Enhancement Of Surveillance

Once patients are receiving maximal tolerated medical therapy for their glaucoma, they should be seen more frequently. A patient with a stable optic nerve head, IOP, and visual fields may be seen every 4 to 6 months. Patients are usually placed on maximal medical therapy, however, due to evidence of more progressive or unstable disease. As a result, examinations ranging from every 2 to 4 months may be in order. These exams should document not only IOP but also the optic nerve head for any changes, even if through an undilated pupil. If progressive changes in the cup or nerve fiber layer are evident, as revealed by physical examination and perhaps structural imaging, then repeat visual field testing is appropriate. In today's environment of managed care, it is important to remember that insurance companies should not determine when a patient with progressive glaucomatous changes should have functional testing; however, the financial consequence of unreimbursible diagnostic evaluation should be considered by the patient and physician.

Increased frequency of visits helps the clinician not only to monitor more closely possible disease progression but also to detect potential medication side effects or allergies that may affect treatment. If patients suspect that a medication is making their eyes irritated or uncomfortable, they will often stop taking the medication without consulting their physician. This will make it difficult to determine which drug is the true culprit. Patients should be encouraged to call the office in the event of adverse drug effects or schedule an earlier follow-up visit to avoid these situations. In the case of the noncompliant patient who is reluctant to undergo surgical procedures, visits as frequently as every 1 to 3 months may be helpful. Such enhanced surveillance will ensure that the patient gets adequate prescription refills and will document the history of noncompliance and uncontrolled disease. This information coupled with the inconvenience of office visits can convince a previously unwilling patient to have a necessary surgical intervention, especially if it means taking fewer eye drops and seeing the doctor less often.

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