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Need Help with Glaucoma Management? Here are Tips from Experts at RANZCO Virtual 2022

Glaucoma management can be a minefield of hidden problems and dangers. However, with better treatments and earlier detection, the impact of this so-called “silent thief of sight” can be reduced — helping sufferers lead a normal, independent life with their vision preserved.

In the Australian and New Zealand Glaucoma Society (ANZGS) Symposium 2022 – Survival Tips from the Glaucoma Experts at the recently held 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Virtual 2022), challenges in managing glaucoma, including patient adherence to medication, were discussed.

Patients can be prescribed the best medications available, but if they fail to take them the proper way, the treatment simply won’t work. Even with the best diagnostic tools available, it still requires interpretation to make a diagnosis.

Here are some tips from glaucoma experts to help you and your patients manage glaucoma better.

1. Identify the Reasons of Adherence Problems

Prof. Ivan Goldberg from the University of Sydney and Sydney Eye Hospital, Australia, shared tips on how to try to optimize medication adherence. “The average adherence among eye disorders is ranked as high as 73%,” said Prof. Goldberg, adding that the rate has been reported as being anywhere between 5% and 85%. According to him, some four billion prescriptions are given out in the United States each year, based on statistics from the Centers for Disease Control and Prevention (CDC). “One in five is never filled at all and for half of those that are filled, the medications are taken incorrectly with respect to timing, dosing frequency, or duration,” he said.

The costs of non-adherence include higher rates of hospital admissions, sub-optimal health outcomes, higher morbidity and mortality for chronic conditions like glaucoma. Skipping doses may lead to increased IOP fluctuations. Data has also shown that over an eight-year period, there is a four-fold increase in loss of visual field sensitivity in patients who admit to not following their prescription. “In conclusion, patients generally do not do what they are ‘supposed’ to do,” Prof. Goldberg said. “Patients will also not tell doctors reliably that they are not doing what they are supposed to be doing, partly because they don’t want to disappoint them, and also because ‘how can you expect me to remember what I have forgotten to do?’”

2. Customize your Adherence Strategy

The barriers to adherence can be divided into financial as well as human resources, the patient’s level of education and understanding about the disease, the goals of treatment and the pitfalls of treatments. The chronicity and asymptomatic nature of glaucoma generally tend to be progressive if it is not well controlled, and patients need to be made aware of this. In summary, strategies must be individualized, and there is no “one size fits all” approach, Prof. Goldberg shared.

3. Know your OCT

Prof. Helen Danesh-Meyer, Sir William Professor of Ophthalmology from the Department of Ophthalmology, University of Auckland, New Zealand, shared how to avoid the pitfalls of optical coherence tomography (OCT). “OCT has revolutionized glaucoma care. It is the most important tool for early diagnosis and management of glaucoma,” she said. She pointed out that the reason for this is that glaucoma is an optic neuropathy. “The damage to the retinal ganglion cells, which formed the inner layers of the retina, and the axons from the retinal nerve fiber layer, converge at the optic nerve head as the neuroretinal rim. So, a device such as the OCT, which allows us to objectively measure these various parameters, is helpful in identifying the stage of glaucoma,” she added.

Factors that undermine OCT accuracy include OCT ‘red disease’ where the non-existent disease is incorrectly indicated by instrumentation, signal quality, scan alignment, scan centration, opacities and segmentation error. She said it is important to look for focal change. The three most common retinal nerve fiber layer (RNFL) progression patterns include a new RNFL defect, widening of an existing defect, and deepening of an existing RNFL defect without widening. To conclude, she noted that the OCT is a powerful tool that requires a systematic approach and is an essential part of glaucoma management.

4. Make SLT Work

Dr. Frank Howes from the Eye and Laser Centre, Gold Coast, spoke about how to make selective laser trabeculoplasty (SLT) work. “The great thing about an SLT is that it works between 80% and 90% of the time. We need to know the laser, the anatomy, the gonioscope and the application routine,” shared Dr. Howes. Choosing the right patient and the correct laser setting are also crucial. SLTs work best as a primary treatment and appear to work in all forms of open-angle glaucoma and ocular hypertension (OHT), whether treated or untreated. They also work on previous trabeculoplasties and stents that need supplementation and medication. However, they don’t work if the angle is closed, or if stents are not working. “The laser energy must be applied with optimal fluence and positioning,” he added.

Patients should not be sent home without a 45-minute post-SLT pressure check or sent home with steroids. Further, he cautioned that a significant number of patients can have an intraocular pressure (IOP) rise post-SLT, particularly in heavily-pigmented angles and in the presence of 360-delivered SLT. It is, therefore, particularly useful to pretreat patients with Iopidine in a busy laser clinic to avoid post-laser congestion. “Do not give up on success until three months after SLT delivery. Success may still be defined as a reduction in the total number of drugs required to reach target IOP,” he concluded.

5. Minimize Side Effects and Provide Support

Other suggestions from experts include minimizing drug administrations, costs and side effects, encouraging communication, providing support and being non-judgemental. Session chair Prof. Graham Lee of the University of Queensland, Australia, suggested advising the patient to take their eye drops together with an activity they do every day around the same time, such as brushing their teeth.

Editor’s Note: A version of this article was first published in Issue 1 of CAKE & PIE POST (52nd RANZCO Brisbane 2022 Edition). The 52nd Annual Scientific Congress of The Royal Australian and New Zealand College of Ophthalmologists (RANZCO Brisbane 2022) was held virtually from February 26 to March 1. Reporting for this story took place during the event.

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