Initial Treatment Modality

After setting a target IOP, the ophthalmologist must decide how to reach it. As discussed above, there is support for initial medical, laser, and surgical interven-tion.20,21,23,41 Therefore, before selecting one of these treatment protocols, it is imperative to have a frank discussion with patients about the status of their disease and all treatment options. Only after all the options have been reviewed and patients' questions answered can patients properly give informed consent to the treatment regimen. If more invasive treatments are not chosen initially, patients will be aware of possible future options. The negative effect of prior long-term medical therapy on the success of filtration surgery is important to consider. With newer medications, maximum medical therapy may be achieved with as few as three medications.

The most common approach is to begin with medical treatment. Glaucoma is a slowly progressive disease. Therefore, obtaining a baseline set of data prior to performing an irreversible procedure is useful. Although studies highlight the benefits of early trabeculectomy and laser trabeculoplasty, these trials did not include the newest generation of medications, which are potent and generally well tolerated. In contrast, CIGTS showed equivalent visual field stability between the medically treated and surgically treated patients over 5 years.41

The failure to adhere to medical therapy is a major problem. Nonadherence has been estimated to cause approximately 10% of all visual loss from glaucoma and is a leading cause of blindness.48 Patients may improperly use medications or use medications only prior to visiting their physician. Side effects discourage patients from using medicines. Complicated dosage regimens can be difficult to follow. Medications containing a combination of drugs may be preferable to separate agents. To help improve patient adherence, pharmaceutical companies are creating medication reminder aids for patients. Theoretically, such devices may be helpful in reminding patients to use their medications; however, actual efficacy remains to be studied. Cost is another important issue. Patients may not be able to afford the high prices of glaucoma medications, especially since the treatment program may be lifelong. Patients must also maintain follow-up with their physicians to monitor the efficacy of medical management. If there are serious concerns regarding adherence, laser trabeculoplasty is a reasonable first-line therapy. Trabeculoplasty has generally been found to be effective for about 5 years in 50% of patients.49

Primary filtering surgery is an appropriate alternative for patients who have advanced initial damage or significantly elevated IOP and whose target IOP is considered not achievable through any other treatment modality. Even in these patients, a trial of medical treatment is warranted if for no other reason than to control IOP prior to surgery. This trial may reduce progressive optic nerve damage and visual field loss in the eye scheduled for initial surgery. In a subset of such patients, an unexpectedly good response to medical therapy may obviate the need for initial surgery.

Regardless of which therapy is initially selected, treatment effect must be followed closely. If, after an adequate trial, one line of therapy does not achieve the target IOP, the clinician should not hesitate to advance to an alternate treatment modality. A common mistake in glaucoma management is not being aggressive enough in achieving the target IOP.

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