Our annual glaucoma issue is always a great opportunity to take stock of optometry’s successes and struggles with this important responsibility. You don’t need me to tell you once again that the only way the burden of glaucoma care can be met is if ODs step up and fully embrace it (oops, I guess I just did).

Anyway, as this is the 30th Annual Glaucoma Report, I took a look at the slate of topics in our first one, published in 1995. There was no mention of OCT or MIGS, of course—two topics that are inescapable today. But we included lots of discussion on disease pathophysiology, exam techniques and how to understand and use meds to lower IOP. Selective laser trabeculoplasty wasn’t mentioned but its precursor ALT was, mostly as an option for late-stage cases that might not be suitable for filtering surgery. And back in 1995, only 31 states allowed ODs to prescribe glaucoma meds, even topical ones (can you imagine?), so that topic was considered cutting edge by many.

Fast-forward to today and the newest legislative frontier is laser procedures, with 12 states currently allowing ODs to perform SLT and LPI. Topical meds, while clearly still a mainstay of care, are waning in importance as first-line SLT becomes more accepted and sustained-release drugs come into their own. Head-mounted visual field testers aim to take the sting out of perimetry, and there are hints that AI-powered OCT will one day be able to do to field testing what SLT and sustained-release are currently doing to old-school topical therapy.

But one topic that only got a cursory discussion in our 1995 series—gonioscopy—seems to still be a thorn in the side of ODs. It’s not cost prohibitive and doesn’t seem difficult to perform, but rates of gonioscopic evaluation have been low for decades. This is a detriment to both patients and the profession. One of the recent scope expansion bills that made the case for optometric laser responsibilities was shot down at least in part because of data its opponents provided showing meager rates of gonioscopy as performed by ODs. “Why should we give them lasers when they don’t do gonio?” was the narrative spun by ophthalmology. And I have to say they’re right. I call out MDs for their spurious claims against optometry all the time but that one has the ring of truth to it. 

However… it turns out that ophthalmologists aren’t exactly glued to their gonio lenses either. A few months ago, AJO published a study of almost 200,000 glaucoma patients/suspects and individuals with narrow angles seen by MDs. Only 20.4% had a record of gonioscopy having been performed on the day of diagnosis and 29.5% within six months. “The overall low rate of gonioscopy is striking,” the researchers wrote. “Gonioscopy represents a crucial junction in the glaucoma management algorithm where appropriate therapy could be prescribed to prevent permanent morbidity.” 

Now, it’s possible that a bunch of those patients did in fact receive a gonioscopic exam and the practice simply didn’t note it in the record. Let’s hope so. Still, that’s not much consolation, as proper documentation is obviously critical to the long-term provision of care and as legal defense against a malpractice claim.

But, you know, two wrongs don’t make a right. Ophthalmology’s negligence here is no excuse for the same behavior in optometry. You can find guidance on gonio technique here, here and here. Good luck!