Patients need to become partners in glaucoma care

For the past 25 years, the medical management of glaucoma has become increasingly successful. The medications currently available have superior tolerability and efficacy compared with the most commonly used drugs 20 years ago.

Throughout the 1980s, non-selective beta-blockers and miotics were the most commonly used agents. The beta-blockers had significant systemic side effects including cardiovascular and pulmonary alterations. Miotics were marred by profound miosis, induced myopia, and the increased risk of retinal detachment.

Next, the prostaglandin analogs were developed, which was a major improvement on efficacy and safety as systemic side effects were replaced with manageable tolerability issues. Newer generations of prostaglandin analogs have recently been introduced and this is the most promising area of future research for glaucoma medications.

Ascertaining patient priorities The Glaucoma Research Foundation patient survey was compiled using responses from the 4,300 readers of GLEAMS, a magazine published by the foundation. The primary objective of the survey was to elucidate patient priorities in glaucoma treatment. Another objective was to gain a better understanding of factors that influence the doctor-patient relationship.

When patients were questioned about the goals of medical therapy for glaucoma, the most impressive answers related to their desire to be offered the most efficacious treatment. Of the respondents, 92% of patients expressed a desire to be prescribed the medication that lowered IOP the most, even after being informed that this medication could cause hyperemia for a period of weeks. Equally as powerful was the finding that 87% of respondents indicated that side effects would not cause them to stop taking their medication. These two findings suggest that in general, physicians may not understand the goals of their patients.

The American Academy of Ophthalmology (AAO) Preferred Practice Patterns has set forth guidelines relative to the treatment of glaucoma. These guidelines suggest that in prescribing, the physician "minimize the side effects of (glaucoma) management, and their impact on the patient's vision, general health, and quality of life." A new-generation prostaglandin analog drug that offers maximum efficacy, and a side-effect profile limited to temporary cosmetic implications, can and should be widely used in the treatment of glaucoma. Temporary cosmetic tolerability issues, such as red eyes, do not have a negative impact on the patient's vision, general health, nor quality of life.

It is imperative as we move into the next decade that physicians become more attuned to patient concerns. Listening to patient concerns is a critical aspect of commu- nication. Presently, patients are less willing to tolerate a physician who does not emphasize communication.

The importance of communication between physician and patient was highlighted in the GLEAMS survey. Within the survey, 28% of respondents switched ophthalmologists. Of those who switched, 60% cited "lack of communication" as the reason for their switch, and 25% cited "inadequate IOP reduction" as the reason for choosing another physician. In fact, a recent study shows that after 22 seconds, physicians tend to interrupt patients who are in the middle of explaining what has been bothering them.¹

The AAO Preferred Practice Pattern Guidelines provide two statements that are important relative to the discordance between patient goals and physician goals. The guidelines state that it is the responsibility of the physician to "Educate and engage the patient in the management of his/her disease." Additionally, they hold that "Patient education and informed participation in treatment decisions may improve compliance and overall effectiveness of glaucoma management."

Clearly, physicians must redouble their efforts to listen to patients. Patients must be allowed to be active partners in making treatment decisions. The choice of which medication for patients to take must be a mutual decision between patient and doctor. The guidelines clearly assert that physicians must inform, educate, and include patients in the decision-making process. The costs of neglecting these responsibilities are grave to physicians and patients. For physicians, the cost is the loss of patients from the practice. For patients, the costs include sub-optimal compliance and ultimately loss of sight.