Glaucoma: Lessons Learned
December 2023
by Liz Hillman
Editorial Co-Director
When Deborah Ristvedt, DO, followed in her grandfather’s and father’s footsteps, becoming a comprehensive ophthalmologist, she said the 45-year-old practice was seeing a lot of primary eyecare at the time she joined.
“My grandfather and dad had built up a strong relationship with so many people for so many years,” she said. “What I found was that I didn’t have the ability to see as many surgical consultations or surgical cases as our community was growing because of those established relationships.”
This was until the practice underwent a major shift away from comprehensive eyecare toward a focus on being a surgical practice. This transition, Dr. Ristvedt said, was in part made possible thanks to relationships that she and her colleagues began to establish with optometrists to comanage primary eyecare, such as patients with stable glaucoma.
“There is no way we can keep up with the level of care, the detail of care, if we don’t work together.”
Deborah Ristvedt, DO
“The biggest thing is not having a fixed mindset. We’re continuing to evolve as ophthalmologists, as optometrists, and really being able to push ourselves into new algorithms and new ways of thinking as our demand for eyecare enhances. I think that has been a beautiful journey in my life, to use the skills that I’ve learned and be in the operating room more for patients who need that. This system works, and it’s nice to be able to utilize our skillset at the optimal level,” Dr. Ristvedt said.
Yen Cheng “Joey” Hsia, MD, told EyeWorld that one of the pros of comanagement is that it allows the ophthalmologist to decompress their schedule to accommodate new patient consults and patients with more severe diseases. He also said that optometrists often have more chair time with patients to go over medications to improve compliance and/or provide more comprehensive eyecare, including refractive needs.
Getting optometrists involved with medical glaucoma and post-surgical management has changed over the years, Dr. Ristvedt said.
“Many optometrists now have technology, like OCT and visual field testing, that allows for more standardization in detecting change or progression,” Dr. Ristvedt said.
Dr. Hsia said when he has comanaged glaucoma with optometrists, they were certified by the California State Board of Optometry to diagnose and treat primary open angle glaucoma for patients 18 and older. He said that comanagement within the same practice often consists of optometrists following POAG suspects with or without ocular hypertension and mild POAG that’s clinically stable, monitoring for progression and treating with medical therapy as indicated. He said that ophthalmologists are “consulted if progression is detected and/or non-medical treatment is warranted.” Dr. Hsia said comanagement can also be appropriate after angle-based MIGS for patients with POAG.
“For this specific postoperative group, optometrists generally see the patients after postoperative month 2 when the risk of complications diminish and the intraocular pressure is more stabilized,” Dr. Hsia said.
Dr. Ristvedt said she and her colleagues have worked to educate the optometric community on the various surgical treatments for glaucoma and how they could be involved in comanagement either before surgery is needed or afterward.
“What we’ve done is educated our optometric community about angle-based surgery as well as more minimally invasive glaucoma procedures, like subconjunctival procedures, so they’re well versed in the multiple technologies we use, the why behind it, and how to manage complications if there is a hyphema or pressure spike. That is the key when it comes to minimally invasive glaucoma surgery and comanagement, especially with cataract surgery,” Dr. Ristvedt said. “Even with standalone cases, I would consider SLT a form of MIGS because a lot of optometrists are sending patients before putting them on drops and seeing it as first line. With standalone glaucoma, it depends on what we’re doing and comfort level. There are certain optometrists who might not be as comfortable managing complications, so that’s a key, too.”
Dr. Ristvedt said it’s important to educate optometrists about the evidence behind SLT as a first-line therapy, especially due to the quality of life and ocular toxicity issues that come from putting patients on more and more glaucoma drops. She said she’s found that once her optometric colleagues understand the why behind her recommendations, they’ll come on board with the mindset.
“Across the board, I think optometrists can manage or comanage a lot of these glaucoma procedures that we do,” Dr. Ristvedt said.
One challenge that ophthalmologists might have in beginning a comanagement relationship with optometrists is the worry that if they were to refer patients, they won’t get them back.
“I think that’s always been a fear that I’m going to refer a patient who I’ve developed this relationship with and I’m not going to get that patient back. That’s where our whole educational series on glaucoma, cornea, cataracts is so crucial. We do work as a team and we need to be able to communicate by phone, in person, by letters what is happening with this patient so we can all be on the same page. Education goes back to understanding the reason why we do something, understanding our thought process, and being able to communicate what that plan is so that they are involved in the treatment plan. … The doctor-doctor relationship is so crucial in effective communication.”
Dr. Hsia also said that communication is key for successful ophthalmologist-optometrist comanagement.
“My preferred method of communication is to be available in person to allow the optometrists to consult me in real time on issues that may be outside of their scope of practice,” Dr. Hsia said. “I also include management guidelines in the patient’s chart, outlining target intraocular pressure range, frequency of glaucoma imaging, and the patient’s individual needs.”
One area where communication is important is how to manage patient feelings when they are referred from the ophthalmologist to the optometrist or vice versa. To avoid the patient feeling abandoned, Dr. Hsia said to alternate or stagger care of the patient between these providers. He also said it can help to introduce patients to the comanagement approach early in their treatment course.
Dr. Hsia said in a comanagement relationship, both parties need to agree on a general management philosophy, clearly defined roles, and what constitutes an emergency.
“Whatever role the optometrist plays, it should fall within the scope of practice for that state. In states with greater overlap in scope of practice, such as those that allow optometrists to perform SLT, there should be agreement on who is doing a given procedure and timing within the agreed upon management philosophy,” he said, adding later that optometrists should attend glaucoma-related continuing education courses on current practice patterns.
Dr. Ristvedt thinks that comanagement between ophthalmologists and optometrists will continue to be especially important.
“There is no way we can keep up with the level of care, the detail of care, if we don’t work together,” she said. “I’m thankful that in our community, we have wonderful relationships built with trust and time and encouraging one another to be at our best. I’m at my best when I’m learning new technology or surgery and I’m pushing the bar in our thought process when it comes to some of these disease processes like glaucoma. That’s where the passion for interventional glaucoma has come from because I’ve seen the beauty and the power in it. I think I’ve also seen the beauty and power in learning. Optometrists are hungry to know more, and when you build that trust and that relationship with your fellow optometrists, it does enhance patient care. Patients will tell me on a weekly basis how much they trust both their primary eye doctor and their surgeon. It is a beautiful system when you can have that communication, support, and understanding that you’re all working together for the ultimate goal of giving better care than you’ve ever given before.”
About the physicians
Yen Cheng “Joey” Hsia, MD
Diablo Eye Associates
Walnut Creek, California
Deborah Ristvedt, DO
Vance Thompson Vision
Alexandria, Minnesota
Relevant disclosures
Hsia: None
Ristvedt: Allergan, Glaukos, RxSight, Sight Sciences
Contact
Hsia: Joey.Hsia@ucsf.edu
Ristvedt: deborah.ristvedt@vancethompsonvision.com
