A 65 year old patient presented with bilateral ARMD and Glaucoma with 0.9 cupping/sinking. Unfortunately she is highly hopeful for good comeback of her vision. What should be done?
I have tried to convince her that visual prognosis is limited with treatment of glaucoma and ARMD, but she seems to disagree.
In advanced glaucoma, the hope of the patient is central vision. But Age Related Macular Degeneration snatches this opportunity too from this patient. I think one can embark on vigorous treatment of both disorders if patient responds to counseling.
It totally depends on type of ARMD whether wet or dry..In case of dry ARMD not threatening much of macula ,the ARMD takes a back seat and vigorous treatment should be directed to advanced glaucoma .In case of wet ARMD ,the prognosis will be guarded so treatment will be based on clinical picture and clinicians discretion
There is not much you can do for dry ARMD, and for wet ARMD, you should try your best with anti-VEGF +/- PDT (in PCV) if indicated. Treat and extend approach would be suggested in this case to keep eye ARMD away from recurrence.
For glaucoma, VF and ganglion call analysis monitoring might be difficult, but always aim for lowish IOP as much as possible +/- surgical filtration surgery to maximise what you could do.
Neuroprotective eyedrop could also be considered.
Despite the pure ideal scientific answer is available, this treatment strategy is quite expensive and exhaustive to patient's quality of life.
Besides, neuroprotective eyedrops like Alphagan P is not easily tolerable with time, from hyperaemia to itchiness.
In addition, repeated anti-VEGF injection does cause great fluctuations of IOP around the injection period. And repeated intraocular procedures (anti-VEGF) is quite risky for patients with trabeculectomy or in-situ glaucoma drainage device, which endophthalmitis risk is significantly raised.
The real-world sustainability of this is almost impossible without financial subsidy, patients' strong will and ophthalmologists' courage.
I have a large Sjögren syndrome clinic, and many elderly patients with secondary disease related to rheumatoid arthritis are on long-term therapy with hydroxychloroquine and have advanced glaucoma. A similar clinical scenario to glaucoma and AMD from the stand point of visual loss risk.
Both, the optic nerve and the macular function are essential for peripheral and central visual performance, respectively. And, although optic nerve damage is irreversible, macular degeneration may also become irreversible if not treated properly. In this respect, it is very difficult to prioritize one over the other. Nowadays, there are no defined consensus on how to proceed in these situations.
Agreed dear Alejandro Rodriguez-Garcia, I am also suffering from the same problem.
This is quite tough for management. If the patient has dry ARMD dietary supplements of multivitamins which includes Lutein , zeaxanthin and beta-carotene along with smoking cessation should be considered. For glaucoma management SLT along with prostaglandin analog can be used.
If the patient has wet ARMD, depending the stages of wet ARMD, intravitreal injection should be done. Multivitamins supplements might be beneficial as well and if the patient are under intravitreal injection management, prostaglandin analog drops should be avoided given the risk of increasing inflammation, Alphagan might be considered.
ARMD and glaucoma both being progressive conditions, visual prognosis is always guarded. Wet ARMD need timely interventions with anti-VEGF and for dry ARMD, supplementation of antioxidants like beta-carotene, Lutein and zeaxanthin might help. Healthy food habits and quitting smoking can be helpful. Side by side , advance glaucoma needs serious consideration with combined anti glaucoma medications most probably beta blockers with prostaglandin analogues. Surgical procedure can be of consideration to maintain target IOP.
Proper consultation with a Glaucoma specialist and Retinal expert is must.
Beside treatment, these patients need Low vision management and rehabilitation. An optometrist should be consulted for better quality of life with low vision management.