Optimising care

[caption id="attachment_8086" align="alignnone" width="300"] Anton Hommer MD[/caption] Ophthalmologists face a host of new challenges in the management of glaucoma as the natural history of the disease becomes better understood and new technologies and surgical techniques become available, said Anton Hommer MD, PhD, Hera Hospital Vienna, Austria. “There are many changes in diagnosis and treatment of glaucoma that have occurred over the past 20 years and the challenge before us today is to provide a very individual strategy for each patient in a cost-effective way,” Dr Hommer told the XXXIV Congress of the ESCRS in Copenhagen, Denmark. He noted, for example, that research now supports much more frequent visual field testing than was previously the case. Depending on the stage of disease, newly diagnosed cases should undergo up to six perimetry sessions in the first two years, current guidelines recommend. “This is a challenge because we have to convince not only the patient, but also the payer whether it's an insurance company or the government health service,” he added. Newer technologies such as optical coherence tomography (OCT) present a similar problem regarding reimbursement. It is also still not clear how often OCT tests should be performed. In addition, the software of the devices provides only the statistical likelihood of abnormality, rather than a diagnosis of glaucoma. Regarding treatment, there are now a range of aqueous drainage devices for use in minimally invasive glaucoma surgery. The mainly ab interno devices have shown promising results in the short to medium term and their implantation involves a fairly simple procedure. However, their true therapeutic benefit and cost-effectiveness cannot be determined until long-term results become available. Meanwhile, numerous large randomised controlled trials have changed the recommendations regarding when to prescribe topical treatment. In eyes with glaucomatous disease, a pressure of 21mmHg was considered acceptably low to prevent progression. Nowadays the target intraocular pressure tends to be lower. That, in turn, naturally increases the number of patients coming into the treatment fold and increases the overall expenditure on the disease. And that is apart from the increasing prevalence of glaucoma which is resulting from the ageing population, he said. PATIENT-PHYSICIAN PARTNERSHIP Much of the added expenditure will be wasted if patients cannot be convinced of the importance of adhering to their prescribed regimens. Electronic eye drop bottles that remind patients to instil their eye drops and monitor their usage are one option. However, it may be more important to communicate to the patient the importance of following their prescribed regimen, he said. He cited a study in which glaucoma patients were asked what they thought would help them learn more about eye care and eye disease. The greatest proportion rated more time during a consultation with the ophthalmologist. “So the patients want more communication. That is an important consideration, because there is a move towards replacing us with machines. But this is not what the patients want,” he said. Telemedicine is another tool that has been proposed as an enhancement to glaucoma management. He noted that, while it can provide better access to care, the care it provides may not always be better for the patient. “Telemedicine has some disadvantages because there is no personal interaction between the patient and doctor and it’s not a full evaluation of the entire patient,” he said. He added that a failure of communication between the patient and the physician often lies at the root of the failure of treatment. Ophthalmologists therefore need to take more time to listen to their patients’ fears and expectations and explain to them the nature of their disease and its treatment. Unfortunately, such consultations tend to be poorly reimbursed. “This is something we have to change because the patients need this. And if we can provide our patients with a clear understanding of what is at stake, they will be more likely to do what is needed.” Anton Hommer: a.hommer@aon.at