Patient Followup

The physician-patient relationship cannot be overemphasized. Good communication can greatly improve patient adherence with medications and follow-up. The side effect profiles of proposed treatments must be reviewed. Patients need to be clearly informed about the dosage regimen. Written instructions with charts are invaluable, especially when multiple medications are used. Appropriate techniques for administering eye drops need to be taught. Observing patients using eye drops in the office can be very informative. Techniques to reduce systemic absorption and toxicity, such as nasolacrimal occlusion and eyelid closure, should be discussed.75

Once a therapeutic course has been initiated, its efficacy must be documented. A monocular trial in patients with bilateral elevated IOP can be a helpful approach to assess treatment effect. In this manner, the fellow eye is used as an internal control. A lower IOP in the treated eye helps document a positive treatment effect, whereas a lower IOP in both eyes probably indicates baseline IOP fluctuations. Some recent studies have raised questions regarding the potential benefits of monocular trials due to independent IOP variability between eyes and varying efficacy of the same medication between eyes.76,77 Beta blockers can have a contralateral IOP-lowering effect through systemic absorption.78 This effect is usually small and generally does not interfere with a monocular trial.

Because of the chronic nature of glaucoma, appropriate follow-up is mandatory. The AAO has developed guidelines for glaucoma management (table 10.2).5 Every follow-up patient visit should include interval ocular history, general medical history, local or systemic problems with medications, general assessment of impact of

Table 10.2 AAO-Recommended Guidelines for Follow-up

Target IOP

Progression

Duration of

Follow-up

Achieved

of Damage

Control

Interval

Yes

No

<6 months

1 to 6 months

Yes

No

>6 months

3 to 12 months

Yes

Yes

1 week to 4 months

No

1 day to 4 months

Table 10.3 AAO-Recommended Guidelines for Optic Disk Examination

Target IOP

Progression

Duration of

Follow-up

Achieved

of Damage

Control

Interval

Yes

No

<6 months

6 to 12 months

Yes

No

>6 months

6 to 18 months

Yes

Yes

2 to 12 months

No

Yes/no

2 to 12 months

Source: Primary Open-Angle Glaucoma Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2005.

Source: Primary Open-Angle Glaucoma Preferred Practice Pattern. San Francisco, CA: American Academy of Ophthalmology; 2005.

visual function on daily living, and the frequency and time of last glaucoma medications. Visual acuity, IOP check, and slit-lamp examination should be performed in each eye, as well as detailed examination of the optic disk (table 10.3).

Having an appropriate baseline visual field is a prerequisite to accurately identify visual field changes. Obtaining a baseline may require two or more visual field tests for adequate reliability and to eliminate learning effect. In most cases, two visual field tests are satisfactory. If visual field change is identified, it is wise to confirm this with another test to rule out long-term fluctuation as a cause (table 10.4). Newer visual field machines have sophisticated statistical packages to assist in the determination of progression.

If visual function continues to deteriorate, the therapeutic goal and methods must be reevaluated. Signs of nonadherence with prescribed therapy should be sought. The possibility of an alternate diagnosis or the development of a new disease process should also be considered.

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