Combating compliance issues by reducing dependence

September 1, 2013

Here, Dr Noecker discusses options that are available to patients, highlighting the MIGS procedures, which he believes offer promise to reign in compliance issues in glaucoma care.

To treat glaucoma properly, it is necessary to lower eye pressure to a lower-than-average level, and do it on a consistent basis. While other disease states require the patient to simply take a pill, glaucoma requires the patient to administer eye drops multiple times per day, which is more difficult and less comfortable for the patient. It is well documented that among glaucoma patients who have been diagnosed and are prescribed therapy, compliance is far from optimal - a common situation in chronic conditions that are largely asymptomatic (i.e., hyperlipidaemia, hypertension, etc.). Studies have shown that glaucoma patients received their eye drop therapy an average of only 7 out of 10 days.5 Additional studies revealed that 50% of managed care patients had stopped filling their eye drop prescription by one year after diagnosis.6

In the battle for compliance with daily or ongoing medical therapies, the most important factor is keeping the therapy regimen as easy as possible while still treating the disease effectively. My sound bite is really 'keep it simple'. Success comes by minimizing the number of medications that the patient is required to use on a daily basis to maintain low eye pressure. Decreasing complications and decreasing cost translate into the highest likelihood that the patient will comply and manifest the fewest side effects.

As the glaucoma population tends to be elderly, many patients manifest concomitant cataracts. While there is good evidence that removing a cataract in a glaucoma patient can sometimes help to lower IOP, cataract surgery alone may not be sufficient and it has not been proven that cataract surgery produces a sustained lowering of IOP in glaucoma patients. Combining a glaucoma surgery with cataract surgery provides a higher probability of IOP lowering for the patient.

There is a large spectrum of glaucoma surgeries that can potentially be used, and it is important to find one that matches the patient's profile. In general, a trabeculectomy has the highest probability of lowering IOP to a level of 10 mmHg. However, it also has the greatest risk of hypotony and other adverse events. Other incisional surgery options are tube shunts such as the Baerveldt or Ahmed. These require an involved procedure with high morbidity and long recovery periods, so these are typically reserved for situations such as failed trabeculectomy, active uveitis, neovascular glaucoma, or scarred conjunctiva.