EyeWorld Asia-Pacific March 2016 Issue

Glaucoma treatment March 2016 31 EWAP SECONDARY FEATURE that app reminders may only be useful in the short term but true dedication to drop compliance requires embedding it into one’s lifestyle—like brushing one’s teeth. Engaging the family and carers may also pay dividends. Wang Ningli, MD On ‘Extending the duration of glaucoma medications’ To enhance the adherence of glaucoma patients, developing a long-term drug delivery product is very promising. There are a lot of challenges that need to be surmounted as mentioned by other colleagues in this article. The fundamental problem will be how the drug is being released? It consists of 4 “Ws”: Where to implant the product (inside or outside the eye)? Which drug can be designed as long-term delivery product? What concentration will it be released to achieve the best efficacy and risk ratio? What is the frequency (pulsatile delivery or continuously)? After all these have been solved, it then comes to the problem of technology, including 3 “Hs”: How to design the product with minimum irritation to the eye? How to implant without surgical risk? How to ensure the device is still working without leaving the patients under no necessary therapy for the follow- up duration (such as if the device has fallen out or the drug has run out)? Several devices have been designed and may still have a lot of problems; however, as new devices come to the market and longer-term data become available, it is likely that long- term drug delivery products will have increasing options for the medical management of glaucoma and enhance the compliance of patients. On ‘Navigating through the sea of glaucoma medications’ Most glaucoma physicians will commence with medical therapy for newly diagnosed glaucoma patients. When a glaucoma physician prescribes medication, several aspects should be taken into consideration. First, which category of glaucoma medication should be chosen? Second, can the patient endure the side effects? Third, the patient’s compliance. Fourth, whether a prescription is affordable. Most glaucoma physicians agree that prostaglandin analogs (PGAs) are their go-to first-line treatment for newly diagnosed glaucoma. Some patients might not be able to stand the side effects, or they might not be able to afford the medication. The side effect and the financial burden definitely will affect a patient’s compliance. In our practice, we also weigh a lot on compliance and adherence, because it is a big issue in China. We will prescribe PGAs first; if the response is not enough, we will try another PGA because it is probably due to the side effects that affect the patient’s compliance. Then add a beta blocker or switch to combination drops for those with inadequate response. For those patients who cannot undergo regular follow-up or stand the side effects, we will offer LTPs. But physicians should inform their patients that LTP may not be sufficient, eye drops and follow-up are still imperative. It is very important to establish a relationship with mutual trust between physicians and patients: if physicians prescribe the medication according to the patients’ real request, the patients adhere to the prescription and provide feedback on the real effect of the prescription, then patients can benefit more from our decisions. On ‘Non-adherence in glaucoma therapy’ Glaucoma patients usually require lifelong commitment to medical treatment, and there are no great incentives to use drops to relieve pain; therefore, non-adherence often becomes a serious issue in glaucoma patients. Although the physician may have sufficiently explained the importance of the therapy, it’s still a struggle. Experienced physicians may detect non- adherence in patients, but sometimes they still won’t make a correct assessment of the previous prescription and may directly add another medication, which may then add to the financial burden or side effect, and then the compliance may even get worse. To enhance the adherence, it is very important to establish a relationship with mutual trust between the physicians and their patients. For those with obvious non-adherence, laser trabeculoplasty or incisional surgery may be introduced, and they may benefit more from long- term drug delivery products as new devices come to the market and longer-term data becomes available. References 1. Chan HH, Wong TT, Lamoureux E, Perera S. A Survey on the Preference of Sustained Glaucoma Drug Delivery Systems by Singaporean Chinese Patients: A Comparison Between Subconjunctival, Intracameral, and Punctal Plug Routes. J Glaucoma . 2015 Sep;24(7):485-92. 2. Lamoureux EL, Mcintosh R, Constantinou M, et al. Comparing the effectiveness of selective laser trabeculoplasty with topical medication as initial treatment (the Glaucoma Initial Treatment Study): study protocol for a randomised controlled trial. Trials . 2015 Sep 11;16:406. 3. Quek DT, Ong GT, Perera SA, Lamoureux EL, Aung T. Persistence of patients receiving topical glaucoma monotherapy in an Asian population. Arch Ophthalmol . 2011 May;129(5):643-8. Editors’ note: Glaucoma medical treatment relies heavily on patient involvement. As a guide for patients, Prof. Goldberg has co-authored along with Remo Susanna, Jr., the book Glaucoma: How to save your sight! available through Amazon, Google PlayStore, iTunes, and Kugler Publications. Dr. Perera is a consultant for Allergan, Alcon, and Ellex (Adelaide, Australia). Prof. Wang declared no relevant financial interests. Contact information Goldberg: +61-2-9247-9972; eyegoldberg@gmail.com Perera: +6596312157 shamira.perera@snec.com.sg Wang: +86-10-58269920; wningli@vip.163.com