A year ago, in the March 2020 issue, I reported the case of an active, 68-year-old, pseudophakic female who presented with progressing early open-angle glaucoma, despite reporting “good” adherence with her topical prostaglandin analogue monotherapy (bit.ly/OM320Glaucoma ). After discussing the need for further IOP reduction at that time, I offered the patient additional topical therapy or selective laser trabeculoplasty (SLT) as adjunctive therapy. After thoughtful consideration, the patient profoundly asked, “Isn’t one drop enough?” and chose SLT for further IOP reduction.

As a result of her insightful question, I have been more aware of the potential hesitation from providers (as well as the natural reluctance by patients) regarding adjunctive therapy. As this patient scenario is common, I felt it appropriate for a second look at second-choice topical adjunctive therapy to help us provide sustainable medical therapy on behalf of our patients.

REVIEW YOUR GOALS

Setting a target IOP range at the time of the initial treatment and then continually reviewing this goal, based on the age of the patient, the stage of the disease and the associated structural and functional testing at appropriate intervals, provides a goal for us to work toward (or modify) with a patient-centric approach. As a general starting point in this process, Sihota et al recommends the following initial target pressure for primary open-angle glaucoma patients and primary angle-closure glaucoma patients after iridotomy of 15 mmHg to 17 mmHg, 12 mmHg to 15 mmHg, and 10 mmHg to 12mmHg for early, moderate and advanced glaucoma, respectively.¹

REVIEW DRUG ADHERENCE

If the patient’s IOP is not at the target IOP range with the current therapy and there is correlating reliable structural and functional progression, we should first review drop adherence with the patient and evaluate their instillation technique, using open-ended, non-judgmental questions. Personally, I have found it helpful to first recognize the difficulty of taking medications on a long-term basis for relatively asymptomatic, chronic conditions with patients. Then, I ask them how they feel they are doing using their eye drops as prescribed. After these initial open-ended questions, I then ask them to “rate” their adherence to help further clarify their compliance. For example:

“Mr. Jones, because glaucoma is a condition that may not have many symptoms, one of the hardest things about treating glaucoma is just remembering to take the eye drops. How do you feel you do using your eye drops (list specific drops) every day?” Listen to patient response.

“Would you say then that you use them (list specific drops) every day, every other day or only a couple times a week?” Listen to patient response. “Thank you, Mr. Jones, that’s very helpful.”

Other questions to ask that may boost patient adherence and provider understanding:

1. “Are there other activities/medications that you do/take every day and around the same time, that you can pair your glaucoma drops with as well?”
2. “What do you think would be the easiest or most likely time to remember to put in your eye drops?”
3. “Are there any concerns that may affect your ability/willingness to put in eye drops?”
4. “What is your understanding regarding why we have you using eye drops?”

After these initial questions, and in cases of fluctuating IOP and/or IOP levels that are not at target ranges, we can then ask the patient to demonstrate eye drop instillation to evaluate technique. This simple and brief display helps us observe potential challenge points in three general stages, all of which directly affect the medication bioavailability and, by extension, IOP and disease control:

1. Pre-Instillation. Does the patient hold the drops too high or too close to the eye? Instilling the eye drops too high may limit accuracy, while instilling them too close may lead to contamination and/or potential ocular injury. If there are noticeable alignment and/or dexterity issues, soliciting help from family members may be helpful to overcome these initial barriers and/or revisiting SLT for appropriate candidates.
2. During instillation. Does the patient instill multiple drops at a time, which may promote both medication waste and washout?
3. Post-instillation. Does the patient immediately (and forcefully) blink and/or immediately wipe their eyes with a tissue, which may limit the medication time on the eye?

PRESCRIBE AS APPROPRIATE

As suggested above, sometimes, the patient may need more adherence and/or better technique vs. more eye drops and escalating therapy. But, if the patient’s adherence and eye drop instillation technique do not appear to be an issue in cases of progressing glaucoma, we shouldn’t be surprised if the patient needs additional medical or laser therapy to achieve their goal IOP. To that point, the Ocular Hypertension Treatment Study shows that 40% of patients required additional medications to achieve a target IOP of 20% reduction.² Furthermore, the Collaborative Initial Glaucoma Treatment Study and the Advanced Glaucoma Intervention Study reveal that, respectively, 75% and 80% of patients also required adjunctive therapy to meet target pressure goals.^3-4 I have found that referring to these findings (in general terms) at the time of the initial treatment can help provide the patient with reasonable expectations during the course of their treatment, while at the same time limiting discouragement in the patient’s perception when adjunctive therapy is required. As an example, a summary monologue, at the time of initial treatment, may go something like this:

“Mrs. Smith, it appears your repeat testing confirms my previous suspicion for early glaucoma. In general, the best way to treat glaucoma is to lower your eye pressures, and this can be done by using eye drops, lasers and/or surgery. Regarding the eye drops, we have a lot of great options that are easy to use and work very well. Most patients may be able to treat their glaucoma with just one eye drop, while some patients may require a combination of eye drops and/or laser to lower their eye pressure to a safer level to prevent disease progression. We will continue to work together closely to monitor for such potential progression with different tests in the future and adjust the treatment appropriately if (and when) needed.”

After we have determined that the patient needs further adjunctive therapy, I have found that the best course of action is to keep the regimen as simple as possible! For example, fixed combination medication added to a prostaglandin can help maximize IOP reduction, while minimizing cumulative BAK exposure, reducing multiple co-pays, limiting confusion and all while maximizing drop adherence. (See “Fixed Combination Drops” bottom.) Also, we should try to remember that the best treatment(s) (whatever you and the patient decide to use) satisfy four criteria in this patient-centric adjunctive therapy decision process. More specifically, is the treatment:

1. Sufficient? Is the proposed additional treatment(s) likely to achieve the desired IOP reduction in the target IOP range?
2. Sustainable? Will the proposed additional treatment(s) be a sustainable regimen or hard to maintain, due the patient’s lifestyle, travel/work schedule or memory/comprehension?
3. Affordable? If selecting topical therapy, does the proposed additional medication(s) have reasonable coverage, so that the patient is more likely to fill the medication every month?
4. Tolerable? If selecting topical therapy, are there any likely side effects to the new proposed additional medication(s) that would be significant enough to affect adherence or cause other ocular complications?

EDUCATE, GUIDE, SUPPORT

Each glaucoma appointment should include education, guidance and support for the patient; even the minimalistic “IOP checks” should be expanded to cover these opportunities. For example, when starting patients on additional drugs, we should provide a written copy of the updates and go over these changes in real time. Furthermore, we should be sure to schedule a follow-up appointment within a few weeks to emphasize the importance of the change in therapy, review any adherence issues and determine the efficacy of the new adjunctive therapy. As frontline eye care providers, we are many times the patient’s first source for second-line therapy. OM

REFERENCES

1. Sihota R, Angmo D, Ramaswamy D, Dada T. Simplifying “target” intraocular pressure for different stages of primary open-angle glaucoma and primary angle-closure glaucoma. Indian J Ophthalmol. 2018;66(4):495-505.
2. Kass MA, Heuer DK, Higginbotham EJ, et al. The Ocular Hypertension Treatment Study: a randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120(6):701–713.
3. Lichter PR, Musch DC, Gillespie BW, et al; CIGTS Study Group. Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery. Ophthalmology. 2001;108(11):1943–1953.
4. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship between control of intraocular pressure and visual field deterioration. The AGIS Investigators. Am J Ophthalmol. 2000;130(4):429–440.

DR. LIFFERTH is consultative optometrist with an emphasis in glaucoma management at Grossnickle Eye Center. Follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at austinlifferth@yahoo.com.