Treatment Plan

What a Long Way We’ve Come With Glaucoma Management

BY LEO SEMES, OD, FAAO

Many years ago, before the digital age, someone said that the only way to keep up with the current literature was to pile all of the journals in a corner and when a colleague recommends an interesting article, read it. We are perpetually bombarded with new information that occasionally is of great

This just happened to me. A colleague sent me a PDF of an article reporting improvement in vision preservation (Skaat et al, 2012). The authors reported on the 10-year trends in blindness for AMD, glaucoma, diabetic retinopathy, and cataract. For glaucoma, they attribute the 31-percent decline from the previous decade to improved patient compliance, kinder and gentler medical treatment, and early diagnosis. Let’s look at each.

Improved Patient Compliance

Compliance is the current watchword for both successful contact lens care/wear and for persistence and adherence in medical glaucoma treatment. Contributions to our knowledge have formed the template for making consistent and targeted intraocular pressure (IOP) maintenance easier. For example, Hahn (2009) has developed the “ask-tell-ask” paradigm: ask open-ended questions about trouble with the drops, have sympathy and empathy with missed dosages, and suggest means to aid in consistent dosing to complete the circle. While this is the Readers’ Digest version of the whole program, it offers the outline that is significant.

Kinder and Gentler Treatment

Many of you reading this column will recall glaucoma patients who dosed pilocarpine q.i.d. Who remembers the revolution 35 years ago with the introduction of Timoptic (0.5% timolol maleate, Merck)? The b.i.d. dosing and lack of significant ocular side effects was truly remarkable. The cloud to this silver lining, however, was that systemic absorption was significant and could negatively impact pulmonary and, to a lesser extent, cardiac function (Hayreh et al, 1999 Sept. and Nov.).

Fortunately, an alternative came several decades later in the form of the prostaglandin analogs with the introduction of Xalatan (0.005% latanoprost, Pfizer) for q.h.s. dosing in 1996. First-line approval to lower IOP in patients diagnosed with ocular hypertension or glaucoma came in 2002. Considering where we had been just two decades earlier, this was truly another revolution in the medical management of glaucoma. Once-a-day dosing and a 30-percent reduction in IOP to boot!

Early Diagnosis

The other remarkable improvement for glaucoma management was in the arena of instrumentation. Today we are the beneficiaries of refined visual-field testing and inordinately precise and detailed objective measures for diagnosis and progression analysis. The gains in these realms are too numerous to mention on a single page. If we look at another and perhaps parallel trend, the use of visual fields seems to be declining slightly while the use of digital imaging appears to be increasing. Stein and colleagues (2012) attribute this to a number of intangible factors but suggest that the objectivity and rapid imaging offered by such devices as those employing optical coherence tomography technologies may be the main reason.

It’s Worth it to Keep up

Keeping up with the trends may seem like a daunting task to primary eyecare providers. But, when we consider the positive outcomes for our patients, the results are gratifying. CLS

For references, please visit www.clspectrum.com/references.asp and click on document #197.