Key Elements in Handing Off the Surgical Glaucoma Patient

Surgical treatment of glaucoma has improved rapidly and significantly over the past decade. Whereas surgery was previously seen as a late stage option, the advent of microinvasive glaucoma surgery (MIGS) has brought more options to patients at earlier disease stages.¹

With more patients now being managed surgically, it is more imperative than ever that the referring optometrist communicate effectively with both surgeon and patient. The handoff process for glaucoma surgery requires strong communication between doctors in order to achieve good quality outcomes and limit confusion that can lead to patient concerns and frustration. Important steps must be taken in the documentation and discussion prior to patient referral to ensure quality care. I review these steps below.

KEY DATA

Perhaps the most critical part of the communication lies in the patient history. Several key data points must be included upon referral to provide the full picture of the patient’s condition and his or her surgical needs. Key metrics include IOP, visual acuity, testing history, prior treatments, phakic status, and other tests.

IOP

As IOP is the only modifiable aspect of glaucoma management, tracking it through a series of data points is integral in the preparation for surgery. It is important to note maximum, current, and target IOPs. These data points indicate how effective the patient’s current treatment is and how far his or her IOP is from our goal. This will guide the surgeon as to what level of intervention is needed and what options may provide appropriate IOP lowering.

Visual Acuity

The most important metric in eye care, visual acuity, usually remains unaffected by glaucoma until the late stages of the condition. However, if a patient is exhibiting a decrease in acuity that can be attributed to glaucoma, this is crucial to document, as prompt and marked IOP lowering is needed, likely with a highly efficacious drainage device.

Testing History

OCT and visual fields are both essential tests for following glaucoma.² Clear progression of visual fields or rapid thinning on OCT will cue the surgeon to the need for timely and robust surgical measures. Tests that demonstrate stability, or at least very slow progression over time, may allow leeway to try less invasive, but less efficacious, procedures. Using these technologies to establish the severity of disease before surgery also allows us to set proper postoperative expectations for the patient and gauge the procedure’s success (Figure 1).

Prior Treatments

What other treatments has the patient tried? If the patient is on a one-drop regimen, the surgeon may feel comfortable knowing that there are other topical options to control IOP after surgery and thus choose a less invasive MIGS procedure. On the other hand, if there is documented failure of medications and further options are limited, the surgeon may opt for a more robust procedure.

Phakic Status

Trabecular microstent devices are indicated only at the time of cataract surgery, whereas other MIGS options, such as canaloplasty, goniotomy, and subconjunctival stents, may be implanted either in a combined or a standalone procedure.^3-8 Including information on whether or not the patient is a cataract surgery candidate will allow the surgeon to assess the potential options before he or she evaluates the patient.

Other Tests

Other tests and documentation, including pachymetry, gonioscopy, and disc photography, can also be helpful in developing a surgical plan. Gonioscopy is particularly useful, as some MIGS options may be eliminated if the angle is closed or too narrow.

GOALS AND EXPECTATIONS

Your notes should also convey to the surgeon your goal for the surgical referral. Does the patient have well-controlled mild to moderate glaucoma with an emerging cataract, in which case MIGS would be a convenient, but ultimately not critical, option? Is the patient experiencing significant ocular surface complications from his or her drops, in which case a MIGS procedure may be warranted but the need for lower IOP without drops is more critical? Or is the patient’s glaucoma severe and uncontrolled, in which case a more efficacious, but more invasive, procedure such as a tube shunt or trabeculectomy should be considered? Clearly conveying the goals for your surgical referral helps set the table for the surgeon to make these critical decisions, not only on the procedure to be used, but also on the urgency of the surgery.

A discussion of goals and expectations should also take place with the patient before referral. In the case of the controlled cataract-MIGS candidate, discussing the potential benefits of surgical glaucoma intervention (ie, fewer drops, better IOP control) will make for an easier transition to the patient’s surgical evaluation, as the patient will have already heard the options. If more advanced procedures are needed, discussing the importance of prompt intervention to prevent damage and forestall blindness can ensure that the patient follows through on the referral. As an added benefit, when you clearly and appropriately convey the benefits and the necessity for surgery, your patient will gain trust in your understanding of his or her condition and its management.

Finally, setting reasonable expectations for the patient is vital to his or her overall success. A patient with advanced glaucoma should not expect surgery to provide significant visual improvement; rather, the patient must understand that the purpose of surgery is to preserve what vision he or she has. Postoperative care expectations should also be laid out in a reasonable manner. For example, although trabeculectomy and tube shunts offer excellent IOP-lowering capabilities, they can be unpredictable in the short term and require frequent follow-up visits in the early postoperative period (Figure 2). Conveying these expectations before surgery can help prevent frustration down the road.

POSTSURGICAL MANAGEMENT

Of course, glaucoma management does not end with a surgical intervention. Patients still need continued monitoring of their condition after their procedure. Make sure it is known who will be assuming care after the postoperative period. This will limit confusion for the patient and avoid conflict between the comanaging parties.

The decision about who will manage the patient’s care after surgery may depend on multiple factors including disease severity, level of surgical intervention, and the general comfort level of the optometrist. Some ODs may choose to see patients with all levels of disease return to their care, whereas others may choose to defer all postoperative care. Management of patients after glaucoma surgery requires that the optometrist stay up to date on the intricacies of the procedures discussed above and the complications that have the potential to develop in the short and long term. Above all, it is important that you feel comfortable identifying and appropriately managing these complications before you resume care.

IT TAKES A TEAM

Advances in surgical glaucoma management have provided many options for patient care and have led to earlier use of the surgical treatment algorithm for this chronic condition. Taking a measured approach in the handoff for surgery will help ensure quality outcomes for your patients.