Eyeworld

EW FEATURE 64 February 2011 GLAUCOMA February 2011 ing the medications over time is alarming. Various studies have shown that 25% of Medicare glau- coma patients filled one prescription and never filled a second one. "They didn't get to the end of the year and they didn't get to the second pre- scription," Dr. Quigley said. "In that study, we don't know how many pa- tients were handed a prescription and never filled the first one." Because glaucoma is asympto- matic, patients have no physical symptoms reminding them to take their medicine, which is one of the biggest problems. "People don't see the benefits," Dr. Goldberg said. "They don't see the drops making them better. They don't see an improvement in their sight because the drops don't do that. They can't feel that their pres- sure is 12 instead of 22. All they feel and experience are the challenges and side effects." "If patients got a headache every time they forgot to take their eye drops for glaucoma, they'd take their eye drops," Dr. Quigley said. "But patients don't have any symp- toms." One possible solution to the ad- herence problems in developed countries is patient reminder sys- tems, such as an eye drop bottle that rings an alarm every 24 hours or beeps annoyingly until used. Robo calls or daily reminder e-mails can have the same effect, as nowadays more people check e-mail multiple times a day. Diagnosis and screening are other challenges in the U.S. Regard- less of where in the world the glau- coma patient lives, be it North American or North Africa, most peo- ple are unaware they have the dis- ease despite routine eye checkups. "A very large number of those undiagnosed went past an op- tometrist or ophthalmologist within the last year," said Dr. Quigley. "They are largely being missed be- cause doctors are still relying on eye pressure instead of on the examina- tion of the optic disk and doing the appropriate number of visual field tests." Dr. Quigley believes the glau- coma blindness rate in the devel- oped world could be significantly decreased if ophthalmologists in- creased the surveillance of high-risk populations. One of the ways to do that is by examining family history. "If patients have a mother or fa- ther with glaucoma, their chance of getting the disease goes up five times," explained Dr. Goldberg. "If they have a brother or sister with glaucoma, their chance of getting it goes up nine times." Another developed-world issue is the appropriateness of how glau- coma patients are treated, which means finding and treating those patients who are at a significant risk of going blind fast and not over- treating those patients who will never in their life be visually im- paired from the disease. "We could be taking much bet- ter care of glaucoma patients with the same amount of money if we got smarter about it," he said. "The aver- age glaucoma patient in the U.S. is seen four times a year. We don't need to see stable glaucoma patients four times a year. The one-size-fits- all approach we've been taking is wasting a lot of time, effort, and, more importantly, money we don't have." Glaucoma patients are also in need of improved management op- tions across the world, but develop- ment has been slow and cumbersome. The Rho-kinase in- hibitors are "probably closest in terms of a pathway," according to Dr. Quigley. In 2009, Aerie Pharma- ceuticals (Bridgewater, N.J.) an- nounced positive results from a Phase IIa study of these inhibitors for open-angle glaucoma, demon- strating lowered IOP with both once-daily and twice-daily treatment with minimal side effects. "There are a number of viral vector delivered medicines that are potentially useful but not in Phase III," said Dr. Quigley. "Frankly, the drug companies are all sitting there with their motors idling. Two of the largest drug companies in the U.S. that formerly did drug development for glaucoma have no apparent ac- tivity in their research groups. One of the companies would much rather produce cosmetic products than pressure-lowering eye drops. When you only have 2.5 million Americans with glaucoma, maybe that's not a big enough market com- pared to all the ladies who want longer eyelashes." "What we have available now for glaucoma treatment is far from ideal in the sense that we cannot cure glaucoma, which is very disap- pointing after centuries of research," agreed Dr. Melamed. "At best, we can keep it at bay and we should as- pire for something better than that." EW Editors' note: The physicians inter- viewed have no financial interests re- lated to their comments. Contact information Goldberg: eyegoldberg@gmail.com Melamed: melamed.choka88@gmail.com Quigley: hquigley@jhmi.edu Shaarawy: tshaarawy@yahoo.com Glaucoma continued from P. 62 58-81 Feature_EW February 2011-DL2_Layout 1 2/4/11 2:29 PM Page 64

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