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PATIENT CARE PROCESS

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Patient Care Process for the Management of Glaucoma

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Collect

  • Patient characteristics (e.g., age, race, sex, pregnant)

  • Patient history (past medical, family history of glaucoma, social; date and results of past eye examinations)

  • Changes in vision (see Figure 94-4)

  • Current medications, including nonprescription agents and topically applied products, including eye drops (see Table 94-3 for agents that affect intraocular pressure (IOP)

  • Objective data (see Box 94-1)

    • IOP measurements

    • Disc changes and abnormalities—bilateral, symmetrical?

    • Visual field changes and losses

Assess

  • If primary angle closure glaucoma is suspected, manage or refer as ophthalmologic emergency

  • Presence of conditions that can produce secondary cases of open-angle glaucoma (e.g., exfoliation syndrome, pigmentary glaucoma, systemic diseases, trauma, surgery, ocular inflammatory diseases, and medications [see Table 94-3])

  • Current medications that may contribute to or worsen glaucoma (see Table 94-3)

  • Past history of adverse effects to agents used in treatment of glaucoma

  • Identify target IOP goal based on past history and current situation

Plan*

  • Drug therapy regimen designed to achieve target IOP, including specific agent(s), dose, route, frequency, and duration; specify the continuation and discontinuation of existing therapies (see Figure 94-5 and Table 94-4)

  • Monitor IOP for target reductions (usually at least 20% reduction from baseline IOP, if not a reduction of 25% to 30%, at 4–6 weeks after therapy begins, and for adverse effects (e.g., local intolerance or reactions, altered iris pigmentation within 2 years of treatment initiation, hypertrichosis, hyperpigmentation of lids or lashes)

  • Referrals to other providers when appropriate (e.g., ophthalmologist)

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Provide extensive education about administration of eye drops, separation of doses, and reinforcement of importance of adherence to preservation of vision

  • Use motivational interviewing and coaching strategies to maximize adherence

  • Schedule follow-up, usually 4–6 weeks after therapy starts and every 3–4 months once target IOPs are achieved

Follow-up: Monitor and Evaluate

  • Measure Intraocular pressure

  • Optic disc and visual fields

  • Adverse effects to medications

  • Adherence to treatment and drug administration technique

*Collaborate with patient, caregivers, and other health professionals

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CONTENT UPDATE

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Content Update

March 20, 2018

Netarsudil (Rhopressa®), the First Rho Kinase Inhibitor for Treatment of Glaucoma: Netarsudil is a rho kinase (ROCK) inhibitor that lowers intraocular pressure (IOP) though several mechanisms, including increased outflow of aqueous humor through the trabecular meshwork pathway. Controlled clinical trials demonstrated that netarsudil 0.02% once daily is noninferior to timolol 0.05% twice daily in patients with maximum baseline IOP < 25 mm Hg. Netarsudil did not meet the criteria for noninferiority in patients with maximum baseline IOP of 27 mm Hg. Common adverse include conjunctival hyperemia, corneal verticillata, instillation site pain, and conjunctival hemorrhage. In clinical practice, netarsudil will likely be used as additive therapy to prostaglandin analogs but is unlikely to replace prostaglandins as preferred first-line therapy. Because netarsudil is most effective in patients with lower pretreatment IOP's, it may be preferred in patients with low-tension glaucoma (IOP within the normal range). The once-daily dosing regimen makes netarsudil a viable second-line option for patients who are nonresponsive or intolerant to prostaglandin analogs. Appropriate patient selection will be important because the proprietary netarsudil product will likely be much more expensive than many generic alternatives.

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CHAPTER SUMMARY FROM THE PHARMACOTHERAPY HANDBOOK

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For the chapter in the Wells Handbook, please go to Chapter 65. Glaucoma.

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KEY CONCEPTS

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KEY CONCEPTS

  • Image not available. Primary open-angle glaucoma (POAG) or ocular hypertension (OHT) is more prevalent outside Asia than primary angle closure glaucoma (PACG).

  • Image not available. In any form of glaucoma, reduction of intraocular pressure (IOP) is essential.

  • Image not available. IOP is a very important risk factor for ...

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