Survey: Identifying factors to improve compliance among glaucoma patients

Responses included suggestions for memory aids, closer doctor-patient relationships.

NEW ORLEANS — New approaches to the ongoing challenge of improving glaucoma patient compliance could assist both ophthalmologists and patients in improving glaucoma drug adherence, according to a survey presented here at the American Academy of Ophthalmology meeting.

Paul P. Lee, MD, JD, outlined results of the survey, which was conducted by the American Glaucoma Society (AGS), at Glaucoma Subspecialty Day.

Dr. Lee said the AGS initiated the Patient Care Improvement Project to find as many new ideas for improved patient compliance as possible. According to the AGS Web site, the survey was developed in 2005 and distributed in early 2006.

More than 1,000 replies to the survey were received, he said. As part of the project, monetary prizes were awarded to 10 physicians, 10 ophthalmic support staff and 10 patients, all of whom submitted 43 of the best ideas.

Dr. Lee said that while many responses were “simple and conventional,” such as establishing a more personal connection between physician and patient, other ideas were innovative. One, from a patient, suggested that glaucoma patients write about what they would regret most if they lost their vision to glaucoma.

“It gives them a sense of what they might miss,” he said.

Other approaches included using transportation vehicle signage to remind patients to take their medication; distributing calendars to help patients with what drugs they need to take every day; or giving patients a bracelet or necklace that has removable beads, for a visual reminder of what medications they have taken, Dr. Lee said.

These items appeared originally as daily coverage from the meeting on OSNSuperSite.com. Look for more in-depth coverage of these and other topics in upcoming issues of Ocular Surgery News.

Screening family members for glaucoma effective in detection

Glaucoma detection is more efficient when aimed at the family of existing glaucoma patients, possibly allowing for earlier detection, a surgeon said.

“A first-degree relative of a glaucoma patient has more chances to know about the disease and, consequently, has been screened for it,” S. Fabián Lerner, MD, said.

When screening 61 first-degree family members of 35 current glaucoma patients, Dr. Lerner and colleagues found that 26.2% of the family members had glaucoma. In comparison, when screening 50 subjects without a known relative with glaucoma, 6% had glaucoma, Dr. Lerner said.

That statistically significant difference showed primary open-angle glaucoma was more prevalent in relatives of glaucoma patients, making the risk in the relatives group 5.5 times higher, Dr. Lerner said.

He said the increased risk could assist with glaucoma detection campaigns, which are needed to address undiagnosed cases but can be costly and difficult to implement. If glaucoma patients notified their relatives that they could possibly have glaucoma, more people might learn of their disease in a cost-effective way, he said.

More studies needed to explore role of blood pressure, sleep, posture on IOP

The impact of blood pressure, sleep position and circadian cycles on IOP fluctuation remains poorly defined, and research needs to focus on how each of these factors affect IOP, a speaker said.

While it has been established that the range of IOP fluctuation is greater in glaucomatous eyes than nonglaucomatous eyes, the causes of that disparity still have not been well established, Sanjay G. Asrani, MD, said at Glaucoma Subspecialty Day.

Dr. Asrani said the possible causes of that disparity could be changes in aqueous outflow or inflow or a combination of the two. Not knowing the underlying cause behind those fluctuations makes further clinical research necessary to determine their full impact on glaucoma progression, Dr. Asrani said.

“Circadian IOP fluctuations occur in normal and glaucomatous eyes, but a great deal remains unknown due to the lack of a noninvasive method of continuous IOP measurements in the patient’s own environment,” he said. “Control of raised nocturnal IOP using long-acting drugs or surgical therapies may be necessary in patients showing progression, despite good control of their daytime IOP.”

Measuring 24-hour IOP curves, scheduling patient visits at different times of the day and checking IOP with patients in the supine position are methods Dr. Asrani suggested for determining the full range of those fluctuations.

Early phaco lowers IOP more than iridotomy in some glaucoma patients

Performing early phaco on patients with acute primary angle-closure glaucoma unresponsive to medication resulted in lower IOP than with laser peripheral iridotomy, a study found.

The results from a randomized trial of the two techniques could be due to a lower response threshold for phaco in post-acute primary angle-closure glaucoma patients with cataract, Dexter Yu-lung Leung, MBChB, said.

“Further studies will be required to determine the optimal timing of phaco, which would be to reduce complications,” Dr. Leung said.

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The study looked at 62 eyes of 62 subjects who had acute primary open angle-closure glaucoma. Glaucoma was treated with topical and or systemic anti-glaucoma medication, Dr. Leung said. Phaco with IOL implantation of AcrySof (Alcon) was performed by a single surgeon under topical or peribulbar anesthesia with a temporal 3.5 mm clear corneal incision, he said. Laser peripheral iridotomy was performed under topical anesthesia with a sequential argon YAG technique.

Vision rehabilitation assists in restoring glaucoma patients’ quality of life

Training glaucoma patients to use their remaining vision more effectively can help them maintain their independence and self-esteem after visual loss, a glaucoma expert said.

Eydie Miller-Ellis, MD, spoke about rehabilitation at Glaucoma Subspecialty Day. She said a physician’s job is not only to lower glaucoma patients’ IOP, but also to help them adapt to visual changes.

“Vision loss takes a toll on our patients,” Dr. Miller-Ellis said. “They need low vision services to maximize function.”

She recommended that physicians conduct “functional histories” of patients’ visual abilities to determine what areas of their lives have been most affected by visual loss and what assistance they require. The effect of visual loss on specific areas of their lives, including near vision tasks, distance vision tasks, mobility and communication skills, should be established, Dr. Miller-Ellis said.

Those effects can then be addressed with low-vision rehabilitation services, she said. The use of devices, such as talking clocks and appliances, signature guides and large print material, can help patients learn how to live with visual loss and continue to take part in everyday activities, she explained.

Even the most inconsequential change can greatly assist patients, Dr. Miller-Ellis said. For instance, the contrasting use of color — dark furniture coupled with light carpet or floors or light plates coupled with dark food — can make a difference in a glaucoma patient’s environmental adaptation for contrast sensitivity loss.

Marked response in inflammatory markers found with topical drug

Treating conjunctival inflammation with topical cyclosporine 0.05% after trabeculectomy showed various responses from the cell markers that determine inflammation, a study showed.

In testing four different cell markers for their response to inflammation, João F. Lopes, MD, and colleagues showed that there were no statistical differences in their responses to postoperative inflammation.

“This was an important step toward better understanding how these markers work,” he said.

Dr. Lopes presented the randomized, prospective, double-masked clinical trial, which looked at 44 patients, at a free paper session.

Conjunctival biopsy samples and immunohistochemical staining for four markers were taken at surgery and 6 months postoperatively, he said. Immunoreactive cell analysis was conducted on CD3, a pan T-lymphocyte marker; ICAM-1, an immune activation marker; HLA-DR, an immune activation marker; and MUCSAC, a goblet cell marker, according to Dr. Lopes.

Results showed a noticeable variability in response of inflammatory and goblet cell markers, and surgery might increase the number of goblet cells, whereas other markers have been shown to restrain the immune response, he said. Directly addressing those responses could assist in producing the most effective topical medical regimen.

Stent lowers IOP in 50% of advanced glaucoma patients

A trabecular micro-bypass stent reduced IOP in more than 50% of patients with advanced cases of glaucoma, a surgeon said.

Carlo E. Traverso

The study examined the iStent trabecular micro-bypass stent (Glaukos), which was implanted in 45 subjects with high IOP who had failed conventional glaucoma surgery or were poor candidates for glaucoma surgery, study author Carlo E. Traverso, MD, said.

“With a population of patients who had failed on prior therapy and/or surgery or considered poor candidates for filtering procedures, the implantation of the stent resulted in a statistically significant reduction both in mean IOP and IOP-lowering medications,” Dr. Traverso said.

Subjects in the prospective, multicenter study had open-angle glaucoma with a baseline IOP of 25.5 ± 6.39 mm Hg on maximal tolerated medical therapy, he said.

One-year interim results found that IOP was 18.8 ± 4.74 mm Hg. At 1 year, 55%, or 23 of the 43 patients who remained in the study, had IOP less than 21 mm Hg with a decrease or no change in medications. Those patients had no need for further filtration surgery, Dr. Traverso said. Of those, 79% had IOP less than 21 mm Hg with medication, while 21% had IOP of less than 21 mm Hg and no glaucoma medications.

Complementary therapy could treat IOP-independent risk factors

Complementary or alternative therapy could assist in treating IOP-independent risk factors of glaucoma patients, but physicians must first embrace the treatments, a physician said.

Polytherapy involving plant extracts, antioxidants and vitamins should be more utilized in the ophthalmic community for treating chronic diseases such as glaucoma, Robert Ritch, MD, FACS, said at a Late Breakers Symposium.

He said many physicians say there is no treatment for IOP-independent risk factors, but with many alternative treatments with limited side effects available, investigating other options should be seriously considered.

“Polytherapy affects multiple systems enough to balance an effect, thus reducing side effects,” Dr. Ritch said. “But over the years, with the advent of pharmaceutical medicine and the establishment of monotherapy, alternative medicine came to be regarded with ridicule and contempt, and people just dismissed it.”

He used Ginkgo biloba extract as an example of a viable polytherapy for glaucoma treatment. Dr. Ritch said the extract improves peripheral, cerebral and ocular blood flow while decreasing platelet aggregation and stabilizing visual fields.

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