Provide written instructions

The physician, nurse, or patient should record the drug name(s), drug description(s) if indicated (e.g., green top, yellow label), and frequency and time(s) of administration(s). Many patients

become confused about how often and when medication should be taken.137,138 Four times daily may be interpreted to mean 8 am,

10 am, 12 noon, and 2 pm, leaving 18 hours between the last dose of the day and the first dose the next morning.This problem is often compounded by the fact that patients with glaucoma are often elderly and are taking vitamins and multiple medications for systemic problems such as hypertension, heart disease, diabetes, anxiety, and hormone replacement.

Booklets like Understanding and Living with Glaucoma provided by the Glaucoma Research Foundation (251 Post Street, Suite 600, San Francisco, CA 94108, 1-800-826-6693) are extremely helpful in teaching the patient in simple language about glaucoma, its consequences, its treatment, and specifically how to use drops. Their toll-free number provides advice and counsel about the condition from long-term patients and helps to direct patients to resources that may be helpful. Similarly, several pharmaceutical companies provide devices that may make using drops easier for those with physical problems such as arthritis or balance problems. Some even provide electronic alarms and/or monitoring devices.

Communicate with the patient’s family physician

Increased communication may provide important information to the ophthalmologist and to the general physician and may prevent drug-induced side effects. Many general physicians need to be reminded that topically administered antiglaucoma medications (e.g., strong miotics, epinephrine, -adrenergic antagonists) are capable of producing serious and even fatal systemic reactions. Many patients have been hospitalized for tests and treatment while continuing to receive the eyedrops responsible for the problem. The general physician can provide important information about the patient’s general health (e.g., a patient with severe respiratory acidosis should not be treated with a carbonic anhydrase inhibitor, or one with chronic obstructive pulmonary disease a -blocker). Many patients do not have a clear picture of their current and past health status and do not know the names or purposes of their medications.

Ask about problems with the medical regimen

Patients should be questioned directly about expense, inconvenience, and possible medication-induced side effects. Patients may not connect systemic symptoms to an eyedrop (e.g., they may not realize that palpitations are caused by topical epinephrine).

Consider defaulting as an explanation for the failure of medical treatment

As noted previously, poor compliance is a frequent cause of medical failure.This problem can be associated with poor understanding of the disease, long waiting time to see the doctor, high cost of the medication, and a complex regimen.

Educate patients about their illness and its treatment

An informed patient is more likely to accept treatment and return for follow-up examinations. It is especially important to warn patients about common drug-induced side effects. Patients warned in advance are more likely to deal successfully with a difficult situation.Those who are not warned in advance are more likely to be frightened and to lose faith in the physician.

Stop treatment periodically to determine continuing effectiveness

It is useful to stop a medication for a short time in one eye to confirm continued therapeutic benefit. If a drug is no longer effective, it should be discontinued and replaced if necessary. However, some agents may have a prolonged washout period. -Blocking agents,

for example, usually take 2 weeks but may take as much as a month to completely wash out of the eye.139,140 This may be too long to

go without treatment for some patients with advanced disease.

Measure intraocular pressure at different times of the day and at different intervals after the last administration of medication

The variability of IOP may be as important a factor in the progression of glaucoma as the absolute IOP level. Patients and physicians often fall into a pattern of scheduling appointments at the same time of day (e.g., early in the morning or after work).The patient may compound this situation by instilling his or her medication immediately before the appointment with the doctor so as to have a ‘good showing.’

Recommend comparison shopping for medications

Physicians often forget the high cost of chronic medical treatment, especially for older patients on fixed incomes. Prices at dif-

ferent pharmacies in the same neighborhood may vary by a factor of 2.141,142 Patients should be encouraged to buy medications at

the pharmacy that offers the best price provided that the pharmacy also offers the services required by the individual (e.g., home delivery, comprehensive medication record). In recent years, Web-based pharmacies have become increasingly popular because of highly competitive prices. Of course, appropriate care is necessary to avoid being scammed. Generic drugs are often less expensive than drugs

sold under a brand name. However, some glaucoma medications are not available as generic products (e.g., dorzolamide).138,141 Generic

products are sometimes less comfortable to use than are the brandname products. With the increasing influence of managed care in recent years, generic products may be substituted when a brandname product was specifically prescribed or a more expensive, recently released brand-name drug may not be available at all.

One approach to treatment of most chronic glaucoma patients follows.The pharmacology of individual agents will be discussed in the following chapters. Start with agents that are likely to be effective and unlikely to produce significant side effects. Most physicians would start with a prostaglandin. The prostaglandin analogs are all now approved in the United States as first-line therapy and are the most commonly prescribed due to their efficacy, once-daily dosing