As the sector marks World Glaucoma Week (10-16 March), recent developments have provided eyecare professionals with even more confidence the disease can be managed and optimism for patients.
With an ageing population and more than 300,000 people estimated to be living with glaucoma in Australia – half of those completely unaware they even have the condition – new surgical interventions, translational research projects and innovative care models are emerging to soften its impact.
One such development is the transition from traditional therapeutic avenues as first line treatment to medication free alternatives. As issues with compliance and a reduction of life-quality are commonly associated with eye drops, the industry is exploring new avenues that are revolutionising the treatment landscape.
A current snapshot of glaucoma management shows that newly diagnosed glaucoma patients are increasingly being treated with selective laser trabeculoplasty (SLT) as a first line treatment. This is based on evidence from the LiGHT trial; a landmark study demonstrating that starting with SLT as first line therapy compared to medical therapy exhibited greater intraocular pressure (IOP) control and thus patients were more likely to be medication free.
Currently, nearly three-quarters of these patients are still medication free, six years after SLT. More importantly, people treated with laser first have a lower rate of losing peripheral vision and a much lower rate of needing to go on to have further invasive surgery.
One surgeon who has been following the data closely is Dr Nathan Kerr, of Eye Surgery Associates in Melbourne, a researcher at the Centre for Eye Research Australia (CERA) and one of Australia’s most well- credentialled glaucoma specialists.
“In recent years, SLT has emerged as the preferred first line approach for open-angle glaucoma and ocular hypertension, offering a more patient-centric solution. This method significantly reduces the challenges associated with adherence – a notable obstacle, as numerous patients find daily eye drop application challenging. Moreover, SLT avoids the potential side effects commonly associated with eye drops and reduces the risk of field progression and need for incisional glaucoma surgery. By integrating SLT as our initial treatment strategy, we effectively address these concerns, enhancing overall patient care and outcomes,” Kerr says.
He says that the industry is witnessing a profound paradigm shift in the approach to treating glaucoma.
“A decade ago, the standard protocol involved initiating treatment with medical therapy. Typically, if a single agent proved insufficient, we escalated the treatment, often incorporating up to three different medications before even considering laser therapy. However, now we have a deeper understanding of the benefits of SLT.”
Kerr completed the first surgery in Australia using the iStar MINIject minimally invasive glaucoma surgery (MIGS) device late last year since it became commercially available. He says the device represents a significant advancement in MIGS, which is a surgical option for patients where medical therapy is ineffective or poorly tolerated.
“MIGS is playing a pivotal role in reducing the need for trabeculectomy. While trabeculectomy is a highly effective procedure, it’s also considerably invasive and demands an extended recovery period. The current market offers a range of MIGS devices, supported by a robust and continually growing body of evidence underscoring their safety and efficacy. This advancement has revolutionised the management of glaucoma,” Kerr says.
Ultimately, the goal of these procedures is to extend beyond preventing vision loss; with the aim to enhance overall quality of life. This involves minimising reliance on medications, lowering the risk of side effects, and ensuring a swift recovery so that patients can return to their normal activities.
“These innovative technologies are not just about treating a condition; they’re about offering a superior patient experience and significantly improving their quality of life. It’s an incredibly exciting time in the field of ophthalmology,” Kerr says.
There are two natural drainage routes inside the eye: The conventional pathway (Schlemm’s canal) – which the iStent, Hydrus, and iTrack utilise – has been shown to be safe and effective; and the uveoscleral pathway which is the focus of the MINIject. This procedure creates a pathway for aqueous to flow into the suprachoroidal space, which effectively lowers IOP. Additionally, the suprachoroidal space is less prone to scarring compared to traditional filtration surgeries, possibly leading to more sustained IOP control.
“Unlike MIGS devices which primarily facilitate aqueous outflow through Schlemm’s canal and into the episcleral venous system, the MINIject offers an alternate approach. It bypasses the episcleral venous pressure floor, which inherently limits the extent to which IOP can be reduced. This bypass mechanism allows the MINIject to potentially achieve lower IOP levels, granting it a unique advantage in certain clinical scenarios,” Kerr says.
When performed with routine cataract surgery, Kerr says that Schlemm’s canal and MINIject procedures boast good safety profiles that are very similar to that of standalone cataract surgery.
MIGS preserves the ocular surface by avoiding glaucoma drops so the patient’s ocular surface remains intact which is important for intraocular lens (IOL) performance. Therefore, the outcomes of cataract surgery are improved.
“The integration of MIGS during routine cataract surgery not only maintains an excellent safety profile but also enhances the overall surgical outcomes. By reducing or eliminating the need for glaucoma drops, MIGS plays a crucial role in improving the ocular surface which is vital for optimal IOL performance. Patients benefit from a dual therapeutic approach that addresses both cataract and glaucoma in a single, streamlined procedure,” Kerr says.
Although relatively new to the Australian market, large ophthalmic studies have mitigated uncertainty surrounding the MIGS procedure.
“As we approach a decade of utilising MIGS in Australia, our understanding and expertise in this field have grown significantly. Globally, the body of data on MIGS devices has surpassed the 10-year mark. Notably, the HORIZON study on the Hydrus Microstent stands out as not only the largest trial specifically focused on MIGS but also one of the most extensive in the field of surgical ophthalmology,” Kerr says.
“Initially, there was a degree of uncertainty surrounding the safety and efficacy of MIGS. However, with nearly 10 years of clinical experience and robust data, we’ve effectively addressed these concerns. The current focus is now on ensuring that this advanced care is accessible to all patients who could benefit from it.”
Kerr says the trajectory of the glaucoma landscape not only offers a wide range of treatment options that can be tailored to patients’ needs, but provides quality-of-life that traditional methods have not been able to achieve.
“The advancements in glaucoma treatment over the past few years have been truly remarkable. While our primary objective continues to be the preservation of vision, the scope of our care has broadened significantly,” he says.
In the past, postoperative periods following conventional surgical methods often meant a prolonged recovery for patients, characterised by frequent follow-up visits, blurred vision, and eye discomfort. Kerr welcomes the shift towards newer techniques that facilitate a quicker and more comfortable recovery process.
“Being able to provide these advanced treatment options and witnessing the positive impact on our patients’ lives is exceptionally rewarding. It’s an indication of meaningful progress in our field, enhancing both the effectiveness of our treatments and the quality of life for our patients,” he says.
Working together
With the rising numbers of patients diagnosed with glaucoma – and oversubscription of public ophthalmology departments – the Glaucoma Community Collaborative Care Program (G3CP) at the Royal Victorian Eye and Ear Hospital (Eye and Ear) in Melbourne is designed to alleviate some of this pressure.
The Glaucoma Unit at the Eye and Ear provides more than 12,000 outpatient appointments a year, but there are still challenges with demand for services exceeding capacity. Established in 2018, the G3CP aims to ease this demand at the same time as ensuring patients receive appropriate and timely care. It is the largest program of its kind in Australia and has proven successful with a high degree of patient and practitioner satisfaction.
The program focuses on low-risk or suspect patients with stable glaucoma who need to remain under the care of an ophthalmologist and require close monitoring, but do not need to come to hospital clinic for every appointment.
The hospital has partnered with community optometrists who are recruited to provide care in geographical areas with high demand. Instead of having to attend the hospital for glaucoma monitoring, the clinical assessment is performed by the participating optometrists with the results of testing forwarded to the hospital and reviewed by a glaucoma specialist.
After the initial pilot program, which demonstrated safety, effectiveness and high patient and clinician satisfaction,the program is continuing to expand, with an additional 20 optometrists recently recruited.
Dr Catherine Green, AO, head of the Glaucoma Unit and ophthalmology lead of G3CP says the program has been shown to be very safe and effective. It allows patients easier access to appointments because the public system is oversubscribed by a substantial amount with low-risk patients often having their appointments delayed.
A defining characteristic of G3CP is its affordable delivery of eyecare services which allows it to make a difference in patients’ lives, particularly in a cost-of-living crisis.
“I think a key strength of our program is the informed consent, because some patients do have a small out-of-pocket expense that needs to be discussed with them while participating optometrists provide as low cost care as they can,” Green says.
In adherence to RANZCO glaucoma collaborative care guidelines, G3CP recruits optometrists through an expression of interest. They are required, at minimum, to have a means of applanation tonometry, optic disc imaging, and access to visual field testing.
Patients are assessed in clinic by a glaucoma specialist, and those that are stable are deemed suitable for G3CP. From then on, community-based optometrists can monitor IOP and prescribe medication, working within specific guidelines. If a change in treatment is required, they will defer to the Eye and Ear for a decision.
“It means G3CP patients don’t need to see an ophthalmologist every time they get an eye check. And this is in keeping with the RANZCO Glaucoma Collaborative care guidelines,” Green says.
Through the program, patients enjoy convenience and peace-of-mind, while optometrists enjoy an expanded scope-of-practice.
“There’s a very high acceptance from patients that they actually preferred seeing a local optometrist for some of the visits knowing they are still under the supervision of the glaucoma clinic and glaucoma specialists, and very high satisfaction from the optometrists in that they enjoyed seeing slightly more complex patients,” Green says.
“A key component has been continuing professional development opportunities for the participating optometrists so they have access to the glaucoma doctors at the hospital and are also part of a community of practice all doing the same thing.”
A helping hand
Despite a sophisticated eyecare system in Australia, Glaucoma Australia’s biggest challenge is ensuring the disease is diagnosed before it results in vision loss. It does this through encouraging the community to get their eyes tested regularly, so that glaucoma can be identified early.
Glaucoma Australia CEO Mr Richard Wylie says that he is pleased with the strides being made in this space, with Specsavers offering OCT scans as part of general checkups, at no cost to the patient.
But more importantly, he heralds a new saliva DNA test to assess individual risk of developing glaucoma, known as SightScore by Seonix Bio and developed by Professor Jamie Craig and his team at Flinders University.
If widely adopted, Wylie says this represents a game changer and can be used for patients who may have a genetic likelihood of developing the disease, based on familial disease patterns. He wants to see broad implementation of the tests in the health system.
A $2.9 million funding injection from the Australian Government Medical Research Future Fund (MRFF) Genomics Health Futures in November last year will support the rollout of the test in Australia.
“Now we have the ability to simply send a patient saliva-based testing which is not much different to COVID tests. The test is sent back to a lab and within four weeks, you can be given a probability of developing glaucoma at some stage in your life,” he says.
“As an organisation we’re now currently working with Professor Craig and commercial partners to see how we might be able to use that test in the Australian health system to identify people who might be at risk even though they may not know it.”
Ideally, this system would encourage immediate relatives of glaucoma patients to participate in early testing.
“The system would make sure these patients schedule in regular appointments and determine whether the optometrist is going to be a part of their lives going forward. It would determine whether they need to undergo proactive treatment so the disease doesn’t progress in the first place. That’s a massive opportunity,” Wylie says.
“We’re very, very interested to see how this availability of the new saliva test impacts ongoing identification and also, treatment of patients going forward.”
Wylie cites not only glaucoma, but its comorbidities, as a major economic burden for Australia. It’s been predicted by health economists that the strain to the overall health system is going to reach $4.3 billion by 2025, largely due to Australia’s ageing population.
“In terms of some of the consequences for the health system, people with low vision and glaucoma are four to eight times more likely to have falls. And obviously, hip fracture is a significant risk of falls so there’s also a greater risk of hospitalisations and premature death,” he says.
“Additionally, people with low vision are admitted to aged care earlier than those with full vision. And they’re also twice as likely to suffer from depression. So, not surprisingly, the consequences of having mid- and late-stage sight loss are quite substantial.”
To mitigate this growing burden, Glaucoma Australia’s SiGHTWiSE program is a valuable asset featuring a free support line that people can access to speak with qualified healthcare counsellors. The program also features a comprehensive website, series of live monthly Q&A webinars with expert speakers, social media support groups, bi-monthly newsletters and various brochures and fact sheets to support patients.
“It’s been shown that SiGHTWiSE patients are more compliant with their prescribed therapies. They attend their appointments with their eye health professionals more regularly, and they’re also generally more knowledgeable about their glaucoma. They also have reduced anxiety about the future,” Wylie says.
To reflect growing glaucoma incidence and detection rates, demand for the program is growing annually. However, these enrolments only constitute a small percentage of current glaucoma patients.
As part of Glaucoma Australia’s long-term vision, and to alleviate strain on public ophthalmology services and raise awareness of the program, its integration with the health system is among Wylie’s top priorities. This would entail enrolling those on the waiting lists on to SiGHTWiSE at no cost and educating them on their treatment or referral options.
“We had around 2,800 people enrol in the program over the past 12 months and almost 23,000 active on the program right now. But really, we’re only scratching the surface of the total population,” Wylie says.
More reading
Revolutionising the diagnosis and monitoring of glaucoma
Glaucoma genetic test taken from mouth swab a step closer to the clinic in Australia
Flinders University to trial SLT for high risk glaucoma patients in world first
