ING EDUC INU AT NT IO CO N uA Contin ing Education Review for Optometrists from the New England College of Optometry CE Issue 2

Current Medical Treatment or more of their visits had worsening of about 0.63 units in visual field defect of score.5 Commonly used IOP-lowering drugs can be divided into four major Brue c E. Onofrey, RPh, OD, FAAO classes: PGAs, beta-blockers, alpha- agonists, and carbonic anhydrase in- With a wide range of medical therapies for glaucoma, it is hibitors (CAIs). Also available are fixed imperative to assess both the efficacy and safety of an agent to make combinations of glaucoma drugs—usu- the best choice for the individual patient. ally from different classes and with additive mechanisms of action. With Medical therapy is the cornerstone treatments, including laser therapies two or more agents combined into a of disease management for the major- and surgery involving blebs, stents, single bottle, fixed-combination for- ity of glaucoma patients. In the devel- and/or filtering devices, are typically mulations aim to maximize efficacy oped world, the standard initial inter- withheld as options to fall back on and improve compliance. vention for glaucoma is a topical ocular when initial medical therapy fails. medication, typically a prostaglandin Untreated glaucoma can cause Prostaglandin Analogs analog (PGA). Non-pharmaceutical progressive visual loss potentially lead- Because they are relatively safe and ing to severe visual disability. Once the can lower IOP by more than 30% with decision to begin medical treatment is once-a-day dosing, PGAs are the most TEARG T AUDIENCE This educational activity is intended for optometrists. made, the goal is clear: to reduce pro- popular first-line agents for glaucoma LEARNING OBJECTIVES Upon completion of this activity, gression risk by preventing, or at least in the US and much of the rest of the participants will be able to: slowing, glaucomatous damage to the world.7-9 The introduction of PGAs 1. Select appropriate medical therapy for the individual patient by evaluating both the efficacy and safety of glaucoma drugs. optic nerve. To this day, lowering in- almost 20 years ago revolutionized the 2. Identify ocular perfusion pressure as a risk factor for glaucoma traocular pressure (IOP) has been the management of glaucoma; at the time, progression. only means to accomplish this goal, only filtering surgery could reliably 3. Identify barriers to medication adherence among their pa- tients. regardless of the stage of the disease. produce that degree of IOP-lowering. 4. Take steps to reduce nonadherence among glaucoma patients PGAs quickly became the drugs of in their practices. EDITORIAL COMMITTEE Benefit of IOP Reduction choice for glaucoma, while the use of Baharak Asefzadeh, OD, MS, FAAO, is an adjunct assistant Elevated IOP has been established other medications, as well as surgery, professor of optometry at the New England College of Optometry as the main risk factor for disease dropped dramatically. and director of the VA Boston Optometric Research Fellowship. Tony Cavallerano, OD, FAAO, is an adjunct professor of optom- evolution in glaucoma, and there is In addition to efficacy, the PGAs etry at the New England College of Optometry, where he is also strong evidence that strict IOP control are notable for a paucity of systemic the director of professional relations and the executive director 1-6 of clinical training and patient care. can delay progression of the disease. (cardiovascular or pulmonary) side Mark T. Dunbar, OD, FAAO, is the director of optometric services In the Early Manifest Glaucoma Trial, effects because these compounds are and optometry residency supervisor at Bascom Palmer Eye Insti- each 1-mm-Hg decrease in IOP was rapidly cleared from the bloodstream. tute, University of Miami Miller School of Medicine. associated with a roughly 10% reduc- Mild ocular side effects, however, are Key Issues in Glaucoma Management: A Review for Optometrists is sponsored by the New England College of Optometry and tion in the risk of visual field or optic not uncommon, including darkening supported by an unrestricted educational grant from Bausch + disc progression.6 In the treated group of periocular skin, irreversible dark- Lomb, Inc. This publication is administered by an independent editorial committee. (mean IOP reduction: 25%), progres- ening of the iris, growth of lashes, © 2015 Candeo Clinical/Science Communications, LLC. All rights sion risk decreased by half compared reserved. Neither the New England College of Optometry nor to untreated controls. In the Advanced Candeo Clinical/Science Communications, LLC, assumes any responsibility for injury or damage to persons or property arising Glaucoma Intervention Study, patients M ore INSIDE: from the use of information or ideas contained in this publication. whose IOP was under 18 mm Hg at Improving Adherence to COURSE DIRECTOR every visit over 6 years had almost no Glaucoma Medications Tony Cavallerano, OD, FAAO New England College of Optometry visual field progression, while patients Baharak Asefzadeh, OD, MS, FAAO Boston, MA, USA whose IOP was over 18 mm Hg on half

Supported by an unrestrictedKey Issues educational in Glaucoma grant from M Bauschanag +ement Lomb, Inc.1 periorbital fat loss, stinging, and stay medical treatment for glaucoma. depression to hallucinations. In people conjunctival hyperemia. Although These agents lower IOP by decreasing with diabetes, use of beta-blockers can most of these effects are cosmetic, aqueous production; the effect—at mask hypoglycemic signs and symp- some patients find them worrisome least a 25% pressure reduction—occurs toms, sometimes resulting in danger- or unacceptable, making it important primarily during the day.10 Although ously low blood sugar. Additionally, to counsel patients about the potential highly effective and generally well tol- beta-blockers have the potential to ocular effects of PGAs beforehand. erated, in susceptible individuals beta- raise serum triglycerides, and thereby Also, caution should be used when blockers can produce cardiovascular increase the risk of cardiovascular dis- these medications are used in only one and respiratory side effects, including ease. If used in patients who are highly eye because of potential for asymmetric bradycardia, arrhythmia, heart block, allergic to substances like peanuts or ocular side effects. and bronchiolar constriction. They can insect venom, beta-blockers can reduce also cause sexual dysfunction. Adverse the efficacy of injected epinephrine. Beta-blockers central nervous system effects are also Clinically, it is vital to identify pa- Beta-blockers were once the main- common, ranging from weakness to tients who may be susceptible to these potential dangers. Contraindications to beta-blocker use include asthma, Key Issues in Glaucoma Management — Issue 2 chronic obstructive pulmonary dis- STATEMENT OF NEED ACCREDITATION STATEMENT ease, bradycardia, and congestive heart Glaucoma, a group of ocular diseases characterized by progres- This activity has been planned and implemented through the sive damage to the optic nerve, is the second leading cause of joint sponsorship of the New England College of Optometry failure. A careful clinical history is blindness worldwide. It affects a significant and growing portion and Candeo Clinical/Science Communications, LLC. The New often helpful in recognizing patients of the US population.1,2 England College of Optometry is accredited by The Council on As primary eyecare providers, medical optometrists are well Optometric Practitioner Education® (COPE® ), created by the As- at risk. When a topical beta-blocker is positioned to identify patients at risk and to diagnose, monitor, sociation of Regulatory Boards of Optometry (ARBO) to accredit prescribed, patients should be told of continuing education on behalf of optometric licensing boards. and treat glaucoma. However, given that the expanded scope its potential systemic side effects and of practice incorporating glaucoma treatment is relatively new, CREDIT DESIGNATION STATEMENT many optometrists lack confidence in their ability to treat this The New England College of Optometry designates this activity instructed to measure blood pressure potentially blinding disease. In order to instill confidence and for a maximum of 1 hour of COPE-approved continuing education and pulse regularly. help optometrists make sound clinical judgments about the care credit. Clinicians should only claim credit commensurate with the of glaucoma patients, Key Issues in Glaucoma Management extent of their participation in the activity. will help optometrists better understand the various aspects and nuances of the disease, including our current understand- EDITORIAL COMMMITTEE DISCLOSURE STATEMENTS Selective Alpha Agonists ing of the role of intraocular pressure (IOP) in glaucomatous Baharak Asefzadeh, OD, MS, FAAO, is an adjunct assistant Alpha-2 agonists lower IOP by optic nerve damage. Course content will also include current professor of optometry at the New England College of Optometry rationale on glaucoma diagnosis and evidence-based strate- and director of the VA Boston Optometric Research Fellowship. about 20-25%, but the dosing schedule gies for reducing IOP. She has no financial disclosures related to this activity. for monotherapy—three times daily—is Each installment of Key Issues in Glaucoma Management will Tony Cavallerano, OD, FAAO, is an adjunct professor of op- inconvenient. These agents can, how- look at an important topic in glaucoma diagnosis or therapy. tometry at the New England College of Optometry, where he Each issue will build from a basic level to instill understanding is also the Director of Professional Relations and the Executive ever, be used in combination with and confidence in medical optometrists. Key Issues in Glaucoma Director of Clinical Training and Patient Care. He has no financial other drugs, allowing for twice-a-day Management aims to support optometrists’ clinical reason- disclosures related to this activity. ing and decision-making abilities and help them turn medical Mark T. Dunbar, OD, FAAO, is the director of optometric services dosing. Alpha-2 agonists are generally management of glaucoma into a vital segment of their practices. and optometry residency supervisor at Bascom Palmer Eye Insti- well-tolerated but may stimulate al- REFERENCES tute, University of Miami Miller School of Medicine. He states that in the last 12 months, he has been a consultant for Allergan and pha-2 receptors of the central nervous 1. Resnikoff S, Pascolini D, Etya’ale D, et al. Global data on visual has participated in advisory boards for Carl Zeiss, Regeneron impairment in the year 2002. Bull World Health Organ. 2004 system and produce adverse systemic Pharmaceuticals, Inc., Bio-Tissue, ArcticDx, and B&L Nutrition. November;82(11):844-51. reactions such as low blood pressure 2. Eye Diseases Prevalence Research Group. Prevalence of AUTHOR DISCLOSURE STATEMENT open-angle glaucoma among adults in the United States. Arch Bruce E. Onofrey, RPh, OD, FAAO, is a clinical professor at the and orthostatic hypotension. Alpha-2 Ophthalmol. 2004;122:532-8. University of Houston College of Optometry in Houston, TX. He agonists can also cause allergic re- OFF-LABEL USE STATEMENT is a founding member of the Optometric Glaucoma Society and author of two textbooks, the Ocular Therapeutics Handbook and sponses, at rates ranging from 12% to This work may discuss off-label uses of medications. Clinical Optometric Pharmacology and Therapeutics. He has no 25%.11 They should be avoided or used GENERAL INFORMATION financial disclosures related to this activity. with caution in children due to the This CE activity is sponsored by the New England College of DISCLAIMER Optometry and is supported by an unrestricted educational Participants have an implied responsibility to use the newly potential for central nervous system grant from Bausch + Lomb, Inc. acquired information to enhance patient outcomes and profes- depression. Directions: Circle the best answer to each question in the exam sional development. The information presented in this activity (questions 1–10) and in the evaluation (questions 11–16). The New is not meant to serve as a guideline for patient care. Any proce- The two selective alpha-agonists England College of Optometry designates this activity for a maxi- dures, medications, or other courses of diagnosis or treatment in clinical use today are apraclonidine mum of 1 hour of COPE-approved continuing education credit. discussed or suggested in this activity should not be used by clini- There is no fee to participate in this activity. In order to receive CE cians without evaluation of their patients’ conditions and possible and . Apraclonidine, the credit, participants should read the report and then take the post- contraindications or dangers in use, applicable manufacturers’ first relatively selective alpha-2 agonist test. A score of 70% is required to qualify for CE credit. Estimated product information, and comparison with recommendations time to complete the activity is 60 minutes. On completion, tear of other authorities. available, was initially used to treat out or photocopy the answer sheet and send it to: New England College of Optometry COMMERCIAL SUPPORTERS open-angle glaucoma. Allergy and ATTN: Ms. Margery Warren This activity is supported by an unrestricted educational grant diminution of therapeutic effect with 424 Beacon Street from Bausch + Lomb, Inc. Boston, MA 02115 repeated use (tachyphylaxis) have DATE OF ORIGINAL RELEASE December 2015. Approved for limited its usefulness to short-term ap- a period of 24 months. plications, such as preventing pressure spikes after anterior segment laser pro-

2 Key Issues in Glaucoma management cedures. Brimonidine, which is more fi cient time to penetrate into the eye. alpha-2 selective than apraclonidine, is A review of clinical evidence and coRe concePts 12 more appropriate for chronic therapy. expert opinions suggests that a PGA ● The goal of glaucoma treatment coupled with a topical CAI may be the is to stop or slow disease caRBonic anhydRase best combination to lower IOP.15,16 progression. Current glaucoma inhiBitoRs The pair synergistically reduces IOP medications achieve this almost Reducing IOP by about 20%, CAIs with minimal systemic risk. My own exclusively through reduction of have less IOP-lowering effi cacy than primary choice of drug is a PGA, fol- iOP. PGAs.13,14 Because they reduce IOP by lowed by a topical CAI. After that I ● glaucoma medications lower iOP decreasing aqueous production, these would add either an alpha-agonist or a by either decreasing aqueous sulfonamide agents are often used ad- beta-blocker. If three medications can- humor production or increasing junctively with PGAs, which lower IOP not bring the patient to target IOP, the aqueous outfl ow. by increasing non-trabecular aqueous patient should probably be referred for ● The success of medical outflow (uveoscleral outflow). Like laser or surgical intervention. glaucoma therapy is determined PGAs, topical CAIs have no effect on Patient compliance is critically by not only iOP-lowering effi cacy blood pressure, heart rate, or pulmo- important to the success of chronic but also by absence of side nary function. medical therapy for glaucoma. Patients eff ects and patient compliance. But because they are sulfonamides, must understand that glaucoma is ● Highly eff ective in lowering CAIs can cause allergic reactions in a lifetime disease, that the damage iOP, and having virtually no sensitive patients. Oral CAIs (eg, ac- from open-angle glaucoma is usually signifi cant cardiovascular or etazolamide) are also associated with imperceptible from one day to the next, pulmonary side eff ects, PgAs are a number of systemic side effects, and the success of therapy requires the most often selected fi rst-line agents for initial treatment of including dehydration, metabolic commitment to the medication regi- glaucoma. acidosis, renal calculus formation, men and continuing assessment. In paresthetsias, taste disturbances, he- addition to teaching the importance of ● Ocular perfusion pressure is a matologic abnormalities, and sickle adherence, clinicians can help patients newly recognized risk factor for glaucoma progression. cell crisis in susceptible patients. by choosing a simpler medication Since topical CAIs ( and regimen with as few doses per day as ● Compliance is a critical aspect ) have become available, possible, and by selecting agents that of the medical management of the use of oral CAIs today is generally are safe and comfortable to use. glaucoma. educating patients limited to angle closure glaucoma and Most glaucoma eye drops, espe- about glaucoma and available therapeutic choices can help secondary forms of glaucoma such as cially preserved ones, can cause minor improve compliance with uveitic glaucoma. disruptions in the ocular surface and treatment and follow-up. can exacerbate dry eye signs and symp- medication selection toms. Treating pre-existing dry eye and There are two key factors in se- other ocular surface conditions may progression.20 lecting any medication: effi cacy and help improve tolerability and prevent Maintaining ocular perfusion pres- safety. The PGAs are today’s preferred noncompliance. Of course, if a topical sure at appropriate levels may be ben- choice for initial therapy owing to their lubricant is used at the same time as efi cial in the treatment of glaucoma. combination of greater IOP-lowering glaucoma medications, it should be By defi nition, the perfusion pressure effi cacy and systemic safety. Before applied last and at least 5 minutes after increases as blood pressure increases initiating treatment, clinicians should any glaucoma medication. and as IOP drops. The PGAs and CAIs, obtain a thorough history and deter- with little effect on blood pressure or mine whether their drug of choice is oculaR PeRfusion cardiac output, may enhance perfusion safe for that particular patient. In the PRessuRe pressure by lowering IOP alone. The case of a PGA, the side effects are, as Recent clinical studies have pro- alpha-agonists and beta-blockers, on noted, mainly local and cosmetic. But vided strong evidence that low perfu- the other hand, have a greater potential when an alternative or a second agent sion pressure is connected to glau- to reduce blood pressure and cardiac is warranted, systemic risks such as coma damage and progression.17-19 output. As a result, they may lower cardiovascular or pulmonary disease A refl ection of vascular status at the perfusion pressure and thus increase or allergy become important consid- optic disc, ocular perfusion pressure is the risk of progression, which may erations. Patients who take more than defi ned as the difference between the to some degree undermine their IOP- one topical eye medication at the same mean arterial blood pressure and IOP. lowering effect. time of day must be reminded to wait It is believed that perfusion pressures One new agent, latanoprostene at least 5 minutes between medica- lower than 50 to 55 mm Hg are associ- bunod, which is not approved in the tions, so that each medication has suf- ated with increased risk of glaucoma US but is in phase III clinical trials,

Key Issues In Glaucoma manaGement 3 combines the PGA with a Handbook and Clinical Optometric Pharma- the United States. The United States Latanoprost nitric acid donating moiety and may cology and Therapeutics. He has no financial Study Group. Ophthalmology. 1996;103(1):138-47. 10. Liu JH, Kripke DF, Weinreb RN. Comparison of disclosures related to this activity. Medical writer have a positive impact on perfusion the nocturnal effects of once-daily and pressure as well as on IOP. Ying Guo, PhD, MBBS, assisted in the preparation latanoprost on intraocular pressure. Am J Oph- At present, blood pressure is not of this article. thalmol. 2004;138(3):389-95. 11. Blondeau P1, Rousseau JA. Allergic reactions to routinely measured in patients with brimonidine in patients treated for glaucoma. Can REFERENCES glaucoma. Including this parameter in J Ophthalmol. 2002 Feb;37(1):21-6. 1. Anderson DR. Glaucoma: the damage caused by 12. Burke J, Schwartz M. Preclinical evaluation of glaucoma management will allow us pressure. XLVI Edward Jackson memorial lecture. brimonidine. Surv Ophthalmol. 1996;41 Suppl to evaluate the perfusion pressure at Am J Ophthalmol. 1989;108(5):485-95. 1:S9-18. follow-up visits and perhaps improve 2. Quigley HA. Neuronal death in glaucoma. Prog Retin Eye Res. 1999;18(1):39-57. 13. Lippa EA, Carlson LE, Ehinger B, et al. Dose the efficacy of glaucoma treatment. 3. Collaborative Normal-Tension Glaucoma Study response and duration of action of dorzolamide, In cases where a glaucoma patient is Group. Comparison of glaucomatous progression a topical carbonic anhydrase inhibitor. Arch Oph- thalmol. 1992;110(4):495-9. also being treated for high blood pres- between untreated patients with normal-tension glaucoma and patients with therapeutically 14. Strahlman E, Tipping R, Vogel R. A double- sure, IOP reduction may be helped by reduced intraocular pressures. Am J Ophthalmol. masked, randomized 1-year study comparing a discussion with the primary care 1998;126(4):487-97. dorzolamide (Trusopt), timolol, and . International Dorzolamide Study Group. Arch physician of the possibility of lowering 4. Collaborative Normal-Tension Glaucoma Study Group. The effectiveness of intraocular pressure Ophthalmol. 1995;113(8):1009-16. the dose of blood pressure medication reduction in the treatment of normal-tension glau- 15. Singh K, Lee BL, Wilson MR; Glaucoma Modified or changing the dosing schedule from coma. Am J Ophthalmol. 1998;126(4):498-505. RAND-Like Methodology Group. A panel assess- ment of glaucoma management: modification of the evening to the morning. 5. The AGIS Investigators. The Advanced Glaucoma Intervention Study (AGIS): 7. The relationship existing RAND-like methodology for consensus The clinical significance of ocular between control of intraocular pressure and in ophthalmology. Part II: Results and interpreta- perfusion pressure, though in need visual field deterioration. Am J Ophthalmol. tion. Am J Ophthalmol. 2008;145(3):575-81. 16. Bateman DN, Clark R, Azuara-Blanco A. The ef- of further elucidation, highlights the 2000;130(4):429-40. 6. Leske MC, Heijl A, Hussein M, Bengtsson B, fects of new topical treatments on management impact of other factors on the dis- Hyman L, Komaroff E; Early Manifest Glaucoma of glaucoma in Scotland: an examination of ease process of glaucoma. In the end, Trial Group. Factors for glaucoma progression and ophthalmological health care. Br J Ophthalmol. 2002 May;86(5):551-4. medical management of glaucoma the effect of treatment: the early manifest glau- coma trial. Arch Ophthalmol. 2003;121(1):48-56. 17. Leske MC, Wu SY, Hennis A, et al. Risk Factors is not just about pharmacology. It is 7. Alm A, Stjernschantz J. Effects on intraocular for Incident Open-Angle Glaucoma: The Barbados also about our knowledge of all the pressure and side effects of 0.005% latanoprost Eye Studies. Ophthalmology. 2008;115:85-93. variables that contribute to the onset applied once daily, evening or morning. A compari- 18. Leske MC, Heijl A, Hyman L, Bengtsson B, Dong son with timolol. Scandinavian Latanoprost Study L, Yang Z, EMGT Group. Predictors of long-term and progression of the disease. Group. Ophthalmology. 1995;102(12):1743-52. progression in the early manifest glaucoma trial. 8. Watson P, Stjernschantz J. A six-month, random- Ophthalmology. 2007; 114(11):1965-72. ized, double-masked study comparing latanoprost 19. Hulsman CA, Vingerling JR, Hofman A, et al. Bruce E. Onofrey, RPh, OD, FAAO, is a clinical with timolol in open-angle glaucoma and ocular Blood pressure, arterial stiffness, and open-angle professor at the University of Houston College hypertension. The Latanoprost Study Group. glaucoma: the Rotterdam study. Arch Ophthalmol. of Optometry in Houston, TX. He is a founding Ophthalmology. 1996;103(1):126-37. 2007;125:805-12. 9. Camras CB. Comparison of latanoprost and timo- 20. Leske MC. Ocular perfusion pressure and glau- member of the Optometric Glaucoma Society and lol in patients with ocular hypertension and glau- coma: clinical trial and epidemiologic findings. author of two textbooks, the Ocular Therapeutics coma: a six-month masked, multicenter trial in Curr Opin Ophthalmol. 2009 Mar;20(2):73-8.

4 Key Issues in Glaucoma Management that their medications will help are less Improving Adherence to likely to adhere to therapy, particularly if they are experiencing side effects or Glaucoma Medications have other justification for stopping. In contrast, believing that you have control over your disease—called “self- Baharak Asefzadeh, OD, MS, FAAO efficacy”—increases engagement and likelihood of success.9 Medication nonadherence is one of the most important issues in glaucoma care. Understanding its complex origins is the first step in Identifying helping steer patients toward greater control of their disease. Nonadherence Patients often report much higher As eyecare providers, our most (defined as possessing the correct adherence than found when electronic diligent efforts to identify and treat amount of medication at least 80% of monitoring is used in studies.1 In gen- patients with glaucoma are thwarted the time) within the first 12 months of eral, physicians are poor predictors of when patients fail to take their medica- ocular hypotensive therapy continued patient adherence.10 A useful way to tions. Proper adherence requires that to have at least moderately good persis- gain better insight into patient prac- patients fill their prescriptions, instill tence over the course of the drops with appropriate technique the subsequent 3 years. and timing, and do so with daily con- Conversely, patients sistency.1 A breakdown in any step with persistently “very compromises adherence and threatens poor” or “declining” ad- efficacy. herence in year 1 rarely Improving adherence requires that achieved good adher- we acknowledge glaucoma patients’ ence in later years.5 central role in their disease manage- Barriers to adher- ment and use the most effective means ence vary widely, and available for supporting them. Good most patients have mul- communication is key to uncovering tiple barriers. In one barriers to adherence and providing survey, 10% of glau- practical strategies for eliminating or coma patients reported reducing those barriers. a single barrier to adher- Figure 1 good communication is often the doctor’s best ence, and 61% reported weapon against nonadherence. Scope of the Problem multiple barriers.7 Com- Medication nonadherence is highly mon barriers to medication adherence tices is to ask questions that are both prevalent among patients being treated include polypharmacy/complex regi- open-ended and specific (eg, “How for glaucoma.2-4 A 2005 literature mens, forgetfulness, cost, and difficulty often do you take your drops?”), rather review showed that up to 80% of pa- instilling drops due to arthritis or other than closed (answerable by yes or no; tients deviate significantly from their physical comorbidities. Poor health lit- eg, “Are you taking your drops?”) or prescribed antihypertensive treatment eracy—for example, poor understand- just skimming the surface (eg, “How regimen. Roughly one in 13 newly ing of what is required for appropriate are you doing with your drops?”). A diagnosed patients never fills their disease management—may lower pa- patient’s loved one or caregiver may first prescription for anti-glaucoma tient engagement and medication ad- provide information that the patient medication.5 Among newly diagnosed herence.1 In focus groups, patients cite will not; when they accompany the patients who fill their prescriptions, insufficient knowledge of glaucoma as patient to the office, I involve them persistence (defined as starting and a leading barrier to optimal adherence in the conversation and inquire about continuing therapy as prescribed for a to glaucoma treatment.8 Even patients the patient’s medication-taking and certain period of time) has been esti- with a good understanding of their any barriers to adherence (Figure 1). mated at 50% at 6 months and about disease and strong motivation may be Begin to suspect nonadherence 31% at 12 months.3,4,6 frustrated by the lack of identifiable when IOP does not decrease as ex- Successful therapy initiation and payoff to taking their drops. pected in a new patient or when pre- persistence in the early months is Patients’ perceptions and beliefs viously controlled IOP starts to creep critically important for successful directly affect their willingness to back up. In the latter case, waning long-term adherence. According to one engage meaningfully in their care.9 medication effectiveness should also study using insurance records, patients Patients who are not aware that their be considered. In some settings, such with “persistently good adherence” condition is serious or do not believe as a Veterans Administration hospital

Key Issues in Glaucoma Management 5 system, pharmacy data is accessible to should be counseled on what to expect clinicians, providing a useful means from their disease and its treatment, coRe concePts for uncovering discrepancies between including side effects. When prescrib- ● Helping patients adhere to patient reporting of medication usage ing prostaglandin analogs, for ex- medical therapy can save their and refi ll frequency. In most instances, ample, an upfront conversation about vision. though, refi ll information is not avail- the potential for lash lengthening, iris ● Nonadherence is widespread able to providers, and we depend on changes, or loss of periorbital fat can among glaucoma patients; patients to tell us the truth. prepare patients, should any of these its origins may relate to occur. Also, providing guidelines for psychological, circumstantial, or communication matteRs notifying the offi ce can help patients treatment-related barriers. to Patients keep minor side effects in perspective: ● Patient beliefs about their Managing glaucoma can be frus- for example, explain to patients that disease and their treatment trating for both patient and doctor. a bit of stinging with medication is impacts medication adherence. Rather than performing a clearly posi- normal, but anything worse should ● good communication can help tive function for patients, like alleviat- prompt a phone call. identify and eliminate barriers to ing suffering or restoring lost vision, To assess their understanding, adherence. ocular hypotensive medications typi- sometimes asking surprise questions is ● eff ective communication cally counter a silent process. In some helpful—for example, saying to the pa- includes asking specifi c, open- ways, patients are taking a leap of faith tient, “You tell me: what is glaucoma?” ended questions and listening when they follow our recommendation A surprising number of patients con- carefully and respectfully to for lifelong medication. fuse glaucoma with cataracts. When responses. Considering the level of trust re- they do, they are less inclined to worry ● To remedy nonadherence, quired, it is not surprising that many about it because they wrongly presume address individual patients’ patients place a high value on the qual- that an outpatient surgery will fi x it specifi c barriers to success. ity (and quantity) of interactions they down the road. By simply asking the ● More research is needed have with their eye care provider. One question, misunderstandings that may to understand how much of the simplest and most meaningful be contributing to nonadherence have adherence is necessary for good things we can do to build trust with pa- a chance to surface, providing an op- outcomes. tients is to listen. In one survey, when portunity to remedy that by educating patients were asked about perceived the patient on the spot. barriers to effective glaucoma control, tions) and/or waiting room videos the most common responses related to caReful listening can be useful in reinforcing verbal pitfalls in the doctor–patient relation- Listen for implied or explicitly messages. Using point-of-care tools to ship. Specifi cally, patients lamented stated barriers to success so that you help patients visualize their disease can doctors not taking time to talk with can tailor a solution. For example, a help ground conversations and make them, ask questions, or listen to their patient who forgets to take her medi- abstract ideas more real to patients. concerns.7 cation needs a way to remember, such Even for patients who are not very One study showed that, in a as a visual reminder or linking her forgetful, reminders may improve ad- 16-minute offi ce visit, only 49 seconds bedtime dose to an already ingrained herence. One study showed that the were devoted to proper use of medi- habit such as brushing their teeth. By use of telephone and text reminders cations. That’s clearly inadequate! A contrast, a patient who holds the belief signifi cantly improved medication ad- separate study showed that physicians that his medication is of no impor- herence among patients on once-daily who communicate well have 19% tance will not benefi t from a discussion medical treatment for glaucoma.13 The higher adherence rates compared with about reminder systems. Rather, this intervention was inexpensive, about those who communicate poorly.11 patient needs to be invited to express $20 per patient per year, and was well the underlying reasons for his cynicism received by patients. However, not all adheRence stRategies so they can be addressed. patients stand to benefi t from tech- Another strategy to help patients When time is limited, it is valu- nology-based reminders. One survey stay on track is to keep medication able to have a staff member—such as of glaucoma patients concluded that regimens as simple and as convenient a nurse, nurse practitioner, technician, email or text-based reminder systems as possible. A well-known tenet of or coach—available to counsel patients were generally best suited to the un- prescribing, one that is particularly who are at risk for nonadherence. der-40 demographic.14 important to glaucoma care, is to Adjunctive communications such as Smartphone apps that remind use once-a-day medication whenever pamphlets (eg, containing disease patients to take their medications possible. and treatment information as well may also be useful. Dozens of phone At the time of diagnosis, patients as answers to commonly asked ques- and tablet apps are available for help-

6 Key Issues In Glaucoma manaGement ing patients stay on course with their The impact of nonadherence will more time with patients, nonjudg- therapies, including several specifically be easier to study as IOP-monitoring mental listening, recruiting help from for managing eye drop regimens. technology evolves. In addition, I look staff and caregivers, and employing forward to the day we can prescribe patient-specific strategies for over- Future Studies drug-eluting contact lenses, punctal coming barriers and incorporating Surprisingly, no studies show plugs, and other devices that not only eye drops into daily life all can help conclusively that improved adherence improve adherence, but improve drug improve adherence. improves outcomes in glaucoma. As delivery as well. Effortless adherence providers, we may agree that adher- plus continuous IOP monitoring will ence is important, but we do not fully usher in a new era in the medical understand how the degree of adher- treatment of glaucoma and render Baharak Asefzadeh, OD, MS, FAAO, is an adjunct ence (eg, taking 50% of doses vs 70%) nonadherence a nonissue. assistant professor of optometry at the New Eng- affects visual function. Are different land College of Optometry and director of the VA levels of adherence needed at different Conclusion Boston Optometric Research Fellowship. She has stages of disease? Research in these The doctor–patient relationship no financial disclosures related to this activity. and related areas will help us advise can be the difference between adher- Medical writer Noelle Lake, MD, assisted in the patients more effectively. ence and nonadherence. Spending preparation of this manuscript.

REFERENCES Four Years of Follow-Up. Ophthalmology. 2015 tence with glaucoma therapy. Surv Ophthalmol. 1. Muir KW, Lee PP. Glaucoma medication adher- Aug 4. E-pub ahead of print. 2008;53:S57-68. ence. Arch Ophthalmol. 2011;129:243-5. 6. Waterman H, Evans JR, Gray TA, et al. Interven- 11. Tarn DM, Paterniti DA, Kravitz RL, et al. How 2. Olthoff CM, Schouten JS, van de Borne BW, tions for improving adherence to ocular hypo- much time does it take to prescribe a new medica- et al. Noncompliance with ocular hypotensive tensive therapy. Cochrane Database of Systematic tion? Patient Educ Couns. 2008;72(2):311-9. treatment in patients with glaucoma or ocular Reviews. 2013;4:CD006132. 12. Zolnierek KBH, DiMatteo MR. Physician com- hypertension: an evidence-based review. Oph- 7. Newman-Casey PA, Shtein RM, Coleman AL, et munication and patient adherence to treatment: thalmology. 2005;112:953-61. al. Why patients with glaucoma lose vision: the a meta-analysis. Medical Care. 2009;47:826-34. 3. Reardon G, Kotak S, Schwartz GF. Objective patient perspective. J Glaucoma. 2015 Aug 27. 13. Boland MV, Chang DS, Frazier T, et al. Electronic assessment of compliance and persistence Epub ahead of print. monitoring to assess adherence with once-daily among patients treated for glaucoma and ocular 8. Newman-Casey PA, Robin AL, Blachley T, et al. glaucoma medications and risk factors for non- hypertension: a systematic review. Patient Prefer The most common barriers to glaucoma medica- adherence: The Automated Dosing Reminder Adherence. 2011;5:441-63. tion adherence: a crosssectional survey. Ophthal- Study. JAMA Ophthalmol. 2014. doi:10.1001/ 4. Nordstrom BL, Freidman DS, Mozaffari E, et al. mology. 2015;122:1308-16. jamaophthalmol.2014.856. Persistence and adherence with topical glaucoma 9. Morse AR. Improving Medication Adherence to 14. Saeedi OJ, Luzuriaga C, Ellish N, et al. Potential therapy. Am J Ophthalmol. 2005;140:598-606. reduce vision loss in patients with glaucoma: low limitations of e-mail and text messaging in 5. Newman-Casey PA, Blachley T, Lee PP, et al. Pat- hanging fruit? Ophthalmology. 2015;122:1280-2. improving adherence in glaucoma and ocular terns of Glaucoma Medication Adherence over 10. Schwartz GF, Quigley HA. Adherence and persis- hypertension. J Glaucoma. 2015;24:e95-102.

Key Issues in Glaucoma Management 7 Examination Answer sheet — Key Issues in Glaucoma Management — Issue 2

This Distance Learning CE course is sponsored by New England College of Optometry and is supported by an unrestricted educational grant from Bausch + Lomb. For that reason, there is no registration fee to participate. After reading the issue, candidates must complete the online post-course test to verify learning and qualify for 1 hour/unit of COPE-Accredited CE. A printable certificate of completion is generated for participants who successfully pass the post-course test with a score of 70% or higher. The instructional time is a minimum of 50 minutes. Access to the test is available at http://www.neco.edu/academics/continuing-education/online-ce/key-issues-glaucoma. IMPORTANT NOTE: Distance Learning/ Multimedia courses do not qualify as CEE Courses. Only live lectures qualify as CEE courses. Course ID #47762-GL Event ID #110598 Expiration: 01-08-2019

1. Which of the 4. Which of the following is 7. Which of the following following is NOT a NOT a potential side effect factors can potentially potential contraindication of PGAs? compromise compliance in to topical use? A. Change of eye color glaucoma treatment? A. Asthma B. Growth of lashes A. Failure to B. Rheumatoid arthritis C. Hyperemia communicate the importance of C. Chronic obstructive D. Sulfonamide allergy pulmonary disease treatment and follow-up visits D. Bradycardia 5. Among newly B. Side effects of diagnosed glaucoma glaucoma eye drops 2. Which of the patients who fill their first C. Ocular surface following characteristics of prescription, the conditions prostaglandin analogs percentage who remain on is most likely to support the medication at 6 D. All of the above adherence? months is approximately: A. High efficacy A. 95% 8. Effective communication 10. The term “self- B. Once-daily dosing B. 80% helps achieve which of the efficacy” refers to: C. Potential for iris color C. 50% following glaucoma-care objectives? A. Patients’ sense of change D. 15% A. Identifying medication control over their D. Over-the-counter nonadherence disease availability 6. In addition to IOP, B. Patients’ ability to which one of the following B. Identifying barriers to adherence select their medication 3. Which of the following measurements is required C. Patients’ ability to instill is NOT a potential barrier to determine ocular C. Preventing eye drops properly to adherence? perfusion pressure? nonadherence D. Study design based on A. Sourcing accurate A. Blood pressure D. All of the above self-report information about B. Trabecular meshwork glaucoma from the status 9. Glaucoma drugs Internet C. Aqueous humor from which class may B. Not understanding the prostaglandin level mask hypoglycemic signs and symptoms in disease D. None of the above, diabetics? C. Distrusting the provider perfusion pressure is A. PGAs D. Leading a very busy life measured directly B. Beta-blockers C. CAIs D. Alpha-agonists

8 KEY ISSUES IN GLAUCOMA MANAGEMENT To take the test online and obtain CE credit for this activity, go to http://www.neco.edu/academics/continuing-education/online-ce/key-issues-glaucoma