Glaucoma Medical Therapy Research Articles

Evaluating adherence to ocular hypotensives using the Travatan dosing aid

Correspondence: Leslie O’Dell May eye Care Center, 250 Fame Avenue suite 225, hanover, PA 17331-1587, UsA Tel +1 717 521 7161 email leslieod@hotmail.com Purpose: The TravatanTM Dosing Aid (TDA) is the first commercially available device designed to aid in patients’ adherence to their glaucoma therapies and to record patients’ eyedrop administration, so that doctors can better assess adherence. No prior studies have objectively evaluated adherence to glaucoma medications and its relationship to the severity of glaucoma or the use of multiple systemic medications. Methods: We enrolled 100 consecutive subjects from a private glaucoma practice, all currently using topical travoprost 0.004%. Each subject was issued a TDA to record the time and date of each drop instilled. Informed consents were signed and the subjects were aware that their medication use was being monitored. Patients returned for follow-up 30–60 days after their initial exam. Results: 89 subjects completed the study: 44 were male, with a mean age of 67 years, and 69.7% were Caucasian. Overall, patient adherence was 74.8% (range 22%–100%) improving to 85.4% on the day prior to follow-up. The mean number of missed doses per month was 6.24 ± 5.9. Only 7.9% of the study population never missed a dose and 23.6% ± 4.3% missed more than ten drops per month. No marked association was observed between the severity of glaucoma, race, or the number of systemic medications and adherence. A marked improvement in adherence was noted in patients using travoprost 0.004% as monocular therapy rather than binocular therapy, 84.0% ± 17.1% vs 67.4% ± 23.5% (P , 0.005). Conclusion: Patient adherence to glaucoma medical therapy is a major barrier in the management and treatment of glaucoma patients given the chronic nature and asymptomatic course of the disease. Until recently, an objective tool has not been available to the clinician to identify individual patients’ rate of adherence. The TDA is an accurate, adjunctive tool available for assessing patient adherence on an individual level.

Prostaglandin-Timolol Fixed Combinations Efficacy: Myth or Reality?

Prostaglandin-timolol fixed combinations (PTFCs) were introduced several years ago to improve adherence to chronic topical medical therapy in glaucoma (1). Published work has stressed that between 28% and 55% of patients do not adhere to their prescribed treatment regimen (2). Insufficient adherence may diminish efficacy, lead to glaucoma progression, and contribute to the current incidence of blindness among glaucoma patients. A recent metaanalysis of medical therapeutic trials has shown that nonadherence to medical therapy is reduced by 24%-26% with fixed-dose combination regimens, compared with unfixed concomitant therapies (3). Theoretically, topical fixed combinations should provide similar advantages in glaucoma treatment as in other fields of medicine. Nevertheless, as yet the precise impact on adherence of all glaucoma fixed combinations remains to be determined. Although the available information relevant to fixed combinations is increasing rapidly, comprehensive evidence is needed to demonstrate to what extent this class of medications improves adherence, decreases adverse events, and improves long-term clinical outcome. The availability of the PTFCs has simplified adjunctive medication regimens. These combinations generally offer more intraocular pressure (IOP) lowering than each of their components alone, whereas their safety profile is almost as good as their individual constituents (1). Importantly, in real life practice these combinations may provide better IOP control in some patients than unfixed concomitant therapy. Presumably this is due to the combined effects of enhanced convenience, elimination of the washout effect from the second drop, and improved adherence. Nevertheless, although PTFCs generally demonstrate greater efficacy than each of their individual components, the enhanced reduction in IOP with these medications has been less than was originally anticipated. This may be due, at Prostaglandin-timolol fixed combinations efficacy: myth or reality?

Persistence of glaucoma medical therapy in the Glasgow Glaucoma Database

AimsTo report the persistence of glaucoma medical therapy in a database of 1006 patients with ocular hypertension (OHT), normal tension glaucoma (NTG) and primary open-angle glaucoma (POAG) attending the Glaucoma...

Surveillance of glaucoma medical therapy in a Glasgow teaching hospital: 26 years’ experience

Aims:To report the initial findings of a unique database of 956 patients with ocular hypertension (OHT), normal tension glaucoma (NTG) and primary open angle glaucoma (POAG) attending the Glaucoma Clinic...

Determinants of Adherence to Glaucoma Medical Therapy in a Long-term Patient Population

Estimate patient adherence to glaucoma medications and identify potential determinants of nonadherence. Descriptive study. Two hundred patients with open angle glaucoma, ocular hypertension, or glaucoma suspects were interviewed regarding their glaucoma and its treatment and their charts were reviewed. Their ophthalmologist completed a brief assessment form. Drug utilization data were extracted from the provincial drug program database. Patients were defined as adherent if they filled at least 75% of the prescribed medication necessary for their treatment. Data were available for 181 patients. About 62.9% were female and the mean age (+/-SD) was 75.1+/-8.8 years. The mean number of years of glaucoma treatment was 10.7+/-9.3. Self-reported treatment adherence was 88.3%. On the basis of the drug database, the proportion of patients who were adherent to treatment was 71.8%. According to physicians, 74.6% of patients were adherent. Among patients considered by physicians as nonadherent, 71.1% (32/45) were adherent and among patients predicted as adherent, 72.1% (98/136) were adherent. There was no significant difference in adherence according to age, sex, education, and income. However, patients using fewer agents (P=0.041), who were widowed (P=0.041), or who lived alone (P=0.042) were more adherent. Patients using prostaglandins analogs or beta-blockers were more adherent than those using carbonic anhydrase inhibitors (P<0.05). Fewer medications, use of prostaglandin analogs or beta-blockers, living alone, and being widowed were significantly associated with adherence. Physicians were unable to significantly predict which patients are adherent.

Bilateral iridocorneal endothelial syndrome in a young girl with Down′s syndrome

We describe the occurrence of bilateral iridocorneal endothelial (ICE) syndrome with glaucoma in a young girl with Down's syndrome. A 16-year-old girl with Down's syndrome was found to have secondary glaucoma in the right eye with features of progressive iris atrophy in both eyes. She was uncontrolled on maximum tolerable medical therapy for glaucoma. She underwent an uneventful trabeculectomy with mitomycin-C in her right eye. Scanning electron microscopy of the trabecular meshwork obtained in this case is described.

Medical Therapy for Glaucoma: The Next 20 Years

Current medical therapy for glaucoma relies on intraocular pressure (IOP) regulation via enhancing aqueous humor outflow and/or decreasing aqueous inflow. The relationship between inflow and outflow determines IOP and may be modulated by receptors or mediators within the eye, which detect changes in IOP and trigger responses to adjust fluid balance. Inflow via aqueous humor formation (AHF) is the result of three physiologic processes: diffusion, ultrafiltration and active secretion, which can be affected by therapies using betablockers, carbonic anhydrase inhibitors and α2-adrenergic agonists. Decreased blood flow can also decrease AHF. Aqueous humor outflow occurs principally via the trabecular and the uveoscleral routes, which are targeted with cholinergics, adrenergic agonists and prostaglandin (PG) analogs. The chronic nature of the disease makes patient compliance with multiple, additive therapies problematic. As described below, the next 20 years will see the development of new treatment strategies with longer duration of effect and increased efficacy that will decrease the role of the patient in the treatment equation and reduce adverse events.

Adherence with antiglaucoma therapy

AbstractIn recent years an increasing attention has been drawn towards the performance of drugs in the real world. Beyond the mere IOP lowering effect, the treatment success implies a number of issues regarding the acceptance and adherence to the therapy.Health outcome studies and studies on compliance showed poor persistency and adherence levels for glaucoma medical therapy with higher scores for prostaglandine analogues. Adherence is in fact linked to many variables: regimen factors (as complexity of treatment, tolerability, side effects), patient factors (as memory, motivation, knowledge), provider factors (as dissatisfaction or poor communication with the physician) and situational factors ( as competing activities, change in routine). The choice of a therapeutic strategy capable of minimally influencing the patients’ quality of life is crucial for optimal adherence and improving doctor‐patient communication is essential in favouring patient’s decision‐making about health‐promoting behaviors.

Fixed-combination travoprost 0.004%/timolol 0.5% for open-angle glaucoma or ocular hypertension

DuoTrav™ eye drop solution is a fixed combination of travoprost 0.004% and timolol 0.5% that has proven efficacious in lowering intraocular pressure in clinical trials. This combination of two of the more potent topical medications available today has the potential to contribute significantly to the success of medical glaucoma therapy. By maximizing patient adherence through the use of a combination drug, the burden of topical glaucoma therapy is reduced and is likely to improve both the convenience of care and clinical outcomes.

What's Your Diagnosis?

&lt;h4&gt;The Case&lt;/h4&gt; &lt;p&gt;A 6-month-old infant presented for evaluation of anisocoria. At 1 month of age, a left nasolacrimal duct obstruction (NLDO) was recognized. Treatment with TobraDex ointment (Alcon, Fort Worth, TX) twice daily was started and continued until 5 months of age, when enlargement of the left cornea was noticed (Figure). Successful NLDO probing was then performed, and examination with anesthesia revealed an enlarged eye, anisocoria, intraocular pressure (IOP) of 30 mm Hg, and optic disc cupping on the left. A 2-month trial of medical glaucoma therapy failed, and a goniotomy was advised (S. Salim, MD, and D. S. Walton, MD, unpublished data, 2005). At 20 months after goniotomy, the IOP is well controlled without medication.&lt;/p&gt;

Zur Problematik des Glaukoms in Afrika - ein Erfahrungsbericht aus Kamerun

Glaucoma is one of the most common causes of blindness in the world. This aspect is well known for the developed countries, however in Africa blindness mainly occurs due to cataract, trachoma and onchocercosis. Glaucoma is not mentioned enough. Patients present with severe findings after a long-lasting history of disease. In our project experienced surgeons and young medical doctors have been practising regularly in Cameroon since 2001. By means of support from the "Komitee zur Verhütung von Blindheit" and medical industries we keep in contact with a local ophthalmologist. During the consultation of hundreds of patients we have often seen highly advanced glaucoma cases. The medical therapy of glaucoma and also the surgical procedures are limited -- modern antiglaucomatosa are not available. We achieved sufficient regulation of intraocular pressure after trabeculectomy with or without cataract surgery in many cases. The success rate was decreased by severe scar reactions especially in young black people. In advanced glaucoma cases and oculus ultimus we also used the old techniques of iridencleisis. There was a good postoperative regulation of eye pressure, but sometimes we saw a giant filtering bleb after this iris-mutilating procedure. Glaucoma is a very complex problem, also in Cameroon. Although the diagnostic possibilities are limited, the therapeutic spectrum is differentiated. The introduction of a robust laser for cyclophotocoagulation would be a useful alternative.

Medical Therapy of Glaucoma

Prescribing medical treatment for glaucoma requires a complex decision-making process that involves the patient, the severity of the disease, the therapeutic options available, and their potential side effects. Lowering intraocular pressure, a known risk factor for progression, has been the mainstay of glaucoma treatment. Most patients who are first diagnosed with glaucoma in the United States are started on topical medications. As our understanding of the disease changes and newer treatments become available, glaucoma therapies may need to be reassessed and changed if necessary.

Cost considerations of the new fixed combinations for glaucoma medical therapy

To compare the costs of the new fixed combinations for glaucoma medical therapy. The studied drugs were: Cosopt (5-mL bottle), Combigan (5-mL bottle) and Xalacom (2.5-mL bottle). Five bottles of each drug were obtained from pharmacies, and the medications lot numbers were recorded. To calculate the drop volume, 10 drops and 1 mL of each bottle were weighed with a digital precision scale. Drop volume was calculated by the relation between volume and weight. The cost of each bottle of medication was determined from the average retail price in Canada. The prices were obtained in Canadian dollars (dollars). The drops of Cosopt (39.60 +/- 0.45 microL) were considerably larger than the drops of Combigan (33.75 +/- 0.60 microL) and Xalacom (30.87 +/- 0.37 microL). The average number of drops per millilitre varied from 25.25 +/- 0.29 (Cosopt) to 32.40 +/- 0.39 microL (Xalacom). Combigan presented the lowest daily cost (dollars 0.87 +/- 0.02) followed by Xalacom (dollars 1.09 +/- 0.01) and Cosopt (dollars 1.22 +/- 0.01). The average cost by year varied from dollars 316.75 +/- 5.59 (Combigan) to dollars 445.96 +/- 5.16 (Cosopt), with a total difference of dollars 129.21 per year of treatment. There was a statistically significant difference in average drop size and cost among the three studied drugs. Combigan presented the lowest daily cost followed by Xalacom and Cosopt.

Gold standard medical therapy for glaucoma: Defining the criteria identifying measures for an evidence-based analysis

Background: Over the past decade, several new medical therapies have become available for the treatment of primary open-angle glaucoma (POAG). A systematic evidence-based approach for identifying an optimal therapeutic agent is lacking. Objectives: The aims of this review were to critically evaluate published treatment recommendations for POAG and, based on a systematic review of the literature, to develop criteria that would define a “gold standard” medical therapy that reflects new treatment advances and established therapeutic goals. Methods: A MEDLINE search spanning the years 1966 to 2002 and using the search terms gold standard, drug of choice, agent of choice, benchmark, ophthalmology, eye, and glaucoma was conducted and the results reviewed by a panel of 15 experts in the field of glaucoma. Published treatment recommendations for POAG were discussed. Criteria, anchored to medical evidence, for distinguishing a standard of medical therapy for POAG were defined. Results: The terms connoting a gold standard therapy were found in only 258 of ∼368,000 ophthalmology-related citations and 53 of almost 23,000 glaucoma citations, validating the need to define therapeutic standards. The lack of recommendations for the use of new classes of ocular hypotensive agents was acknowledged. Criteria identified to evaluate intraocular pressure (IOP)—lowering agents as gold standards included the following: efficacy in reducing IOP consistently over a 24-hour period to a level that will preserve the visual field and protect the optic nerve without inducing tachyphylaxis and tolerance, paucity of local and systemic adverse effects, promotion of patient compliance, and applicability in diverse patient populations. Conclusions: These criteria should be employed as measures for evidence-based analyses to evaluate available and future IOP-lowering medical therapies for POAG. The conceptual framework presented may be applicable to other therapeutic areas.

Glaucoma Implant Surgery With Autogenous Fascia Lata in Scleromalacia Perforans

A 51-year-old woman with bilateral scleromalacia perforans and advanced glaucoma in the left eye was evaluated. Glaucoma implant surgery with autogenous fascia lata graft for reinforcement of the underlying sclera and a patch graft overlying the tube to prevent tube erosion was planned because of insufficient response to medical glaucoma therapy. Intraocular pressure decreased from 55 to 15 mm Hg and remained under 20 mm Hg throughout the follow-up period of 24 months. No complication was noted. Glaucoma implant surgery using autogenous fascia lata to form a healthy ground and a patch graft to prevent tube erosion seems to be a safe and effective method when normal sclera is lacking, such as in scleromalacia perforans.

Medical therapy cost considerations for glaucoma

PurposeTo determine the calculated daily patient cost (cost minimization) of medical glaucoma therapy and review cost trends. DesignExperimental, controlled, prospective study. MethodsThe actual volume of various glaucoma medications or glaucoma medications with redesigned bottles was determined for most commercially available sizes of the tested products. The drops per milliliter based on the actual volume and the daily costs of the dosage schedules recommended by the manufacturers were compared. The cost of each bottle of medication was determined from the average wholesale price (AWP) in the United States. A comparison to 1999 prices where applicable will be analyzed to review costing trends. ResultsThe generic timolol products (range, $0.38– $0.46 per day) were similar on a cost per day basis vs Betimol (Santen, Napa Valley, California, USA), Optipranolol (Bausch and Lomb Pharmaceuticals, Tampa, Florida, USA) and Timoptic (Merck, West Point, Pennsylvania, USA). Their percentage cost increase ranged from 5% to 22% since 1999, except for generic timolol XE gel-forming solution (48%). Betagan (Allergan, Irvine, California, USA), Betoptic S (Alcon Laboratories, Fort Worth, Texas, USA), and Ocupress (Novartis, Duluth, Georgia, USA) ranged from $0.88 to $1.11 per day, and their percentage cost increase ranged from 33% to 53%. Some brand-only products have raised their AWPs a greater percentage, including Betoptic S (37%), Iopidine (Alcon, Fort Worth, Texas, USA) (50%), Ocupress (Novartis Ophthalmics, Duluth, Georgia, USA) (53%), and Pilopine gel (Alcon, Fort Worth, Texas, USA) (32%).The mean cost per day for the topical carbonic anhydrase inhibitors Azopt (Alcon Laboratories; $1.33 per day) and Trusopt (Merck; $1.05 per day) differed from 1999 when prices were almost identical. Cosopt (Merck; timolol 0.5% plus dorzolamide 2%, $1.04 per day) was less than the cost of separate bottles of a topical carbonic anhydrase inhibitor and a β-blocker.The selective α-2 agonist brimonidine 0.15% with Purite (Alphagan-P, Allergan, 5 ml) twice daily was $1.29 per day. The prostaglandin analogs were comparably priced with Lumigan (Allergan) $0.95 per day, Xalatan (Pharmacia and Upjohn, Kalamazoo, Michigan, USA) $1.25 per day, Travatan (Alcon Laboratories) $1.01 per day, and Rescula (Novartis) $0.90 per day. ConclusionsAll generic timolol, Betimol, Optipranolol, Timoptic, and Timoptic XE (Merck) ranged from $0.38 to $0.50 per day. Other β-blocker products were about twice as costly, ranging from $0.88 to $1.11 per day. Cosopt ($1.05 per day) was less costly than separate bottles of a topical β-blocker and a topical carbonic anhydrase inhibitor dosed three times daily or twice daily. The prostaglandin analogs ranged from $0.90 per day (Rescula) to $1.25 per day (Xalatan). Newer glaucoma medications exhibit similar costs per day in many cases, compared with more traditional medications, especially with greater price increases in older brand-only products.

Glaucoma medical treatment--2002: does yearly cost now equal the year?

To review costs of the wide array of glaucoma medications available today as well as patient-assistance programs. Potential yearly costs for current frequently used single and multiple drug therapies were determined, taking into account the actual (not labeled) volume of drops in the bottled medications. Alternative modes for obtaining medications, such as compassionate-use programs, were also surveyed. "Maximum" medical therapy may cost over $2000 per year. Allergan, Ciba, Merck, Pharmacia-Upjohn, and Alcon offer patient-assistance programs of variable simplicity of use. The cost of maximum glaucoma medical therapy can assume a significant proportion of an elderly patient's yearly income.

Clinical Pathways in Glaucoma

Clinical Pathways in Glaucoma, Thom J. Zimmerman, M.D., Ph.D., editor, Thieme Medical Publisher, Inc., New York, 2001, $99.00 This is a great book! While most of the glaucoma texts on my shelf can be considered references, this book is a clinical tool. This book is one in a series of “Clinical Pathways” titles. The book consists of twenty-two chapters by twenty-six authors. Each chapter covers a different topic, such as childhood glaucoma, normal tension glaucoma, glaucoma associated with inflammation, and glaucoma associated with intraocular tumors, for the first seventeen chapters. Chapters eighteen through twenty-two address specific clinical situations: medical therapy of glaucoma; surgical therapy of glaucoma; management of cataract and glaucoma; management of glaucoma in pregnancy; and management of blind, painful eyes from glaucoma. Each chapter is arranged with the major headings: “definition, epidemiology and importance, diagnosis and differential diagnosis, treatment and management, and future considerations”. Within these major headings, the text is organized with clinically relevant questions. For example, in the diagnosis and differential diagnosis section of the chapter normal tension glaucoma by Mundorf, the subheading questions are: What are the findings in NTG? What are the visual field findings in NTG? How should the NTG patient be evaluated? In the excellent chapter on Childhood Glaucoma by Warren and Gökmen, under the heading Diagnosis and Differential Diagnosis, some of the questions are: How is childhood glaucoma diagnosed? How does primary infantile (congenital) glaucoma present? How does juvenile open-angle glaucoma present? What is the best way to examine a child if glaucoma is suspected? What are the clinical signs to look for during the examination? How does one determine if the child has primary infantile glaucoma or another form or childhood glaucoma? Can other disease processes in children mimic childhood glaucoma? What are other causes of excessive tearing? What are other causes of a cloudy cornea? These are the questions that are important to a clinician when managing a patient and the answers are brief and pertinent. The book is abundantly illustrated with useful flow charts. These flow charts are not exhaustive, but rather are clinically practical guides to working through complex diagnostic and management problems. The text is five hundred forty-five pages, and is well indexed. Most of the authors have been associated with one of the two editors, either during fellowship, or being in the same academic departments. Despite this, there are a refreshing variety of approaches. The authors, first and foremost, are experienced clinicians who share their insights with the reader. This book is highly recommended for ophthalmologists in training. I know of no other contemporary source so full of clinically practical material. It would also serve well on a bookshelf of the comprehensive ophthalmologist who wants a useful clinical text to assist in making appropriate patient care decisions. The chapters are short, clearly written, and each can be easily digested in a single session. While glaucoma specialists might quibble over some of the fine points in these chapters, any comprehensive ophthalmologist who practices glaucoma treatment to the standards outlined in this book will be doing a fine job indeed. I only wish the publishers had prepared crib cards with the flow charts for me to hand out to our residents.

The risk of obstructive airways disease in a glaucoma population.

Asthma and chronic obstructive pulmonary disease (COPD), defined as obstructive airways disease (OAD), are two common chronic conditions especially in the elderly. Glaucoma is also a common disease in the elderly with a prevalence close to 5% among those older than 75 years. Most medical therapy for glaucoma is given as eye drops. It has been described that small amounts of systemically absorbed beta-blockers can produce significant respiratory adverse events in predisposed patients. Population-based cohort study with nested case-control analysis using the UK General Practice Research Database (GPRD). We studied the prevalence of OAD in a cohort of patients 60 to 85 years old with a first ever diagnosis of glaucoma and compared it to the prevalence in an age- and sex-matched cohort sampled from the general population. We also calculated the RR and 95% CI of worsening asthma in non-severe asthma patients among the two cohorts. Incidence of OAD was studied in a cohort of glaucoma patients 60 to 85 years old and in an age- and sex-matched cohort from the general population. The prevalence of OAD was the same between the glaucoma cohort and the general population (OR 1.1; 95% CI 0.9-1.4). The risk of worsening asthma associated with glaucoma was OR 1.2 (95% CI 0.5-2.8). The incidence of OAD was similar in both cohorts. Current users of ophthalmic drugs presented a RR of 1.2 (95% CI 0.8-1.9) of developing asthma compared to non-users in the glaucoma population. The risk in the first month of treatment with topical beta-blockers was 2.1 (95% CI 0.7-6.7). We did not find an association between glaucoma and OAD. Use of topical glaucoma medication was not associated with a major increased risk of asthma.

Ocular pharmacology

Many new drugs come on the market each year, and some very useful ones become unavailable. Medical treatment of some of the more common ophthalmic conditions observed in small animal practice are discussed in this article. Selection of the appropriate antibiotic or antiviral is critical for effective treatment, and indications for these drugs are provided. Anti-inflammatory medications and their indications and contraindications are also discussed. Medical therapy of glaucoma is also addressed.