patients with glaucoma because of the number of medications that can be required to control IOP, the inherent difficulty of applying medications to the eyes and the silent nature of the disease. Medication cost is also a very frequent issue. Adherence with medications is important because fluctuations in IOP may affect disease progression. Patients need to maintain IOP control over time. Based on managed care data, the best persistency for a one drop per day eye medication is 60 percent of patients still on at one year. This is not adequate for preventing vision loss. To improve persistency, we need better medications that require infrequent dosing. Surgery is a longer lasting treatment option; 80 percent of patients treated surgically will still be under control at one year. For medication noncompliant patients, it is a very viable treatment option. Patients need to be educated on the role of medicines in maintaining eyesight and the need for maintaining a consistently low IOP. Showing them the techniques for applying drops is very important. Additionally, eye drops can seem unimportant to non-eye health care providers. Many times a patient’s glaucoma medications get discontinued during hospitalization or other change in health care setting because providers do not understand their importance.
ting. To have a long-lasting surgical procedure that eliminates the need for medications for the majority of patients is the ultimate goal. Conclusion
In order to provide cost-effective care, glaucoma needs to be detected and treated early. Glaucoma risk factor assessment and eye imaging techniques can assist in early detection and treatment determination. Appropriate target pressures, medication selections, and surgical decisions have to be individualized for every patient. As surgical procedures improve, this will become a surgically managed disease rather than medically managed. Steven D. Vold, MD is CEO of Vold Vision, PLLC in Springdale, AR.
References 1. Adapted from Professor Robert N. Weinreb. Hamilton Glaucoma Center, University California San Diego. 2. Gordon MO, Beiser JA, Brandt JD, et al. The Ocular Hypertension Treatment Study: baseline factors that predict the onset of primary open-angle glaucoma. Arch Ophthalmol. 2002;120:714-20. 3. Collaborative Normal Tension Glaucoma Study Group. Comparison of glaucomatous progression between untreated patients with normal-tension glaucoma and patients with therapeutically reduced intraocular pressures. Am J Ophthalmol. 1998;126:487-97. 4. Anderson DR, Drance SM, Schulzer M, et al. Risk Factors for Progression
Glaucoma Surgery
The optimal glaucoma surgery would be safe, easy, effective, repeatable, and combinable with cataract surgery. The trabecular network in the eye is thought to contribute to the increased eye pressure in glaucoma. Trabeculectomy has been the standard surgical method for treating glaucoma but is really a procedure for advanced stage disease. A newer option is minimally penetrating glaucoma surgery. One type of minimally penetrating surgery is the use of the Ex-PRESS device (Exhibit 5). The Ex-PRESS is a very small (<3mm) stainless steel implant that reduces intraocular pressure by diverting the aqueous humor from the anterior chamber of the eye to the subscleral space. This implant is inserted in a minimally invasive procedure under a scleral flap with no tissue removal. Post-op aqueous outflow is controlled by a unique flow-modulating design in the implanted device and the scleral flap. This procedure is at least as effective as trabeculectomy at five years. It appears to reduce postoperative complications and recovery period when compared to trabeculectomy. It is an excellent surgical option in most patients with moderate to severe glaucoma. With the amazing progress that is being made with minimally invasive procedures, these procedures will ultimately be performed in the office set-
of Visual Field abnormalities in Normal Tension Glaucoma. Am J Ophthalmol. 2001;131:699-708. 5. Musch DC, Gillespie BW, Niziol LM, et al. Intraocular pressure control and long-term visual field loss in the Collaborative Initial Glaucoma Treatment Study. Ophthalmology. 2011;118:1766-73. 6. Heijl A, Leske MC, Bengtsson B, et al. Reduction of intraocular pressure and glaucoma progression: results from the Early Manifest Glaucoma Trial. Arch Ophthalmol. 2002;120(:1268-79. 7. American Academy of Ophthalmology. Primary Open Angle Glaucoma Preferred Practice Patterns. 2010. Available at www.aao.org.
30 Journal of Managed Care Medicine | Vol. 15, No. 3 | www.namcp.org