Just as in cataract surgery, patients are raising the bar on the outcome of glaucoma care. They expect medications to be dosed less frequently and to be excellent in terms of efficacy and toler- ability. They also demand aggressive treatment of ocular surface disease. Patients frequently require top- ical and oral antibiotics and anti-inflammatory med- ications, and their use of tear supplements is increas- ing. Surgeons now consider laser trabeculoplasty as initial treatment to improve patients' adherence to prescribed therapy as well as to optimize their visual quality.
Patients also demand better glaucoma surgery. They expect more rapid postoperative recovery, fewer surgical complications, and better visual outcomes. In the past, surgeons focused predominantly on IOP control, sometimes at the cost of postoperative vision. Today, patients are less accepting of astigmatism, hypotony, and bleb-related ocular discomfort. As a result, sur- geons are fine-tuning their techniques for filtering sur- gery to produce more low-lying, diffuse blebs; less residual astigmatism; and faster visual recovery. They are exploring how to modulate wound healing, and they are performing tube shunt surgery and cyclo- photocoagulation earlier in the course of glaucoma.
Cataract surgery's role in glaucoma therapy is expanding as well. In patients with angle-closure glaucoma, cataract extraction may be a definitive glaucoma treatment, and the placement of toric and premium IOLs in the glaucoma population is increas- ing. Toric lenses in particular optimize visual out- comes after filtering surgery, and they can effectively eliminate astigmatism when used in conjunction with minimally invasive glaucoma procedures. In patients with early, well-controlled glaucoma requir- ing cataract surgery, accommodating and multifocal IOL technologies may offer significant benefits. Glaucoma subspecialists must position them- selves as high-quality cataract and anterior segment surgeons as well as trabeculectomy and tube shunt surgeons. All of these skills are nec- essary to provide comprehensive glaucoma care to patients, and they will help glaucoma subspecialists to maintain their position of leader- ship in the anterior segment arena. As more minimally invasive glauco- ma surgeries are developed, com- prehensive ophthalmologists will become increasingly involved in glaucoma management. Glaucoma subspecialists must become refractive glaucoma surgeons. They must meet patients' escalating demands or risk being relegated to managing end-stage disease.
Of course, physicians who treat patients with glau- coma must continue to ensure that the negatives of intervention do not outweigh its benefits. In this issue of Glaucoma Today, Louis Pasquale, MD, and Stanley Berke, MD, call attention to prostaglandin-associated periorbitopathy. Certainly, affected patients may pre- fer alternative therapy to enduring these structural changes, and practitioners must be aware of the problem and ready to address it.
