It might seem hard to believe, but our patients’ lives are often as busy as our own. Next time you think about prescribing a medicine to be taken every day or even several times a day, think about how disruptive even that small change would be to your already hectic schedule.
Glaucoma is a disease that is particularly sneaky because, unlike the flu, by the time patients notice that there is a problem, it may be too late to save their vision. And every medicine has side effects — every glaucoma medication causes or worsens dry eye disease, and they can also cause eye redness, fast or slow heartbeat, exercise intolerance or impotence. In my neck of the woods, there are many patients who have aggressive glaucoma — IOPs of 30 mm Hg and 40 mm Hg aren’t unheard of — and many of them are unable or unwilling to commit to routine medications or even appointments.
Because we work so extensively with dry eye patients, I turn to laser first for glaucoma treatments. I am sure there are exceptions to the rule, but studies show us time and again that all patients are noncompliant patients on chronic therapies. Even if it’s a small treatment gap, over time, it adds up to vision loss. That’s why I go straight to a laser treatment. As a general rule of thumb, I find I can lower IOP sufficiently to relieve patients of one, maybe two, medications with procedures like MicroPulse laser trabeculoplasty (MLT) or selective laser trabeculoplasty (SLT). If I need to lower IOP further, I go straight to MicroPulse cyclophotocoagulation (MP-CPC) with the Cyclo G6 laser (Iridex). With MP-CPC, I can lower IOP roughly equivalent to two to three medications, which is generally equivalent to doing a trabeculectomy without the OR time or lengthy postop recovery. Most of my patients can avoid interventional surgery with this approach.
MicroPulse P3 (MP3) is easy to perform and can be done in the office. If a patient is especially anxious, I have Valium on hand, but 90% of my patients don’t need or request it. It’s time efficient, and I can work laser treatments into any clinical day; I don’t have to set aside time to get to the ASC, change into scrubs or use valuable ASC time for anything other than more invasive surgeries. When you calculate the value of an ophthalmologist’s time plus the cost of OR time and overhead, there are definite economic advantages to performing laser treatment in the office, too. And because it is a stand-alone treatment, I don’t have to combine MP-CPC with cataract surgery and suffer that fee cut. Patients and payers have the savings of reduced topical medication costs, and patients appreciate the improvements to their ocular surface and freedom from drops.
The postop recovery is significantly better than traditional trabeculoplasty. I start patients on Lotemax (loteprednol etabonate, Bausch + Lomb) four times a day and see them back at 1 day, 1 month, 3 months, and then back to a regular monitoring schedule if possible. However, if a patient doesn’t show up for their follow-up appointments, at least I know there is a good chance that their pressure is much better than it was before they came in and will stay that way for 1 to 3 years, according to current data.
There are many newer options out there, but I’d have to say, I’ve been really happy with SLT and then going to MP3 after that because patients can get the results of a more invasive glaucoma surgery with a noninvasive in office procedure. Quick, simple, effective — what could be better than that?
Easy for patients, easy for doctors.
Disclosure: Toyos reports she is a speaker and consultant for Valeant and Sun; conducts research for Lumenis, Magellan and Kala; is a speaker and consultant and does research for Shire, Mallinckrodt and MixtoLasering; is a consultant and does research for DigiSight; does research for Novaliq; and is a consultant for Iridex.