Article

CLINICAL: Glaucoma

Consider a ‘Stop-Go’ Approach

Seven factors can determine treatment for glaucoma patients

When our clinics are running in the “fast lane,” it can be difficult to slow down with each of our glaucoma patients to determine when it is time to initiate, discontinue or modify treatment. At these times, I employ a “stop-go” approach.

Specifically, I first stop to consider what effect treatment change(s) will have on the specific patient — both in the short- and long-term. Then, I use the answers to go with the best treatment. To arrive at these answers, I look at:

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1 PATIENT AGE

The patient’s residual life expectancy, taken in the context of the disease stage, helps to determine the initial target IOP range. Setting a goal IOP range helps guide the rest of the decision process.

2 PATIENT ACTIVITY LEVEL

Does the patient have an irregular schedule? Does their job require frequent travel? Do they work early morning or middle-of-the-night hours? Understanding these real-life obligations affects the patient’s ability to develop an IOP-lowering drop routine. I keep the treatment plan simple.

3 PATIENT ABILITY LEVEL

Is the patient arthritic or do they have shoulder problems that will limit their drop-instillation technique? Do they have other physical limitations that require them to lean on their dependents? These commonly encountered barriers can discourage an otherwise motivated patient. In such situations, SLT as primary therapy may be the best initial treatment.

4 PATIENT ADHERENCE/AWARENESS LEVEL

Patients are more likely to forget or forgo their treatments when they do not see the purpose of the treatment and/or do not accept the diagnosis. In general, patient adherence/awareness is directly proportional to patient education and patient understanding. When nonadherence is a concern, identified through observation or discussion, it is helpful to keep the regimen simple. Plainly discuss the purpose of medication when initiating treatment and then again on future, closely spaced, subsequent visits.

5 PATIENT ANXIETY LEVEL

Some patients who have lower risk glaucoma findings (such as borderline elevated IOP levels with thicker pachymetry readings) but who also have a family history of glaucoma may still feel more comfortable starting treatment. For patients who express such concerns during their exam, a higher target IOP range may be sufficient and, therefore, can be managed easily and inexpensively with topical, once daily monotherapy, if desired.

6 PATIENT ACCESS

A drug may have proven efficacy and minimal side effects, but if the patient is unable to afford it, they will likely not fill the initial prescription, and they are even less likely to refill it in the future. Such patients may also benefit from SLT as primary therapy and/or topical generic medication(s) with closer monitoring in the future to ensure continued efficacy and tolerability.

7 ADVERSE EFFECTS

We should be mindful of the drugs that could adversely affect the patient. For example, when possible, I avoid prescribing monocular PGA therapy, due to associated prostaglandin analogue periorbitopathy.

GET GOING

By stopping to consider the best treatment option for the patient, I find I am better prepared to provide a customized, patient-centric treatment option that is more tolerable in the short term and more sustainable in the long term. OM