Maximum Medical Therapy

With six available classes of topical medications to use for IOP lowering, there is a seemingly bewildering array of treatment choices.1 The large number of these choices has contributed to the ambiguity of the term ''maximum medical therapy.'' The added benefit of a third or fourth topical agent is often minimal for most patients, and certainly the use of six classes of drugs is not feasible. Further, in clinical practice, combinations of each available medical agent at their highest concentrations are not indicated before a surgical approach is considered.

A medical treatment regimen needs to be customized to each individual patient to optimize the benefits and avoid the risks of the administered drugs. Clinicians should generally measure IOP more than once and preferably at different times of the day when establishing baseline IOP prior to surgery. Assuming topical agents have been administered appropriately, a single determination of IOP may be sufficient when it is markedly elevated. Certainly, drugs that have intolerable side effects should be excluded from consideration when assessing whether medical control of IOP can be achieved satisfactorily. An ineffective drug should be discontinued and similarly excluded. Medical contraindications may preclude the use of various agents.

Poor adherence or persistence with a prescribed medical regimen also needs to be considered when assessing maximum tolerable medical therapy. Patients who continue to worsen despite apparent IOP control should be questioned about their use of prescribed medications. Patients who are administering their medication only prior to a scheduled visit to the ophthalmologist, and not during the interval between visits, most likely will benefit little from long-term medical treatment. Patients who have well-controlled IOP when under the surveillance of their ophthalmologist, but who cannot remember to use their eye drops or are poorly persistent for a multitude of other reasons, ought to be considered for surgical treatment. With any patient on maximum tolerable medical therapy, poor adherence or persistence should be suspected because of the greater probability of side effects when numerous drugs are prescribed, as well as the difficult dosing schedules. In the latter situation, patients may have had prescribed six different eye drops with schedules varying from one to four times daily. Therefore, the term ''maximum medical therapy'' is used to indicate that no further escalation of medical treatment is available, appropriate, or likely to provide a clinically significant lowering of IOP.

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