Pressure centric to patient centric glaucoma care: Connecting the dots
Year: 2025
Type: editorial
Abstract: “Medicines cure diseases, only doctors can cure patients”. Carl Jung Glaucoma is a leading cause of irreversible blindness, affecting an estimated 80 million people globally. The burden of Glaucoma in the Indian context is daunting. One in 8 persons or nearly 40 million Indians aged 40 years or above either has glaucoma or is at risk of developing it.[1] In India, the rate of undiagnosed glaucoma is very high (90%), while the level of glaucoma awareness is only 0.32 to 13.5%.[2] This editorial intends to high light some ways that might help health care providers move toward patient centric glaucoma care. It will also offer a glimpse into the possibilities of precision medicine for targeted/personalized glaucoma management. QUALITY OF LIFE: THE MISSING LINK IN PRESENT DAY GLAUCOMA CARE? Control of intraocular pressure to save the visual field is the basic treatment goal for clinicians, but let us not forget that ultimately a higher quality of life (QoL) could be more important for the patient. So, when it comes to defining treatment goals, are we suffering from tubular vision and missing the big picture? Perhaps yes. Here are a few suggestions to move towards patient centricity in present day glaucoma practice: Look beyond the disease, see the patient: It is essential that clinicians dedicate more time for the glaucoma patient to bring out his personal needs, concerns and challenges related to the disease and its treatment. Quality of life assessments should be part of the clinical routine at least at baseline and periodically. Intraocular pressure, optic disc and visual fields may not always tell the whole story. The economic feasibility, compliance issues and toxicity of glaucoma medications are problems clinicians should discuss specifically with their patients. Near work and Mobility are top issues that affect the QoL of glaucoma patients. So, treatment goals of a glaucoma patient should include low vision training, mobility training and counselling as needed, apart from the management of the disease proper. How to check QoL? The ideal QoL questionnaire should be short, simple, and easy to use, with high reliability, reproducibility, sensitivity, and validity. Self-administered questionnaires are preferred. Of the forty odd validated glaucoma QoL questionnaires for the purpose, no single existing questionnaire design suits all purposes. The glaucoma-specific Glau-QoL 36, and the shorter versions GQL-15 and GAL-9 may be the best tools to detect quality of life decline correlating with disease progression, while the MOS SF-36 assesses patient’s general health and wellbeing by noting both physical and mental health status.[3] So you need to choose your questionnaire depending on your objective and the patient needs. In a busy outpatient clinic, formal questionnaires may even have to be trimmed further to selected relevant questions. Attitude and communication: Evidence suggests that glaucoma as well as self-suspicion of it/fear of losing vision can negatively impact QoL and mental health.[4] This means that even glaucoma screening programmed could paradoxically affect some patient’s mental health negatively as they make patients aware of the disease/its possibility. So, we need to be extra cautious and sensitive in our attitude and communication while counselling a freshly detected glaucoma patient or suspect. Training the care givers: It is vital to train care givers on how to make the immediate home environment safe and glaucoma friendly for patients. Our glaucoma awareness activities, currently focused on detection and management of the disease need to include organizing workshops for low vision training/environmental modifications for patients and their caregivers. This can help them face glaucoma related daily life challenges better, thus enhancing QoL. THE PROMISE OF PRECISION MEDICINE FOR TARGETED GLAUCOMA CARE At present, clinical examination, intraocular pressure (IOP) measurements, visual field tests, and optical coherence tomography (OCT) drive diagnostic and therapeutic decision making in glaucoma. This disease often baffles clinicians many a time with its unpredictable nature and varied treatment responses across different patients. It poses difficult questions. Here are a few examples: Why is the target pressure so variable across patients? Why do different patients have variable responses to the same drug? Why do some patients with NTG progress to Primary open angle glaucoma (POAG)? Questions like these point at many missing links in the glaucoma story. The emerging concept of precision medicine and its role in glaucoma care may provide us with some of the answers. Evidence-based medicine (EBM) is defined as a judicious use of treatment for patients as per the results of clinical trials and research, whereas precision medicine (PM) is an individual based approach for patient’s treatment with modifications in the standard treatment after considering variations in genetic makeup, environment, and lifestyle.[5] PM brings in more patient centricity into the treatment paradigm. It is backed by advances in molecular biology and emergence of biomarkers in glaucoma based on Artificial intelligence models, genetic mapping, assessment of NAD/NADH redox state and detection of metabolites/proteins in body fluids.[6] Artificial Intelligence based models: Deep learning models can detect and quantify early glaucomatous damage using Fundus photos/Optical Coherence Tomography/standard automated perimetry fields. Imaging biomarkers may help clinicians decide upon the initial surgical intervention based on a patient’s aqueous vein map.[7] Genetic markers: Discovery of genetic biomarkers opens the possibility to identify new biological pathways that could influence disease manifestation and progression. This accurate information on genes and pathways that could potentially influence a person’s treatment responses can pave way for genetically guided, personalized treatment of glaucoma. Pharmacogenomics may predict the efficacy as well as the vulnerability of a patient to potential side effects of a particular drug. Genetic markers can also allow closer monitoring of family members at risk of developing glaucoma. An excellent example would be predictive gene testing for myocilin-associated glaucoma. MYOC gene mutation is associated with Primary Open Angle Glaucoma, steroid-induced glaucoma, and juvenile-onset glaucoma NAD+/NADH Redox State and Glaucoma: Reduced levels of NAD + represent impaired mitochondrial activity and, consequently neurodegenerative damages. Nicotinamide, the primary precursor of NAD+, was lowered in the plasma of glaucomatous patients, suggesting its potential as a biomarker and a possible therapeutic role for nicotinamide supplementation for POAG Metabolic biomarkers: Multiple metabolites and proteins in different biological fluids (tear film, vitreous, aqueous, serum, and plasma) are being investigated as biomarkers for early diagnosis of glaucoma (example: the plasma levels of Homocysteine and Cysteine). In addition, serum antibody profiling is shown to distinguish glaucomatous patients from controls with a specificity of 93%. Certain autoantibodies against ocular tissues implicated in glaucoma are anti-HSP60, anti-a-A-crystalline, a-B-crystalline, glutathione-S-transferase, retinaldehyde binding protein, glial fibrillary acidic protein, retinal S-antigen, and neuron-specific enolase. Despite all the promise they hold, glaucoma biomarkers need to be considered with caution due to the heterogeneity of disease presentation and the differences in the genetic pattern of individuals. Also, it is unclear whether the alterations in antibody profile are a cause or a consequence of glaucoma-related alterations. Validation studies are currently lacking for biomarkers now available for glaucoma. The next phases of translational research are to integrate the biomarkers with the established clinical risk factors. In summary, the discovery and validation of biomarkers have the potential to shift the current model of event-based care rooted in visual field change towards preventing glaucoma blindness by intervening at a much earlier and fundamental level. While precision medicine promises to be the future of targeted patient care, incorporating Quality of Life goals at each point of glaucoma care delivery is something we all can practice today to make our treatment more patient centric.
Source: Kerala Journal of Ophthalmology
Author: Lathika V. Kamaladevi
Institution: Amala Institute of Medical Sciences
Language: English
Subfield: Ophthalmology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4409623991