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EW GLAUCOMA 100 October 2015 efficacy choices, but no low-risk, high efficacy choices," he said, advising that patient profiles and disease severity will dictate the selection of the most appropriate procedure. Advancing therapy When our first intervention fails to lower IOP adequately, additional measures are called for. Commonly, patients will require multiple drugs for IOP control. The question frequently arises: How many drops is too many? In terms of maximally toler- ated medical therapy, Dr. Fechtner pointed out, "We don't know what is maximally tolerated until we add the drug that is not tolerated." He prefers to think in terms of rational medical therapy, which he describes as 3 drugs in as few bottles as possible. "Choose the drugs you prefer and add them in your pre- ferred order," he said. Long-term monitoring Once the decision has been made to treat, a target IOP has been set and achieved, future care focuses on as- sessing IOP for adequacy of control and monitoring for any evidence of progression. Dr. Fechtner noted that even if target IOP is well maintained, pro- gression can still occur if our target estimate was incorrect. "We cannot know the adequacy of our target IOP except in retrospect. IOP was low enough if the patient did not progress to visual disability." Dr. Grehn agreed. "Success is not an IOP number—it is to keep the best possible vision to provide the patient with a good quality of life." EW Editors' note: The physicians have no financial interests related to this article. Contact information Brandt: jdbrandt@ucdavis.edu Fechtner: Fechtner@njms.rutgers.edu Grehn: grehn_f@ukw.de Liebmann: jml18@earthlink.net 25–30% IOP reduction," said Jeffrey Liebmann, MD, New York. He added that laser therapy can also reduce the medication burden for some patients who require mul- tiple medications for adequate IOP control. "Laser trabeculoplasty is essen- tially a fire-and-forget approach to glaucoma therapy that effectively reduces polypharmacy, but the laser effect does diminish over time," he said. Initial surgery for glaucoma has been suggested by some in the past, although major clinical trials have not supported the practice for most patients. Nevertheless, an occasional patient will present with features of glaucoma that prompt consideration of initial surgery. According to Franz Grehn, MD, Germany, those features include "very high pressure unlikely to be controlled with medical therapy alone, advanced damage in the fellow eye, threats to fixation, as well as intolerance or incapability of medication use." As for the correct procedure for a given patient, Dr. Grehn pointed out that there are many options, each with its own benefits and risks. "We have low-risk, moderate efficacy choices and high-risk, good of developing significant vision loss in their lifetime." Setting goals A target pressure is a useful way to set a therapeutic goal for a patient. "Patients in clinical studies with a target IOP fare better than those without a target IOP," said Robert Fechtner, MD, Newark, N.J. "Setting a target IOP is one of the least evidence-based tasks I per- form," Dr. Fechtner said. What should the target IOP be? "There is no magic number," he said. There is no formula, nor any prospective studies to guide the determination of an optimal target IOP. Instead, the process remains a clinical judgement based on known risk factors for progression. "Target IOP varies between patients—even between eyes—and can change over the patient's lifetime," he said. Laser and surgical options Laser therapy is slowly gaining trac- tion as a viable first line therapy for glaucoma. Many patients prefer laser as a means of avoiding the hassles and potential side effects of topical medications. "Initial laser trabeculoplasty is a reasonable first line option for many patients and provides, on average, G laucoma remains a lead- ing cause of irreversible blindness in the U.S. and globally and represents one of the more com- mon reasons why patients visit the eyecare provider's office. In recent years the number of therapeutic options for initial glaucoma ther- apy has skyrocketed, with new drugs, laser techniques, and surgical procedures. Clinical practice pat- terns are constantly evolving. At the recent biannual meeting of the World Glaucoma Congress in Hong Kong, a panel of experts discussed the current status of initial glaucoma management. To treat or not to treat Glaucoma suspects present a unique challenge. Many will never devel- op glaucoma and thus would not benefit from treatment. Others are destined for glaucoma, and this can be delayed or even prevented with early therapy. How do we decide which patients warrant treatment? We have tools to help with this task. "Our risk assessment tools are getting better every year," said James Brandt, MD, Sacramento, "al- lowing us to focus our surveillance efforts and treat only our highest risk patients." The best of these is the risk cal- culator derived from the combined data sets of the Ocular Hypertension Treatment Study and the European Glaucoma Prevention Study. This tool, available at ohts.wustl.edu/risk/ calculator.html, incorporates known risk factors and provides an estimate of the risk of developing glaucoma within 5 years. This information can assist in determining whether a given patient's risk profile warrants treatment or not. The goal of therapy is not to prevent small visual field defects, but rather to ensure that the patient has adequate visual function to maintain quality of life throughout his or her lifetime. "Most patients do not care about preperimetric glaucoma or even small peripheral defects," said Dr. Brandt, "but they do care about the hassles of daily eye drop therapy and symptomatic vision loss. We should strive to find the balance and avoid treating patients with low risk Tips for initiating medical therapy for glaucoma by Tony Realini, MD, MPH, EyeWorld Contributing Writer

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