Eyeworld

EW GLAUCOMA 78 February 2017 by Maxine Lipner EyeWorld Senior Contributing Writer even the most aggressive treatment continue to get worse, which is where genetics play a role. "The only way to separate the ones who are do- ing badly from the ones who are do- ing well is to follow them regularly," he said. Another way to look at it is to realize that some patients are des- tined to do poorly with this all-too- common condition due to a trifecta of noncompliance, lack of follow-up, and bad genetics. "You can't change their genetics, and compliance with medications is difficult to measure, much less influence. Perhaps the easiest factor to influence is making sure that you keep them in the sys- tem and observe them carefully with the knowledge that there are many treatment options for those getting worse, including medications, laser, and surgery, with the latter two re- moving the burden on the patient to instill eye drops," Dr. Singh said. "If they follow up regularly and are fast progressors, whether or not they're compliant, they're still going to need more aggressive treatment, in- cluding possibly surgery." Whether patients are compliant and worsen or noncompliant and worsen, the upshot is the same, he said, adding that in either situation you do have to consider surgical options. Dr. Lewis agreed that noncom- pliance with follow-up is more serious than noncompliance with medical therapy. "Those are the patients who in my 30-plus years of practicing are the most disturbing— the patients in whom you diagnose it and they don't respect the disease and come back 10 or 15 years later with pronounced advancement of the disease simply because they didn't bother to come in," Dr. Lewis said. On the other hand, a patient who is noncompliant with the treat- ment regimen may not do poorly since many of the drugs last awhile. "If they took the drug three times a week, they might be fine," he said. "But patients who don't show up for years are putting themselves at much more risk." In cases where patients are being careless with their day-to-day treatment regimens, there are some practical measures that physicians can take, Dr. Lewis said. Writing out the exact time and day they should be taking their medication is important. For example, physicians can give patients a sheet of paper not, according to Richard Lewis, MD, Sacramento, California. "With any chronic disease, you depend on patients to comply and adhere to their medical regimen in order to control that disease. With glaucoma in particular—with no symptoms— it's not always easy," he said. "Study after study shows that about half of patients don't comply for a million different reasons." Here, physicians discuss issues related to compliance and offer strategies to encourage patients to adhere to regimens. Compliance can be a complex issue, said Kuldev Singh, MD, pro- fessor of ophthalmology, Stanford University School of Medicine, Stan- ford, California. "Obviously, when you recommend a treatment, you're assuming that when people follow that treatment they're going to do better than when they don't," he said. "So compliance is important." However, determining how import- ant compliance is relative to other factors when it comes to preserving vision in glaucoma patients has not been well studied. "There are at least two other factors that play import- ant roles in determining outcomes," he said, adding that one is genetics and the other is adherence to sched- uled follow-up visits. Considering compliance's importance The fact is not everyone with glau- coma is going to progress, whether or not they take their medication. Dr. Singh cited data from Chauhan and colleagues indicating that most patients with glaucoma have no or mild change over time, even in a real-world setting where many are likely not taking their medications. 1 "There are people who we think have glaucoma, we're treating them for glaucoma, they're not taking their medicines, and yet they're not showing any worsening," he said, adding either the disease is so slow that they're not going to get worse, or perhaps the doctor wrongly deter- mined that they needed treatment for glaucoma since this is not an exact science. The fact is one cannot assume that noncompliance ensures a bad outcome. "Similarly, compliance does not ensure that someone will be OK," Dr. Singh said. "Some people can take their prescribed treatment and still get worse." Some patients with W hile practitioners would love it if all pa- tients were compliant with treatment, the fact is often they're What practitioners need to know Helping glaucoma patients with compliance Pharmaceutical focus CyPass ® Micro-Stent IMPORTANT PRODUCT INFORMATION CAUTION: FEDERAL (USA) LAW RESTRICTS THIS DEVICE TO SALE BY OR ON THE ORDER OF A PHYSICIAN. INDICATION: The CyPass ® Micro-Stent is indicated for use in conjunction with cataract surgery for the reduction of intraocular pressure (IOP) in adult patients with mild to moderate primary open-angle glaucoma (POAG). CONTRAINDICATIONS: Use of the CyPass Micro-Stent is contraindicated in the following circumstances or conditions: (1) in eyes with angle-closure glaucoma; and (2) in eyes with traumatic, malignant, uveitic, or neovascular glaucoma or discernible congenital anomalies of the anterior chamber angle. MRI INFORMATION: The CyPass Micro-Stent is magnetic resonance (MR) Safe: the implant is constructed of polyimide material, a non-conducting, non-metallic, non-magnetic polymer that poses no known hazards in all magnetic resonance imaging environments. WARNINGS: Gonioscopy should be performed prior to surgery to exclude peripheral anterior synechiae (PAS), rubeosis, and other angle abnormalities or conditions that would prohibit adequate visualization of the angle that could lead to improper placement of the stent and pose a hazard. PRECAUTIONS: The surgeon should monitor the patient postoperatively for proper maintenance of intraocular pressure. The safety and effectiveness of the CyPass Micro- Stent has not been established as an alternative to the primary treatment of glaucoma with medications, in patients 21 years or younger, in eyes with significant prior trauma, chronic inflammation, eyes with an abnormal anterior segment, eyes with chronic inflammation, eyes with glaucoma associated with vascular disorders, pseudophakic eyes with glaucoma, eyes with uveitic glaucoma, eyes with pseudoexfoliative or pigmentary glaucoma, eyes with other secondary open-angle glaucomas, eyes that have undergone prior incisional glaucoma surgery or cilioablative procedures, eyes with laser trabeculoplasty performed ≤ 3 months prior to the surgical screening visit, eyes with unmedicated IOP less than 21 mmHg or greater than 33 mmHg, eyes with medicated IOP greater than 25 mmHg, in the setting of complicated cataract surgery with iatrogenic injury to the anterior or posterior segment, and when implantation is without concomitant cataract surgery with IOL implantation for visually significant cataract. The safety and effectiveness of use of more than a single CyPass Micro-Stent has not been established. ADVERSE EVENTS: In a randomized, multicenter clinical trial comparing cataract surgery with the CyPass Micro-Stent to cataract surgery alone, the most common postoperative adverse events included: BCVA loss of 10 or more letters at 3 months after surgery (8.8% for the CyPass Micro-Stent vs. 15.3% for cataract surgery only); anterior chamber cell and flare requiring steroid treatment 30 or more days after surgery (8.6% vs. 3.8%); worsening of visual field mean deviation by 2.5 or more decibels (6.7% vs. 9.9%); IOP increase of 10 or more mmHg 30 or more days after surgery (4.3% vs. 2.3%); and corneal edema 30 or more days after surgery, or severe in nature (3.5% vs. 1.5%). AT TENTION: PLEASE REFER TO THE INSTRUCTIONS FOR A COMPLETE LIST OF CONTRAINDICATIONS, WARNINGS, PRECAUTIONS, AND ADVERSE EVENTS. © 2017 Novartis 1/17 US-CYP-16-E-5201 96599_US-CYP-16-E-5201 PI.indd 1 1/11/17 2:18 PM

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