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surgical approaches for a variety of patients. Case No. 1: Primary open-angle glaucoma This patient is an 83-year-old Caucasian female with primary open-angle glaucoma (POAG), with significant optic nerve dam- age; C:D 0.9. Intraocular pressure (IOP) is 14 mm Hg in the right eye on one med and 23 mm Hg in the left on three meds. She is bilaterally pseudophakic. She had undergone prior Ahmed glaucoma valve in the right eye, but de- veloped strabismus and diplopia postoperatively. by Brian A. Francis, MD, MS Individualizing glaucoma surgery V irtually every one of our glaucoma pa- tients is a potential surgical candidate at some point in their treatment. There are a multitude Brian A. Francis, MD, MS continued on page 7 of procedures that can bene- fit our patients—from inflow procedures such as endoscopic cyclophotocoagulation (ECP) to transscleral cyclophotocoag- ulation, to outflow procedures such as trabeculectomy, shunts and suprachoroidal filtration. The latest approaches include microinvasive glaucoma surgery (MIGS) by internal approach to the trabecular meshwork, filtering surgery by external approach, and suprachoroidal surgeries. We can now individualize our approach, and we should be customizing our treatments. There's no one glauco- ma surgery that's appropriate for every patient. The remainder of this article will illustrate different " We should be customizing our [surgical] treatments. " –Brian A. Francis, MD, MS least 2 medications to reduce pres- sure by 20% after 5 years. 11 The literature suggests only a modest additional IOP reduction from sin- gle-agent adjunct, 12 and there are more than 56,000 potential com- binations from which to choose. 13 Combination therapies simplify treatment. Several are marketed currently; a prostaglan- din plus a fixed combination is a realistic maximal therapy for many patients. References 1. Friedman DS, Quigley HA, Gelb L, et al. Using pharmacy claims data to study adher- ence to glaucoma medications: methodolo- gy and findings of the Glaucoma Adherence and Persistency Study (GAPS). Invest Ophthalmol Vis Sci. 2007;48(11):5052–7. 2. Deokule S, Sadiq S, Shah S. Chronic open angle glaucoma: patient awareness of the nature of the disease, topical medication, compliance and the prevalence of sys- temic symptoms. Ophthalmic Physiol Opt. 2004;24(1):9–15. 3. Stewart WC, Konstas AG, Pfeiffer N. Patient and ophthalmologist attitudes concerning compliance and dosing in glau- coma treatment. J Ocul Pharmacol Ther. 2004;20(6):461–9. 4. Patel SC, Spaeth GL. Compliance in patients prescribed eyedrops for glaucoma. Ophthalmic Surg. 1995;26(3):233–6. 5. Konstas AG, Maskaleris G, Gratsonidis S, Sardelli C. Compliance and viewpoint of glaucoma patients in Greece. Eye (Lond). 2000;14 Pt 5:752–6. 6. Hennessy AL, Katz J, Covert D, et al. A video study of drop instillation in both glaucoma and retina patients with visual impairment. Am J Ophthalmol. 2011;152(6):982–8. 7. Sherwood MB, Craven ER, Chou C, et al. Twice-daily 0.2% brimonidine-0.5% timolol fixed-combination therapy vs. monothera- py with timolol or brimonidine in patients with glaucoma or ocular hypertension: a 12-month randomized trial. Arch Ophthal- mol. 2006;124(9):1230–8. 8. Kholdebarin R, Campbell RJ, Jin YP, Buys YM. Multicenter study of compliance and drop administration in glaucoma. Can J Ophthalmol. 2008;43(4):454–61. 9. Richter A, Anton SE, Koch P, Den- nett SL. The impact of reducing dose frequency on health outcomes. Clin Ther. 2003;25(8):2307–35; discussion 2306. 10. Myers JS, Vold S, Zaman F, et al. Bi- matoprost 0.01% or 0.03% in patients with glaucoma or ocular hypertension previously treated with latanoprost: two random- ized 12-week trials. Clin Ophthalmol. 2014;8:643–52. 11. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Oph- thalmol. 2002;120(6):714–20; discussion 829–30. 12. Tanna AP, Rademaker AW, Stewart WC, Feldman RM. Meta-analysis of the efficacy and safety of alpha2-adrenergic agonists, beta-adrenergic antagonists, and topical carbonic anhydrase inhibitors with prostaglandin analogs. Arch Ophthalmol. 2010;128(7):825–33. 13. Realini T, Fechtner RD. 56,000 ways to treat glaucoma. Ophthalmology. 2002;109(11):1955–6. Dr. Radcliffe is on staff at Weill Cor- nell Eye Associates, New York. He can be contacted at 646-962-2020 or drradcliffe@gmail.com. " We've yet to agree on a universal description about how many drops over what course of time defines 'non-compliance.' " –Nathan Radcliffe, MD continued from page 4 Innovating advanced treatments to increase compliance and improve outcomes for glaucoma patients 6

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