Managing glaucoma means managing patient odds

Identifying and managing the risk factors of glaucoma is key to its effective management. Andrew G. Iwach, MD, says ophthalmologists are not treating means or averages,but individuals, and this requires a customized approach for every eye and every patient.

By Liz Meszaros

Identifying and managing the risk factors of glaucoma is key to its effective management.

“We’re not treating means or averages, we treat individuals, and this requires a customized approach for every eye and every patient,” claims Andrew G. Iwach, MD, associate clinical professor of ophthalmology, University of California, San Francisco.

He noted that the use of prostaglandin analogues continues to grow, while beta-blocker usage remains steady and the use of combined medications is increasing.

Dr. Iwach said many ophthalmologists have turned to compounding pharmacies for certain medications. But, he noted, last year the scope of regulation for compounding pharmacies was expanded to include the FDA, which may impact whether one can use a compounding pharmacy if a specific commercial product is available.

New regulations also have impacted some informed consent, so Dr. Iwach advises a periodic check of informed consent documents and reminded physicians that the Ophthalmic Mutual Insurance Company (OMIC) website has free informed consents for a variety of procedures irrespective of whether physicians are insured by OMIC. Dr. Iwach noted this is an easy, but very important, update to any practice.


Generic drugs changes

Generic drugs are another area seeing much change. Dr. Iwach cautioned that some generic drugs are manufactured in various parts of the world. They sometimes are accompanied by minimal instructions, he said, and can vary not only in formulation, but also in packaging, which can make accurate, consistent dosing a challenge. Because some of these generics are distributed by U.S. health plans, they are used widely, and therefore providers need to be aware of the increasing complexity of generic drug utilization.

He also noted another complicating factor is cost increases that occur when the approval status of well-established generic drugs, such as pilocarpine, suddenly changes based on submission of new drug efficacy data to the FDA.

“In the near future, advances in drug delivery systems are likely where the new major developments will be in pharmaceuticals,” Dr. Iwach said. “There will be a number of innovative new ways to get drugs to the eyes.

Dr. Iwach added that beyond addressing compliance issues, what excites him is the potential reduction in side-effect profiles. He described a new delivery system being studied for sustained-release travoprost (Ocular Therapeutix). Such developments may allow for the use of molecules that were previously untapped because, with newer delivery systems that provide more precise and sustained release, high-peak doses may be avoided.

As for the surgical treatment of glaucoma, Medicare utilization data shows an increase in laser trabeculoplasty since year 2001, while over the same time period there was a 40% decrease in the number of trabeculectomies performed.


“What this suggests is that with the availability of newer medications, combined with laser treatments, we have improved the quality of life for our patients with glaucoma,” he noted. “Any day I do not need to create a filtering bleb is a good day.”

Dr. Iwach emphasized that ophthalmologists continue to play an important role in addressing systemic medical issues. “Surprisingly often, when asked, patients reveal that we may be the only physician they have recently seen,” he said.

“We take histories and ask about systemic hypertension and diabetes. But if we then find out a person’s last physical was 10 years ago, the data is not current,” he continued. “Typically, no data is better than bad data. So our exams provide an important opportunity to improve our patients’ lives, raising important basic issues such as the risks of smoking. Who’s more qualified to talk to them about medical matters than physicians? And we are physicians.”

A tool to help ophthalmologists stay current about counseling patients on recommended screening guidelines is available. Dr. Iwach said he refers to an app called the “electronic Preventive Services Selector application” (ePSS), which tells him what routine screening tests should be done and what their priority level is, as well as the research behind it.

“Like one of our speakers said, Smartphones are our new black bag,” said Dr. Iwach.


Data release

Another area of challenge for ophthalmologists will be the gathering, tracking, and release of individual physician practice pattern data and associated inaccuracies. According to Dr. Iwach, the Freedom of Information Act has allowed release of various databases and subsequent sophisticated cross-analyses of multiple databases that have led to reports of individual physician’s prescribing patterns. An example of this can be view at the ProPublica website.

“So I was curious and looked at my profile,” said Dr. Iwach. “First of all, I found out there are two of me – which right away makes me question the accuracy of the data… And yet this information is available to the public. This seems to be another example of, it’s better to have no data than bad data.”