Eyeworld

117 EW GLAUCOMA September 2015 Doctors need to know how many points to reduce eye pressure by and have to document pressure at each visit." In a chart review study he con- ducted, 2 Dr. Quigley noted that less than one-fifth of patient charts had a documented target pressure. "To- day, electronic patient records have a location for target pressure and a graph function showing progress. A patient's pressure appears as a green line, informing you if you're above or below the mark. "I think it is coming that a doctor is going to have to achieve a certain standard of care. Quality measures are going to require that you set and achieve your target." Dr. Quigley said that in his opinion, the target pressure is typi- cally never less than 20% below the untreated baseline, usually between 20–40%. He measures the baseline pressure 3 times during the course of the day, at 3 different visits. This approach gives him a reasonable and practical estimate of untreated IOP. "The problem in glaucoma is that the damaging pressure varies from patient to patient, and many of those with glaucoma have what is considered to be 'normal' eye pres- sure. That is why we no longer try to 'normalize' pressure—we shoot for a target at least 20% below the patient's untreated baseline pressure to prevent further glaucomatous damage," Dr. Quigley said. EW References 1. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deteriora- tion. The AGIS Investigators. Am J Ophthalmol. 2000; 130:429–440. 2. Quigley, HA, Friedman DS, Hahn SR. Evaluation of practice patterns for the care of open-angle glaucoma compared with claims data: the Glaucoma Adherence and Persistency Study. Ophthalmology. 2007 Sep;114(9):1599–606. Editors' note: Dr. Palmberg has financial interests with AqueSys and InnFocus. Drs. Brown and Quigley have no financial interests related to this article. Contact information Brown: reaymary@comcast.net Palmberg: ppalmberg@med.miami.edu Quigley: hquigley@jhmi.edu The technique gives us more of a pressure estimate, with different technicians potentially reading a different value. We shouldn't live by that number. I wouldn't want my doctor recommending surgery just because my pressure was above the target," he said. Another factor throwing off IOP measurements is central corneal thickness, which causes clinicians to either underestimate the pressure if the cornea is thin or overestimate it if the cornea is thick, with no reliable way to adjust for the discrep- ancy. Dr. Brown prefers to base his decisions on clinical factors such as changes in the visual field—which he said are more conclusive and cumulatively meaningful. "I work to reduce the IOP like anyone else treating glaucoma, but I don't want my therapeutic goal to be achieving a red line target pressure. Glaucoma care is complex and our treatments—especially sur- gery—have significant side effects. So basing treatment on an aggressive target pressure may expose the pa- tient to greater risks. These risks may be avoidable since for each person we only know in retrospect whether a particularly low pressure goal was necessary." Dr. Brown said that target pressure sets patients up for failure. "Glaucoma as a disease is very fear- based. Patients naturally are afraid of blindness. If you declare a target IOP and don't reach it every visit, the patient will be upset. Some patients will be very concerned if they are even a single millimeter above the target, so you will spend a great deal of chair time reassuring them. I think we make a tactical error with our patients when we reduce our complex glaucoma therapy to a single number." Target pressure as a benchmark Helping patients is what target pressure is all about, according to Harry A. Quigley, MD, director of the Glaucoma Center of Excellence, Wilmer Eye Institute, Johns Hopkins University, Baltimore. "Setting a target pressure is a logical approach, and it works. Glaucoma therapy needs to have a goal. Setting a target pressure allows you to see if you are achieving that goal and that the therapy is working, and ultimately that you are helping the patient. A F R E S H P E R S P E C T I V E ™ © 2015 Lacrivera, a division of Stephens Instruments. All rights reserved. 2500 Sandersville Rd ■ Lexington KY 40511 USA lacrivera.com ( 855 ) 857-0518 William J. Faulkner, M.D. Cincinnati Eye Institute The VeraPlug ™ challenge results are in. Try the VeraPlug. ™ What will you say? "The VeraPlug ™ has become my punctal plug of choice. Design features allow easy sizing, quick insertion and longer stability. Both patient and doctor are pleased."

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