Eyeworld

EW INTERNATIONAL 68 August 2016 risk in ocular hypertensive patients and treat patients with low risk of developing glaucoma. These pa- tients might be better off if observed closely without treatment over time. In other patients, we may fail to recognize that therapy is ineffective and continue its use unnecessarily, gaining only side effects without efficacy." In addition to local side effects, some of our medications have sys- temic issues that often go unrecog- nized. "Don't overlook systemic side effects of our treatments," Dr. Shah said. "For instance, beta blockers are associated with depression, sleep dis- turbances, and even increased risk of admissions to hospital. In addition, many elderly patients have mild car- diopulmonary disease and may be unaware of it—our treatments may unmask these conditions." Clinical implications As clinicians, we strive to provide the best possible medical care for our patients. Optimizing therapy and controlling the disease is a major factor in preventing visual dysfunction and preserving quality of life for our patients. Sometimes, though, they need more than the best new medication or diagnostic test. Dr. Shah said, "Our relationship with our patients is one of the key determinants of their quality of life along the glaucoma journey." He emphasized that the time taken to educate patients about their disease and its prognosis can go a long way toward dispelling their fears. A long-time patient with glauco- ma treated at Moorfields Eye Hospi- tal in London reinforced this point. "The best providers give patients the courage to ask as many ques- tions as they need to," the patient said. "To help manage my condi- tion, I want to be able to discuss it with authority." EW Editors' note: Drs. Fechtner, Shah, and Somner have no financial interests related to their comments. Contact information Fechtner: Fechtner@upstate.edu Shah: Peter.shah@uhb.nhs.uk Somner: jsomner@googlemail.com by Tony Realini, MD, MPH home, and are overall less active," he added. Treatment and quality of life In its early and even moderate stages, glaucoma is often asymptom- atic. The treatments we prescribe, however, are not. Said Peter Shah, MBChB, Birmingham, U.K., "In the battle to save the optic nerve head and the eye, it's easy to forget that our treat- ments have an effect on the patient's psychosocial condition." Eye drop medications can cause ocular irritation, redness, and blurry vision, among other side effects. Also, Dr. Shah said, "Ocular surface disease (OSD) is common in glauco- ma patients and is affected by our treatments. Benzalkonium chloride and other excipients contribute to OSD in these patients. Most OSD is initially occult—it begins as dry eye and blepharitis but can spiral out of control in some patients." Strategies for minimizing this problem include reducing polyphar- macy with the use of fixed combi- nations where appropriate, using preservative-free medications in pa- tients who poorly tolerate preserved formulations, and ensuring that patients are not being unnecessarily overtreated. "We overtreat some of our glau- coma patients," Dr. Fechtner said. "This occurs for a variety of reasons. In some cases, we may overestimate visual function and related quality of life, at a sustainable cost," accord- ing to the guidelines. The sentiment is shared by glau- coma specialists on this side of the Atlantic as well. "For our patients, the ideal goal of therapy is to preserve quality of life to allow sufficient independence and dignity," said Robert Fechtner, MD, Syracuse, New York. Many aspects of the disease pose a challenge to quality of life. At the 2016 European Glaucoma Society meeting, an international panel of glaucoma experts discussed strate- gies for optimizing quality of life in patients with glaucoma. Diagnosis and quality of life Much of the adverse impact of glau- coma on quality of life comes early in the care process. "The Collaborative Initial Glau- coma Treatment Study demonstrated an immediate drop in quality of life upon diagnosis," said John Somner, MBChB, Norwich, U.K. "When you give patients the diagnosis of glauco- ma, they have a lot of worry." In addition to the obvious fear of going blind, they also have concerns about falling, being unable to drive, and losing their indepen- dence, he said. As the disease progresses, some of these fears become reality. "Pa- tients with advanced glaucoma go out less often and travel less far from At the 2016 European Glaucoma Society meeting in Prague, an international panel of glaucoma experts discussed strategies for optimizing quality of life I n clinical practice, it is too easy to reduce glaucoma to a series of numbers: intraocular pressure (IOP), cup-disc ratio, mean de- fect of visual field, retinal nerve fiber layer thickness. These numbers drive all of our glaucoma-related clinical decisions: whether or not glaucoma is present, whether or not to treat, what the target IOP should be, what treatment to offer, whether or not treatment is effective. In all of these numbers and decisions, one key component is missing: the patient—or, more accurately, the patient's experience of living with glaucoma. In other words, quality of life is missing. The European Glaucoma Society has crafted a comprehensive set of guidelines for the evaluation and management of glaucoma. During a presentation at the 2016 Euro- pean Glaucoma Society meeting, a group of doctors noted that the evidence-based guidelines were de- veloped with one overarching goal in mind. "The goal of glaucoma treat- ment is to maintain the patient's Preserving quality of life during glaucoma treatment

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