EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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32 EW GLAUCOMA December 2013 February 2011 Pharmaceutical focus Getting glaucoma patients on track by Maxine Lipner EyeWorld Senior Contributing Writer Pharmaceutical education and compliance pearls 'I'm fine if I occasionally take my medication' is wrong." Successful patient education, in his view, is based on the relationship with the treating team of ophthalmologists, as well as the support staff. "I think that it's a continuing process, and it starts when they first meet the practice and learn about the disease," Dr. Lewis said. "In our case when [patients] come in we have brochures and videos and then they interact with our staff." After that he finds it is a continuing process of education and keeping patients up to date. F or patients with glaucoma, medication often becomes a fact of life, according to Louis B. Cantor, MD, professor and chairman, Indiana University School of Medicine, Indianapolis. "The average glaucoma patient is diagnosed somewhere in the fourth or fifth decade of life, and approximately half of those who are diagnosed with glaucoma can be controlled medically," Dr. Cantor said. "Those patients that can be controlled medically are therefore, on average, going to be on therapy for at least three decades or more. Fully one-third to one-half of patients, when they get their initial diagnosis and prescription, may not even (bother to) get the medicine," Dr. Cantor said, citing the work of Alan Robin, MD. Education challenges Educating patients on how serious glaucoma is can be challenging, Dr. Cantor pointed out, describing his approach to each new patient. "On every desk in my office we have plastic 3D eye models. I take it apart and show them where the drains are in the eye and tell them that when these aren't working, that's when the pressure builds up. I explain that high pressure in the eye can damage it, and that the weak spot for pressure effects is in the back of the eye where the nerve is." He likens this to the main telephone cable that carries all the messages from the eye back to the brain and stresses to patients that if they lose that nerve, they can potentially lose all vision. "However, I also explain that glau- Compliance tips coma is very complex and that the eye pressure can be elevated and not cause glaucoma, and that many patients with glaucoma may have a normal eye pressure. Regardless, our best proven treatment for glaucoma nerve damage is to lower the eye pressure." Dr. Cantor then explains how medications can help and tell patients how to use these. "How effective that conversation is, I don't have a clue because we usually never get feedback," he said, noting that there's a breakdown in the loop when it comes to physician, pharmacy, and patient. "We have no idea if the patient even shows up and fills the prescription," he added. He presented some data on this at the Association for Research in Vision and Ophthalmology meeting some years ago. "A lot of patients don't refill their medicines when they should, based on how many times a day they're using the drops and how many drops are in the bottle," he observed. "Others try to get refills too frequently because they're wasting it." Instead of putting in one drop at a time, it's possible that they may put in two or three or forget that they took it and put in an extra one. Either way this can lead to gaps in therapy, he said. If patients run out of drops after two weeks and can't afford to buy more because it is too soon for their insurance to pay for a refill, this may be an issue. Richard A. Lewis, MD, Sacramento, Calif., finds that patients are often under the misconception that treatment cures their glaucoma, and he encounters some compliance issues. "Medication doesn't cure it, it treats it and controls the pressure," he said. "So the misconception that tients will come off at least some of their medications. The advantage to TCP is that it is repeatable, and to avoid giving too much of the laser, Dr. Sarkisian recommends avoiding the 3 o'clock and 9 o'clock positions. Being overaggressive in treating those areas can lead to patients ending up with neurotrophic corneal ulcers. Dr. Sarkisian will make exceptions—he'll opt to use TCP in eyes with silicone oil rather than use a tube shunt. "Those are often single chamber eyes and the oil gets into the tube, so it's likely you won't get satisfactory results," he said. EW Diode continued from page 30 poor visual prognosis. To put them through the rigors of conjunctival filtration surgery and all the postop required is unrealistic for someone who has light perception or hand movement visual acuity," as the visual prognosis is typically more limited. With TCP and ECP, Dr. Parekh always uses subconjunctival steroids to minimize postoperative inflammation. In addition, he'll then keep patients on topical steroids four times daily for a month. Usually, pa- Editors' note: The physicians have no financial interests related to this article. Contact information Parekh: parag2020@gmail.com Sarkisian: steven-sarkisian@dmei.org Determining who is having trouble sticking to a glaucoma medical regimen can be difficult, Dr. Lewis said. However, in cases where it is apparent such as when someone has severe arthritis and can't put drops in, Dr. Lewis opts for surgery instead so that he can avoid chronic drop therapy. "It's a good choice," he said. "You can't assume that patients with Alzheimer's are going to be putting drops in, and their caretakers may or may not be effective at getting the medication in." Dr. Cantor agreed that it can be difficult to determine who is compliant. He recommends asking patients if they're having problems with their drops, as well as how many times they miss their drops in an average week. He finds that if he asks if they're having trouble following the regimen, the answer is invariably, "No." For those who are having difficulty Dr. Cantor recommends simplifying the regimen and prescribing one drop once a day. "Make sure that you're using the most effective drop possible," he said. "Sometimes patients will do just as well on one drop as they will on two because the two in that combination is not as effective and they should be on something else." Also, compliance can fall off with the second drop. Dr. Cantor suggested tying drop instillation to something else that the patient does everyday or taking the drop at easier-to-remember times such as once in the morning and once in the evening. Even with once-a-day medication, such as prostaglandin drops, Dr. Cantor urges flexibility in telling patients when to administer these. "We