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    The dangers of starting and stopping glaucoma treatment

    Keeping patients committed to prescribed treatment is key to success

    The notion of patients not coming in as advised for eye examinations can be troubling. For example, when a patient has an eye disease as potentially significant as glaucoma and chooses to ignore its presence, there is cause for concern on the part of the doctor.

    A chain of events is set into motion when a patient does not show up to our clinic for follow-up care. Several attempts (typically over several days to a couple of weeks) to reach the patient by phone are undertaken and documented in the patient’s record. If that mode of communication fails, we send a letter by certified mail to the patient imploring him to follow up with us or someone else.

    We also offer a referral in instances such as changes to the patient’s insurance coverage. Beyond that, there is not much we can tangibly do to convince that particular patient to continue care.

    Previously from Dr. Casella: Risks of falls in glaucoma patients

    Not long ago, a patient returned for a continuation of glaucoma care after more than two years of no-shows for appointments.

    Initial diagnosis and treatment

    The patient is a 52-year-old African-American male who has a previous history of mild bilateral primary open-angle glaucoma. His medical history is significant for arterial hypertension and a familial history of cataracts and glaucoma. He is otherwise healthy and takes a diuretic medication for his blood pressure. He is a mild myope in each eye and is not a smoker.

    When I first saw him years ago and performed glaucoma testing, his average intraocular pressures (IOP) were in the high 20s in each eye. His vertical cup-to-disc ratios were suspicious and were determined to be 0.65 in each eye. His optic discs were of average size and shape.

    Central corneal thicknesses were 535 µm for the right eye and 526 µm for the left (thin to average). Angles were open to the ciliary body in each quadrant by gonioscopy with flat iris approaches and mild pigment in each trabecular meshwork. Visual field studies were unremarkable for each eye, and spectral domain optical coherence tomography (SD-OCT) studies showed thinning of each eye’s temporal retinal nerve fiber layer.

    Related: Using medications in pregnant glaucoma patients

    At the time of diagnosis, I did not have access to ganglion cell complex analysis on my SD-OCT device. I was performing macular scans on all of my glaucoma patients and glaucoma suspects in anticipation of such software becoming available and being retroactive. Running the patient’s macular scans through the ganglion cell complex algorithm when it became available did show thinning in each eye.

    After compiling and analyzing the patient’s diagnostic data and having a brief conversation with him regarding the evidence, I initiated therapy with a prostaglandin analog and set a target pressure of 15 to 18 mm Hg for each eye. He left with a sample of medication and returned as directed one month later.

    Benjamin P. Casella, OD, FAAO
    Dr. Casella, a 2007 graduate of University of Alabama at Birmingham School of Optometry, practices in Augusta, GA, with his father in ...

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