EyeWorld India March 2016 Issue

Glaucoma treatment March 2016 25 EWAP SECONDARY FEATURE been able to establish a solid relationship with the patient and I think they have a good understanding of what to expect.” Dr. Parekh, on the other hand, gives his patients the option of SLT as a first-line treatment. With newly diagnosed glaucoma, he’ll typically offer patients a choice between SLT and a PGA; about half of his patients choose the laser. He thinks it’s important for the doctor to spend time discussing the pros and cons of both LTP and drops with each patient. “Compliance and adherence are big problems in glaucoma, and I like the idea of SLT because the patient doesn’t have to remember to do it every day,” he said. “I think glaucoma doctors in general hugely underestimate how hard to selecting the right medication for each patient. If a prescription is not affordable, compliance quickly becomes an issue. “Finances and insurance coverage obviously have a large impact on which medications a patient uses,” Dr. Grover said. “In order to provide quality glaucoma care, the physician must understand the financial implications of the recommended treatment plan.” Prices for generic medications have gone up over the past several years, and physicians can no longer assume that the generic option is always the least expensive. “I encourage my patients to shop around with regard to their medications and to find a pharmacy that provides them with the most reasonable cost,” Dr. Grover continued. “I will sometimes send the patient out with a prescription for latanoprost [Xalatan, Pfizer, New York], bimatoprost [Lumigan, Allergan], and travoprost [Travatan, Alcon] and tell them to purchase the one that is least expensive.” Dr. Wallace chooses a brand or generic drop based on what is covered by the patient’s insurance—with certain exceptions. “If a patient has an inadequate response to a generic prostaglandin, I will usually try a brand prostaglandin first before adding a second drop,” she said. “If there is a significant improvement in intraocular pressure with this switch, this is a situation where it is preferable to be on a brand medication if it spares the patient from having to use an additional medication. Also, there are higher rates of allergy with generic alpha- agonists, so I favor the brand for this category of medications.” Although branded and generic medications have the same active ingredient, the inactive ingredients may differ, and patients can have an adverse reaction to either component. But it’s important to remember that no decision is ever final—you can always switch from a generic to a brand-name product or vice versa, Dr. Parekh said. “In medical management of glaucoma, there’s so much follow-up and fine tuning and adjusting that happens,” he said. “It’s about listening to the patient and remembering to ask about side effects. The decision is never final; it’s ‘let’s try this and see how it goes.’” Where does laser trabeculoplasty fit in? As with second- and third-line medical treatments, there is no consensus among physicians on where laser trabeculoplasty (LTP) fits into the treatment paradigm. “In our current healthcare system, I do not think it is appropriate to perform LTP on a newly diagnosed glaucoma patient without attempting a glaucoma drop first,” Dr. Grover said. “Starting a patient on drops, even for a few months, gives them exposure to the challenges of using glaucoma medications and the adverse side effects. During this time, the doctor is also able to establish a relationship with the patient that will set the stage for LTP in the future.” Dr. Grover has found in his experience that too often, patients who choose LTP early in the treatment process without a solid understanding of the disease feel that after laser treatment, their glaucoma is “fixed.” This can alter their compliance with follow-up and often adversely affects their care, he said. “I, therefore, will only perform LTP once I have it is for patients to take their drops, to afford their drops, to remember to go to the pharmacy every month. There are so many obstacles and hurdles that a patient has to go through from the moment the doctor writes the script to the drop actually getting in the eyeball. I think SLT is so nice because it skips all that. If it doesn’t work, you can always do drops then.” EWAP Editors’ note: Drs. Grover and Wallace have financial interests with Allergan. Dr. Parekh has financial interests with Alcon, Allergan, and Bausch + Lomb (Bridgewater, NJ). Contact information Grover: dgrover@glaucomaassociates.com Parekh: parag2020@gmail.com Wallace: danajwallace@gmail.com