Michelle Dalton, ELS

This article was reviewed by Joseph F. Panarelli, MD

, the leading cause of irreversible blindness in the United States, is caused by ocular hypertension, which damages the optic nerve and results in visual field loss.
	
	There is no cure, but the disease can be managed with pharmacologic therapies, among other more invasive treatments, that lower and stabilize intraocular pressure (IOP).

Joseph F. Panarelli, MD, associate professor in the Department of Ophthalmology at NYU Langone Medical Center, New York, and Sahar Bedrood, MD, PhD, a glaucoma specialist at Acuity Eye Group, and assistant professor of clinical ophthalmology at the USC Roski Eye Institute, Los Angeles, recently spoke on the current state and future of glaucoma therapy and how compliance may not be an issue in the coming years. 
	
	

Recently approved therapies to treat open-angle glaucoma 

IOP reduction is the only known modifiable risk factor for open-angle 

a. However, studies have shown that disease progression and blindness are still possible even in patients on maximum medical therapy.


	
	How IOP factors into visual field loss isn’t entirely clear. According to Dr. Bedrood, one theory-known as the stress/strain model-is that IOP strains the sclera and optic nerve, causing apoptosis and loss of retinal ganglion cells.
	
	Another theory-the vascular theory-is when the blood vessels in the optic nerve don’t get enough oxygen, which leads to apoptosis, nerve fiber layer loss, and, eventually, visual field loss.

 are alike, and progression rates vary from person to person. 
	
	

 Stent offers IOP stability more than three years after surgery 

“Some patients who have a very strong genetic component are going to progress very quickly, and some, not so much,” Dr. Bedrood said. 

Co-morbidities such as sleep apnea and IOP fluctuations are other risk factors for visual field progression and greater visual field loss in certain patients. 

The causes of IOP fluctuations are multifactorial and can be due to poor treatment compliance, genetics, and a decline in treatment effectiveness over time.

“After 10-plus years of treatment, some of those treatments that initially worked may not work as well,” Dr. Bedrood said. “Sometimes, patients respond really well in the beginning and then over a couple of months or years they don’t, and then they fluctuate their IOP.”

Over a decade, selective laser trabeculoplasty (SLT) will wear off, requiring patients to have a touchup or a second round of treatment. Patients may develop an allergy or intolerance to glaucoma drops as well. 

“Over a course of 10 years, a lot can change,” Dr. Bedrood said. “Their rate of progression can fluctuate. Their tolerance of drugs can fluctuate. Oftentimes after 10, 15, or 20 years, we’re looking at other modalities of treatment like surgery or something that can regulate their pressure a little bit better-other additional drugs, for instance.” 
	
	

Sustained release implant offers long-term IOP stability, preserved vision control 

Prostaglandin analogues-such as bimatoprost, latanoprost, tafluprost, and travoprost-are common first-line treatments for patients with newly diagnosed 

. They are non-invasive and can reduce IOP by 25% to 30% with once-daily dosing,

Just because they are the most common first-line treatment doesn’t mean they are the best. Clinical trials have shown that SLT is just as safe and effective as drops, with a 20% reduction in IOP that lasts for up to three years without the hassle of daily medication.

Predicting glaucoma progression: More than meets the eye 

However, patients are often uncomfortable with the idea of a procedure initially and underestimate the burden of daily medication. 

Dr. Panarelli believes the pros and cons of SLT versus daily drops is a conversation worth having with patients early on in the treatment process. 

“I think it’s worth having a discussion with them [regarding] whether they prefer to start topical therapy or whether they would like to proceed with laser trabeculoplasty, especially now with data from the LiGHT trial,” he said.

Regardless of the initial approach, certain patients will ultimately progress.  When it is necessary to advance treatment, these patients may need a more aggressive approach.

“It’s a big decision for me to add another medication,” he said, adding that if a second medication is necessary, his preference is to go straight to a fixed-combination agent for those he suspects are “rapid progressors.” 

When selecting a treatment approach, clinicians must consider patient preferences, cost, and other factors impacting compliance. For example, patients with advanced 

 may be taking six to 10 drops a day.
	
	

 Eye-opener: Sticking to glaucoma therapy regimens vital 


	
	Drops that contain preservatives may cause ocular surface disease such as dry eye, leading to patient discomfort and decline in quality of life. Drop burden and unwanted side effects all impact compliance rates. 

“A lot of us are trying to decrease the number of total drops and maybe even move toward some of the preservative-free agents for a lot of our patients,” Dr. Panarelli said. “I think the medication landscape is changing, but I think the biggest thing we have to keep in mind [is] cost and compliance with all of our patients. [We’re] trying to find the most effective medicine in the least number of bottles.”

For the first time in decades, two new classes of drugs have been introduced for the treatment of open-angle 

: latanoprostene bunod and netarsudil. The agents have different mechanisms of action and could be disease modifying. 

Netarsudil is a Rho-kinase inhibitor that targets the outflow pathway.

Rho kinase inhibitors: Filling a gap in glaucoma treatment 

Netarsudil is a drug for the treatment of 

. In the United States in 2017, the FDA approved a 0.02% ophthalmic solution for the lowering of elevated IOP in patients with open-angle glaucoma or ocular hypertension, targeting the trabecular meshwork directly. 

Netarsudil is unique in that “none of the other medicines out there on the market actually work at the level of the trabecular meshwork,” Dr. Panarelli said. “By inhibiting Rho-kinase, we’re able to relax some of the actin and myosin contractions. By relaxing those contractions, we’re able to enhance outflow through the physiologic outflow pathway.”

It has other mechanisms of action as well and has the potential to lower episcleral venous pressure (EVP). “[This is] something that we do not see with other medication classes,” Dr. Panarelli said. 
	
	

The Magnificent 7: How many glaucoma medications are too many?

Latanoprostene bunod is a new version of a prostaglandin that also has a nitric oxide donating moiety.

The exact mechanism of action is somewhat complex, according to Dr. Panarelli, but it’s believed to have a number of benefits including smooth muscle relaxation/enhanced outflow through the trabecular pathway as well as increased uveoscleral outflow.

Fixed-combination netarsudil/latanoprost is another new drug on the market, which was approved by the U.S. Food and Drug Administration in 2019.

 The once-daily drug also reduces IOP by enhancing aqueous outflow through both the trabecular and uveoscleral pathways. 

“What is unique about the netarsudil/latanoprost combination is this is really one of the first times we actually had a medicine go up against latanoprost alone,” Dr. Panarelli said. “Latanoprost is one of our bigger guns out there, so it is encouraging to see that we have these new medicines, and it’s nice to see data that does support good efficacy with these different agents.”
	
	

Although clinical trial data support the efficacy of these agents, how exactly to use them in the real world and in whom are questions clinicians are currently wrestling with. 

“It’s nice to have some new medicines that are out there on the market because I think they all fit into our armamentarium somewhere,” Dr. Panarelli explained. “I think, as clinicians, we are still figuring out exactly how to use these medicines and how to mix them in with our other available agents.”

If a patient is not responding on a prostaglandin analogue, Dr. Panarelli will switch them from either latanoprost to latanoprostene bunod or from latanoprost to combination latanoprost/netarsudil. He also believes there is a place for the medications in patients with low-tension glaucoma, who are traditionally some of the most difficult patients to treat.

Dr. Panarelli has found netarsudil to be particularly useful in these patients because it lowers EVP. 

“Some of my patients can get down to that single-digit range, which is a number I often cannot get with traditional carbonic anhydrase inhibitors, or alpha-2 agonists, or even beta blockers,” he said.
	
	

There are some situations in which Dr. Panarelli will use netarsudil as a first-line agent. 

For example, if a patient is uncomfortable with the potential side effects of increased iris pigmentation and periorbital fat atrophy that come with a prostaglandin analogue, he may recommend netarsudil. 

He may also recommend netarsudil if the patient is already on an oral beta blocker or is hesitant to start on a beta blocker generally. 

“I have had several patients where I  have talked about having surgery,” he said. “We started netarsudil, and it’s actually been great in that they have gotten to their target IOP without me having to perform a trabeculectomy, which is huge for my patients.”
	
	

Researchers find long-term statin use linked to lower POAG risk

are not yet approved but currently in development. For example, bimatoprost sustained release (bimatoprost SR) is a first-in-class, sustained-release, investigational, biodegradable implant for the treatment of open-angle glaucoma. 

If approved, Dr. Panarelli said he believes bimatoprost SR could be “a game-changer” in that it completely takes patient compliance out of the equation and significantly reduces the overall treatment burden glaucoma patients face.

With bimatoprost SR, “all we ask [patients] to do is to come once every several months to get their treatment,” Dr. Panarelli said. “This can have a meaningful impact for our patients. It is one thing to talk to a patient and tell them that they are going to have an injection once every four to six months for the rest of their lives, but if we can give a patient a loading dose of a medicine and not need to reinject them from anywhere from one to (maybe) three years, that will resonate well.”
	
	

Defining alternative therapies for glaucoma

The big unknown with the implant is safety. Will there be any complications or adverse effects from an injectable form of medicine delivered into the eye every six months?
	
	Although data are limited to abstracts presented during conferences such as the Academy of Ophthalmology and American Glaucoma Society, Dr. Panarelli considers the safety and efficacy of bimatoprost SR to be positive so far.

“We have questions regarding issues with the cornea, and we have concerns about infection,” Dr. Panarelli said. “One of the things that has impressed me most is the fact that a lot of patients (up to 80%) who receive three doses over the first year did not need to be rescued over the next year that they were followed.”

Initially, Dr. Panarelli sees a place for bimatoprost SR as a second-line treatment when a patient is progressing or not achieving the IOP reduction needed on a prostaglandin or after SLT.
	
	

Greater IOP-lowering potential with iStent inject


	
	Once clinicians become more comfortable with the injection and have less concerns about the safety profile, clinicians may start with the injection rather than topical therapy. 

“If we can show very good safety profiles for these medicines, I think we are going to see a lot of physicians using this treatment early in their treatment algorithm,” he said. 

One of the primary issues in glaucoma is patient compliance. Up to 60% of glaucoma patients are non-compliant with daily drops.

 The reasons for this are multifold.
	
	First,

patients are generally older (people over age 60 are at increased risk for the disease). Second, glaucoma is a life-long disease. Patients may tire of daily drops and may struggle with opening the bottle or even getting the drops in the eye correct as they age. 

“They physically have to open up the bottles and place it in their eyes every single day,” Dr. Bedrood said. “That act is very different than taking a pill, and it is oftentimes more difficult for patients.”

Cost is a frequent issue as well, as eye drops are often more expensive than generic medications for other conditions. To address this, Dr. Bedrood suggests providing patients with coupons and enrolling them onto special programs where they can get lower prices. 
	
	

Reimbursement remains a hurdle for teleglaucoma

 is also asymptomatic, causing patients to be less aware of their disease. 

“[Patients] think, ‘Oh, I am fine. I am not feeling anything, I am not seeing any differently, and I will skip my dose today,’” Dr. Bedrood pointed out.

Dr. Panarelli said ophthalmologists  talk about glaucoma being a silent thief. However, it can be an issue for patients. 

“That is a big problem for our patients,” he explained. “They don’t physically see the need often to come to these appointments, or they don’t see the need to take their drops quite like some other conditions that are possibly affecting them.”

Dr. Bedrood stresses the importance of having frank conversations with patients on the importance of compliance, and if compliance remains an issue telling them pointblank they could face surgery.

She recommends asking how they’re doing on the medication and if they are able to open the cap. She even asks them to demonstrate how they are administering the drops into their eyes to ensure they have the proper technique. 

According to Drt. Bedrood, clinicians can also involve family members and/or caregivers to help as well. 

“If a family member is present, I usually like to ask them, ‘Who is giving the drop, and how often?’ It places kind of an onus of responsibility on whoever is in the room to help with this whole regimen,” she said.
	
	

Practical tips, pearls to help ease patients' financial burdens

If compliance issues on drops persist despite these strategies for improvement, the patient is left SLT or minimally invasive surgery. Clinicians must make this clear.

“I talk about surgery with patients because it perks their ears up and they say, ‘Oh, wait, I do not want surgery,’” Dr. Bedrood said. “And sometimes it reminds them that maybe it is better for them to use the drops.”

Despite these potential challenges, both physicians agree that, with all the new agents on the horizon, it is an exciting time in the field of glaucoma. 

“The sustained release, the implants, the ocular inserts, all of these things promise a way to deliver medications without having the patients do it,” Dr. Bedrood said. “Having it in a very sustained, steady way is a really exciting part of our future in

. I think that it will really help our patients in the long-term.”
	
	

Dr. Panarelli has no financial disclosures related to this content.

Articles

Pharmacologic treatment an option for open-angle glaucoma

Nearly 50% of eyes with wet age-related macular degeneration (AMD) have stable or improved vision after long-term, 8-year pro re nata (PRN) treatment with ranibizumab, according to a group of U.K. clinicians.

Nearly 50% of eyes with wet age-related macular degeneration (AMD) have stable or improved vision after long-term, 8-year pro re nata (PRN) treatment with ranibizumab, according to a group of U.K. clinicians. Additionally, patients received a total of 31.6 mean injections during the same time frame, with fewer injections needed in year 8 (three) versus year 1 (six).

Horner et al. conducted a retrospective review of treatment-naÃ¯ve patients (86 patients, 95 eyes) treated with PRN ranibizumab from January to December 2009 and who completed 8 years of follow-up at the U.K. National Health Service, assessing the cohort’s visual letter gain or loss and number of injections.

The group then compared their findings with other pivotal studies on ranibizumab from the United States (SEVEN-UP), Belgium (Jacob et al.), and Australia (Gillies et al.).

The average age of patients was 72, and the majority were female. All patients were treated with standard of care ranibizumab, including three loading doses. (These baseline parameters were similar across all the studies evaluated as well.)

Patients were assessed on a monthly basis for the first 6 months and extended to 8 weeks if the treatment was efficacious. 
	Baseline median visual acuity (VA) was 61.1 letters. Patients experienced a mean loss of 9.1 ± 25.0 letters after 8 years, bringing their median VA to 54.9 letters. After the full follow-up period, nearly 50% of eyes had maintained or improved vision, with 11% gaining ≥ 15 letters; however, 34% lost ≥ 15 letters.

Table 1 compares the VA in this analysis to the other studies. The study authors point out that the highest visual gain was achieved after the initial loading-phase, with a subsequent steady decline, 26.3% (compared to baseline 33.4%) achieved driving vision standard

While the average number of injections was 31 over 8 years, half of the patients needed yearly injections, and a quarter of the patients were able to stop injections for a year or more due to stable or inactive disease.

Table 2 shows the injection frequency compared with the Australian and Belgian trials. Investigators did not compare their injection frequency to the SEVEN-UP trial.

Further, clinical trial cohorts do not typically translate to real-world settings, and clinicians frequently modify best-practice recommendations to accommodate the reality of the clinic and the patients seen. This study had a much lower rate of attrition (45%) than other longitudinal studies, where attrition has been reported to be as high as 89%.

In this analysis, vision gains were noted through year 2, but then declined steadily, findings that are comparable to SEVEN-UP.

  There was “little difference” in the mean injection frequency that would help explain the difference in VA compared with other studies, they said.

Finally, “our cohort results could also serve as useful, relevant information in counselling neovascular AMD patients in terms of expectation in visual prognosis and driving eligibility in 8 years of anti-VEGF therapy and for practitioners to plan for future local healthcare provision.”

Horner F, Lip PL, Clark H, Chavan R, Sarmad A, Mushtaq B. Real-World Visual And Clinical Outcomes For Patients With Neovascular Age-Related Macular Degeneration Treated With Intravitreal Ranibizumab: An 8-Year Observational Cohort (AMD8). Clin Ophthalmol 2019;13:2461-2467.
	2. Jacob J, Brie H, Leys A, et al. Six-year outcomes in neovascular age-related macular degeneration with ranibizumab. Int J Ophthalmol 2017;10:81-90.
	3. Rofagha S, Bhisitkul RB, Boyer DS, Sadda SR, Zhang K. Seven-year outcomes in ranibizumab-treated patients in ANCHOR, MARINA, and HORIZON: a multicenter cohort study (SEVEN-UP). Ophthalmology 2013;120:2292-9.
	4. Gillies MC, Campain A, Barthelmes D, et al. Long-Term Outcomes of Treatment of Neovascular Age-Related Macular Degeneration: Data from an Observational Study. Ophthalmology 2015;122:1837-45.

PRN ranibizumab outcomes over the long term in real world

An internationally renowned working group of retina specialists, ocular imaging experts, and ocular pathologists have suggested standardizing definitions for age-related macular degeneration (AMD) and its subtypes.

The group, called the Consensus on Neovascular AMD Nomenclature (CONAN), convened and collaborated with outside experts over the course of 3 years to create consistent definitions of AMD, its components, and its sub-classifications.1 (It should be noted that there is also the Beckman Classification, which was proposed in 2013).

The CONAN working group deemed standardization necessary because advances in retinal imaging have revealed other forms of AMD and nuances in pathology that previous definitions did not reflect.

CONAN defines AMD as “a process by which the structure and function of the macula deteriorates over time in association with distinguishing signs and symptoms that typically become evident clinically beyond 50 years of age and do not seem to be secondary to other processes such as pathologic myopia, central serous chorioretinopathy, monogenetic inherited retinal disease, chorioretinal uveitic syndromes or infections, or trauma.”

The group defined macular neovascularization (MNV) as “an invasion by vascular and associated tissues into the outer retina, subretinal space, or sub-retinal pigment epithelial (RPE) space in varying combinations,” with three subtypes:

Type 1 MNV is an ingrowth of vessels initially from the choriocapillaris into the sub-RPE space

Type 2 MNV refers to the proliferation of new vessels arising from the choroid into the subretinal space

Type 3 MNV refers to a downgrowth of vessels from the retinal circulation toward the outer retina (therefore, the term “choroidal neovascularization” is not accurate for this type of MNV)

CONAN noted there could be no “direct porting of the new terms to the old ones and vice versa exists because newer imaging technologies, such as OCT and OCT angiography, have an ability to detect abnormalities not imaged by color fundus photography or fluorescein angiography and have greater precision for many entities that are imaged using these technologies.”

For neovascular lesion nomenclature, the CONAN group proposed specific terms be used:

Type 3 neovascularization is to be used when the vascular complex originates in the retina.

Type 1 neovascularization is applied when the vessels originate from the choroid and remain under the RPE.

Type 2 neovascularization is denoted if neovascularization that originates in the choroid breaks through the RPE to reach the subretinal space.

The CONAN group followed the lead of the Classification of Atrophy Meetings group and adapted their definitions for non-neovascular AMD to describe atrophy in the context of neovascular disease.

However, the group was unable to come to a consensus on all definitions, despite acknowledging that the current nomenclature must change.

For example, CONAN notes that the term “polypoidal choroidal vasculopathy” is imprecise because a polyp is not a vascular aberration-it’s a solid tissue growth. A new, more accurate term-aneurysmal type 1 neovascularization-was suggested to replace polypoidal choroidal vasculopathy, but the group could not reach an agreement beyond the general inaccuracy of the current term. 

Importantly, CONAN notes that ocular coherence tomography (OCT) and OCT-angiography (OCT-A) should not replace fluorescein angiography or color photography; rather, OCT and OCT-A should be considered complimentary imaging, providing clinicians with additional data to help classify disease type and staging.

The group also recommends diagnosing AMD by patient and not by eye because measures to stave-off AMD development and progression, such as vitamin supplements, are given to the whole person.

Finally, the CONAN group acknowledges that to keep pace with advances in imaging modalities, these standardized definitions must be updated as clinician understanding of AMD pathology improves.

As advances in retinal imaging have furthered the understanding of how AMD develops, progresses, and appears, the way researchers and clinicians speak about the disease must evolve with it.

The CONAN group recommends their definitions be immediately incorporated into future clinical trials and studies on AMD. The CONAN group believes that unifying the definitions will help researchers speak the same language across the literature, thereby assisting in comparing trial outcomes and reducing confusion.

Lastly, the group also believes an extension of the proposed terminology will be developed to describe disease severity in neovascular AMD.

1. Spaide RF, Jaffe GJ, Sarraf D, et al. Consensus Nomenclature for Reporting Neovascular Age-Related Macular Degeneration Data: Consensus on Neovascular Age-Related Macular Degeneration Nomenclature Study Group. Ophthalmology 2019 Nov 14. pii: S0161-6420(19)32243-2. doi: 10.1016/j.ophtha.2019.11.004. [Epub ahead of print]
	2. Ferris FL, Wilkinson CP, Bird A, et al. Clinical classification of ageârelated macular degeneration. Ophthalmology 2013; 120: 844–851.

Consensus group redefines, standardizes AMD classifications 

Optometry Australia’s chairside reference suggests limiting the use of terms such as “age-related maculopathy,” “wet,” and “dry” AMD, and instead use the Beckman classification

Optometry Australia has developed an AMD chairside reference in consultation with a member-based working group comprised of experienced practitioners. It provides an evidence-based approach to current best practice in the diagnosis and management of AMD.

(In the U.S., the most recent guideline from the American Optometric Association [AOA] was reviewed in 2004.) The AOA does recommend antioxidant nutritional supplementation (e.g., vitamins C, E, beta-carotene and zinc), as they may prevent or impede the progression of AMD. The anti-oxidants in these supplements may convert free radicals into stable compounds before they interact with cell membranes to produce damage.

Optometry Australia’s chairside reference suggests limiting the use of terms such as “age-related maculopathy,” “wet,” and “dry” AMD, and instead use the Beckman classification.

The Beckman Initiative for Macular Research classification scheme is based on clinical exam (using an ophthalmoscope or slitlamp with accessory lenses) or evaluation of a fundus photo. In patients older than 55, small drusen are less than half the vein width (< 63 Î¼m), medium drusen are between half and oneâfull width of the vein (63–125 Î¼m), and large drusen are wider than 125 Î¼m.

Of particular importance is the increased risk (to about 47%) of developing late stage AMD if a person has both large drusen and pigmentary abnormalities in both eyes (which is considered intermediate AMD).

Table 1 shows the 5-year risk of progression to late AMD.

Finally, the Beckman classification scheme renames geographic atrophy as complete retinal pigment epithelium and outer retinal atrophy in the absence of choroidal neovascularization.

OD assessments equal to ophthalmologists’

A recent U.K. study found optometrists were as effective at identifying developments in AMD as ophthalmologists, and that “shared care with optometrist monitoring quiescent wet AMD lesions has the potential to reduce workload in hospitals.”

The study found 84.5% of optometrists (n = 48) and 85.4% of ophthalmologists (n=48) classified lesions correctly. One finding of the study of potential interest, however, is that optometrists were more cautious and more likely to reclassify a lesion as re-activated.

These results clashed with an earlier study, however, that found optometrists were less able to recognize macular edema and drusen, although they “perform satisfactorily” in identifying the symptoms.

At the time, it was suggested additional training may improve diagnostic outcomes. That may have been borne out by a study

 published last year. In that, it was suggested that optical coherence tomography (OCT) improves optometrists’ diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment caseâfinding for glaucoma and retinal disease.

Patient education at the time of diagnosis is a crucial component of treatment, but also involves a significant amount of chair time. (It is often recommended that family members be present during the initial consultation.) Not all patients with AMD will develop vision loss, and not all patients who do develop vision loss will go blind, two points that need to be emphasized when talking to patients.

Finally, eyecare professionals in Australia considered poor care pathways, people with AMD having a poor disease understanding / denial, and cost of care / lack of funding, as the most significant barriers to AMD care; they considered shared care model, access, and communication as the most significant enablers to good AMD care.

1. Hart KM, Abbott C, Ly A, et al. Optometry Australia’s chairside reference for the diagnosis and management of age-related macular degeneration. Clin Exper Optom 2019. DOI:10.1111/cxo.12964
	2. Ferris FL, Wilkinson CP, Bird A, et al. Clinical classification of ageârelated macular degeneration. Ophthalmology 2013; 120: 844–851
	3. Ferris FL, Davis MD, Clemons TE, et al. A simplified severity scale for ageârelated macular degeneration: AREDS Report No. 18. Arch Ophthalmol 2005; 123: 1570–1574.
	4. Reeves BC, Scott LJ, Taylor J, et al. Effectiveness of community versus hospital eye service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial. BMJ Open 2016;6:e010685. doi:10.1136/bmjopen-2015-010685
	5. Muen WJ, Hewick SA. Quality of optometry referrals to neovascular age-related macular degeneration clinic: a prospective study. JRSM Short Rep. 2011;2(8):64. doi:10.1258/shorts.2011.011042
	6. Jindal A, Ctori I, Fidalgo B, Dabasia P, Balaskas K, Lawrenson JG. Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study. Ophthalmic Physiol Opt. 2019;39(3):205–215. doi:10.1111/opo.12613
	7. Jalbert I, Rahardjo D, Yashadhana A, Liew G, Gopinath B (2020) A qualitative exploration of Australian eyecare professional perspectives on Age-Related Macular Degeneration (AMD) care. PLoS ONE 15(2): e0228858. https://doi.org/ 10.1371/journal.pone.0228858

Author | Michelle Dalton, ELS

Articles

Pharmacologic treatment an option for open-angle glaucoma

PRN ranibizumab outcomes over the long term in real world

Consensus group redefines, standardizes AMD classifications

Diagnosing AMD for the non-retina specialist