Harry Quigley, MD, shares glaucoma pearls at SECO

Atlanta, GA-Harry Quigley, MD, of the Wilmer Eye Institute at John Hopkins, shared some of his pearls for diagnosing and treating glaucoma, during a special session at SECO.

“The single most important thing I could tell you is that glaucoma is not a disease of elevated eye pressure; it is a disease in which the eye pressure is a very important factor in the patient’s care,” says Dr. Quigley.

He said glaucoma occurs at normal pressure. The risk is not an elevated intraocular pressure (IOP), but the level of the IOP that matters.

About 50% of open-angle glaucoma (OAG) is undiagnosed. Dr. Quigley said eyecare professionals miss about a third of the OAG by stressing the “magic number” 21. The risk of field loss in patients with ocular hypertension varies by age and gender. Once you determine the risk, it is important to determine the baseline IOP over 3 visits and find a target IOP.

The vast majority of OAG patients progress relatively slowly, says Dr. Quigley. Early on, optometrists should conduct visual field tests several times a year.

“After 4 or 5 field tests, you’re going to be able to tell who’s stable. There are some patients who worsen catastrophically, and you have to locate them. The only way we’ll know that is through field testing, and doing more field testing than we are now,” says Dr. Quigley.

When it comes to drop therapy, Dr. Quigley said he is in favor of unilateral eye drop trials over the course of 2 to 3 visits. While the 2 eyes are not exactly correlated, they are highly correlated. Using the drop in just one eye can help you judge the side effects.

Dr. Quigley said fewer than 50% of OAG patients who were given a first prescription for drops were still taking those drops after one year.

To promote compliance, first identify those patients who are likely to be non-adherent:

• They admit they missed 1 or 2 drops in the past 2 weeks

• They cannot name their drops

• They miss return visits (“No show means no drops,” says Dr. Quigley.)

• The youngest and oldest patients

• They do not know anyone who lost vision from glaucoma

• African-Americans

Dr. Quigley said in interviews with patients and their doctors, 95% of patients claim to take every drop; doctors think 80% of patients are compliant; but patients are taking drops only 70% of the time.

To help with compliance:

• Drops need to kept in a place where the patient will see them-not in a refrigerator, as is sometimes recommended by pharmacists.

• Have the patient set an alarm on her cell phone to go off at the same time every night as a reminder.

• Let the patient know he likely won’t have to use the drops for the rest of his life; new technology will allow for other methods of medication administration in the near future.