus Eye Surgery Center, for information about glaucoma, including treatment options, common misconceptions and new research regarding this disease.
Of all the areas of specialty, why did you choose glaucoma?
I chose a glaucoma specialty in my second year of residency. I think specializing in glaucoma is a good blend of medicine and surgery, and good care can really improve a patient’s quality of life. I enjoy a long-term relationship with my patients, and I have had patients that I’ve seen my entire practice life of 25 years. I also like the challenges of glaucoma surgery. It is been a good choice for me.
Is there a correlation between exercise and good eye health?
There may be a correlation between an active lifestyle and good eye health. Eye disease may be more prevalent in people who are inactive. There are always exceptions, of course. It is possible for healthy, active people to have eye problems and for inactive people to not experience eye issues at all. Although there is nothing I can cite scientifically, I’d say anecdotally, it can only benefit your general eye health to live an active, healthy lifestyle.
What is the most common question patients ask about glaucoma?
The question that most patients want answered, whether they voice it or not, is, “Am I going to lose vision from my condition?” One of my first goals is that I try to alleviate their fears. If we intervene early and treatment is successful, patients will not lose their vision. Many people want to know whether glaucoma will alter their lifestyle and prevent them from seeing what they want to see. All patients are concerned about this, even if they don’t ask the question. I try to assure my patients that as long as we detect glaucoma in an early stage and treat it appropriately, they will not lose a significant amount of their vision.
What are some myths or misconceptions about glaucoma?
Patients who do not have an adequate understanding about glaucoma may think that it is only a matter of time before they go blind. It is nice to reassure my patients that this is not true. There is a great deal of comfort in knowing that there is a high likelihood that treatment will preserve their vision.
Another misconception is that there are not many treatments available for glaucoma. Many patients think that eye drops are the only treatment option that exists, but there are many surgical and laser procedures that are not as well-known but are extremely effective. This general lack of knowledge may be due to the fact that we don’t talk about glaucoma very much, and glaucoma news is not widely disseminated in the media. Glaucoma Awareness Month has had many positive benefits, but it tends to highlight detection and diagnosis more than treatment.
How has glaucoma treatment changed over the years?
Glaucoma treatment has changed quite a bit. Now we have our second-generation laser. In the past, the course of treatment was eye drops followed by a procedure called argon laser trabeculoplasty (ALT). This procedure involved placing a lens on the eye under topical anesthesia and lasering the trabecular meshwork. I used this procedure for about fourteen years until selective laser trabeculoplasty (SLT) became available. This new laser uses 2000 times less energy than the argon laser. It targets the trabecular meshwork cells (the cells responsible for draining the aqueous humor out of the eye) and stimulates regeneration and restoration. Basically, it is destroying old cells and growing new cells. The advantage is that there is no scarring of the delicate trabecular meshwork. It can be repeated and it is a very low-risk procedure. In many patients, it actually helps prevent or delay eye drops.
For these reasons, we are now offering lasers as first-line treatment. I try to engage patients in the decision-making process and offer many options for treatment. Most patients, however, choose the laser over drops at least for initial treatment.
Is there anything that people can do to prevent glaucoma?
Just as there is no cure for glaucoma, there is no way to prevent glaucoma either. Early detection is important because glaucoma is much easier to treat at an early stage. Comprehensive eye exams every three to four years until the age of 40 or 50, and every year or two after that, will help detect glaucoma early. What people need to be aware of is their own personal risk for glaucoma. The most significant risk factors for glaucoma are age, race (Africa Americans have higher risk) and family history.
Cataract and glaucoma surgery are often being performed simultaneously. Would you talk about some different glaucoma procedures that are available and what type of patient would be the best candidate for each?
Cataracts and glaucoma both increase in prevalence with age, and there are several methods to treat both conditions. One can remove the cataract alone and hope that glaucoma remains stable. Another option is to do cataract surgery along with glaucoma surgery. A third option is to do sequential surgery and perform the glaucoma surgery first to get the pressure down and do cataract surgery later.
Sometimes, removing the cataract alone can be enough to lower the eye pressure, especially when glaucoma is well-controlled and mild. It has been widely reported that cataract surgery alone can lower the intraocular pressure a modest amount and help to control glaucoma. For patients with more advanced glaucoma, this approach may not be ideal. Eye pressure can spike after cataract surgery (whether due to inflammation or microtrauma), and that small amount of increased intraocular pressure could do irreversible harm to the optic nerve. This is especially the case in patients who do not have ideal intraocular pressure control.
These are situations where it may be more beneficial to perform both surgeries simultaneously. I have three preferred methods when I do cataract and glaucoma surgery together:
- For individuals with advanced glaucoma who need to get the pressure down quite a bit, I favor a trabeculectomy or Ex-PRESS shunt.
- For individuals with more mild glaucoma or moderate glaucoma, I favor a less invasive glaucoma surgery called canaloplasty where I do not have to actually enter the eye during the glaucoma surgery
- For individuals with mild glaucoma who are just taking one or two drops per day but would like to eliminate the eye drops, I like to insert an iStent. The advantage of the iStent is that I use the same incision as the cataract procedure and insert the iStent into the trabecular meshwork so there is no external incision. This is a quicker procedure and it is very low-risk, but we do not see the pressure decrease like we do with the trabeculectomy or the canaloplasty.
What new research has recently become available for glaucoma?
Glaucoma is an optic nerve disease. The optic nerve is like a cable that relays images from the eye to the brain. We know that increased eye pressure damages the optic nerve in some people. The level of intraocular pressure that they eye can handle without optic nerve damage will vary from individual to individual. Generally speaking, the higher the pressure, the greater the risk for damage. Currently, the only means that we have to treat glaucoma is to lower the intraocular pressure, so no matter whether it is eye drops, laser or surgery, the treatments are designed to lower the intraocular pressure to help preserve the health of the optic nerve.
Our first challenge is to ensure that patients are taking their medication as directed so we can control intraocular pressure. Numerous studies show that people may skip as many as fifty percent of the drops they are supposed to administer, and clearly this is not helping their glaucoma. There are some trials being done now with implants that are put into the eye that deliver medication for a year, thereby preventing missed doses. There are also specialized plugs that are designed to be implanted into the tear duct and can deliver medication for an extended period of time. These two methods improve the patient’s “adherence” to their medication so doses are not missed. Although these novel methods of drug delivery are not ready for widespread use, they are very exciting.
There is no current treatment to restore, regenerate or protect the optic nerve but this may change in the near future. There are medications in the pipeline that are protective in nature—they are neuroprotective agents to protect the optic nerve against damage. What would be even more exciting would be the ability to regenerate the optic nerve, almost like regenerating the spinal cord. In the next five years or so, we may see a neuroprotective agent become available, and that would be an entirely different line of treatment for those with glaucoma.
Dr. Derick has been with Columbus Ophthalmology Associates for 14 years and specializes in glaucoma surgery and consultation, as well as small-incision cataract surgery. A native of Chicago, Dr. Derick received his bachelor’s degree from the University of Notre Dame, his medical degree from the University of Illinois College of Medicine, and he completed his residency at The Ohio State University. Dr. Derick completed a glaucoma fellowship at Johns Hopkins University Wilmer Eye Institute in Baltimore. Before joining Columbus Ophthalmology Associates, he conducted glaucoma research and clinical services at The Ohio State University for 10 years.