In glaucoma care, being honest with patients in a direct yet caring way is essential for building a successful doctor-patient relationship. Our patients are bound to be anxious about their glaucoma diagnosis, and it is important we properly prepare them for their journey. To help set realistic expectations, we must explain to patients that we may need to adjust and sometimes change treatment strategies along the way to achieve the best outcomes.

For patients receiving a new glaucoma diagnosis who have early disease, the initial conversation is relatively simple. My approach is to let these patients know we can probably manage their condition with eye drops and, perhaps, a laser procedure, but we do not need to be thinking about surgery at this stage. A much harder conversation, however, is with an undiagnosed patient who is presenting with moderate to severe disease. It is extremely difficult to tell a patient that not only do they have a potentially blinding condition that has already progressed, but surgery is very likely going to be necessary.

IT IS PERMANENT

In speaking with all patients, I explain that vision loss from glaucoma is permanent. Our goal, therefore, is to keep them seeing as well as they do today for the rest of their life. That requires we lower their IOP, and we have a number of ways we can achieve that.

Traditionally, we start with a drop. If one doesn’t work, we can try another one. Or if one works but it’s not enough, we can add to that. I tell them there is likely to be a laser involved somewhere down the road. Depending on the patient’s wishes and how they feel about taking medication, that can be early or later in the course of the disease.

As caregivers, we need to be aware that this initial conversation sets the tone with patients. I believe it is important that we tell them what is in our toolbox. That way, if it does come time for surgery because they are not responding to or are nonadherent with medication or the laser did not work, they will not be surprised.

FOLLOW-UP

During the first few visits after starting the patient on therapy, I have multiple goals, including rounding out the baseline data. I may be repeating a visual field or OCT, for example. Next, I need to determine whether the patient is tolerating the drops and whether they have met the target pressure.

I will ask them how they are using the drops and whether they are experiencing any side effects that they cannot tolerate. It is important to note that there are nuances to the decisions made at this point — glaucoma therapy is very case specific with very little black and white.

In my area with my mix of insurers, a generic prostaglandin analog (PGA) is required as a first-line treatment, however, my recommendation is to be familiar with the formularies in your area and/or watch on your e-prescribing software to see whether your favorite brand name first-line drug is allowed and whether the patient agrees to the listed copay while in your office to help you determine the easiest and best first-line medication.

There are three main reasons to change therapy: (1) if the patient is not tolerating the drop due to an allergic reaction or side effects; (2) if they are not meeting the target pressure; or (3) the most important reason, which is typically much later on, is an indication that the patient is progressing at a rapid rate like a confirmed change on the VF or OCT, or the presence of an optic disc hemorrhage. At that point, I need to change the target pressure as well.

A VARIETY OF OPTIONS

When escalation of therapy is needed, it is important to consider all available options. There are many medications, including fixed-combination medications, as well as selective laser trabeculoplasty (SLT) that can be considered. Glaucoma therapy is different for every patient.

For the patient who is very close to target on a generic PGA, I consider switching them to a branded or different PGA to see whether it will provide the additional IOP-lowering needed to reach the target IOP.

If that switch doesn’t achieve the target, or if the pressure is far from the target, then additional medication or a laser will be needed.

EMPHASIZING ADHERENCE: WALKING A TIGHTROPE

We have to walk somewhat of a tightrope when we emphasize to patients that the need for their adherence to treatment is critical. Although it is a serious situation, we also do not want to scare our patients. If they are already in a moderate or severe state, I will show patients their VF and explain that dark areas represent areas of lost vision that they cannot get back. To stop vision loss, we must reduce IOP. I do not believe in scare tactics; however, I do tell patients we both have a role in managing their glaucoma. I say, “My role is to come up with the best treatment plan for you, to monitor you, to see how that treatment plan is working. But you have the main role. If you don’t use your medicine, every day, the way that we instruct you to, it doesn’t matter what I prescribe. You run the risk of losing more vision.”

My staff and I watch for signs of nonadherence, such as patients missing follow-up visits or coming in for appointments and claiming they “just ran out” of their medication. Those patients are probably struggling with adherence. If a patient has good IOP but their disease is progressing, sometimes I will need to do a little digging into their compliance. I start this delicate conversation by acknowledging how hard it is to take drops every day. I will say, “Can you give me a sense over the last month of how many times you haven’t been able to get your drops in?” That statement gives them permission to be a little more truthful. It may take a few minutes longer to have that conversation, but you are likely to get a truthful answer.

A JOB TO TAKE PRIDE IN

It is our job to make sure glaucoma patients understand that they have a life-long disease; they are not going to use medications for a while and then stop using medications. They will never not have glaucoma. But also, optometrists must reassure them that together they will develop a treatment regimen that can preserve their vision for years to come. OM

FDA-Approved Combination Drugs

 

Brinzolamide-brimonidine (Simbrinza; Alcon Laboratories, Inc.)

 

 

Netarsudil and latanoprost ophthalmic solution 0.02%/0.005% (Rocklatan, Aerie Pharmaceuticals, Inc.).

 

 

Timolol-dorzolamide (Cosopt; Merck & Co., Inc.)

 

 

Timolol-brimonidine (Combigan; Allergan, Inc.)

 

DR. MARRELLI is the assistant dean for clinical education and director of ocular diagnostic and medical eye service, both at the University of Houston College of Optometry, Houston. Financial disclosure: Consultant and Speaker (Aerie, Bausch + Lomb, Carl Zeiss Meditec); Speaker (Bausch & Lomb, Carl Zeiss Meditec).