Despite Being Overlooked, Glaucoma Is Serious and Costly

Las Vegas—Approximately 60 million people worldwide have glaucoma, a group of eye diseases that are the leading cause of blindness. In the United States, annual glaucoma expenditures are >$2.5 billion, with additional costs for falls, driving accidents, poor health, and depression related to glaucoma. Still, glaucoma is often not considered as a serious health problem, according to Steven D. Vold, MD, glaucoma specialist and founder of Vold Vision, PLLC. “People don’t realize how important eyesight is to patients,” said Dr. Vold, who spoke at the Fall Managed Care Forum in a session titled Cost Effective Glaucoma Care in the Managed Care Setting. “It’s very important.… Vision is a big deal when we’re talking about quality of life.” In fact, Dr. Vold said the top 3 fears patients have are cancer, blindness, and heart disease. He mentioned there are several drugs available to treat glaucoma, ranging in cost from $151 per year to $916 per year. With managed care becoming more important in the treatment of glaucoma, Dr. Vold said there will be an increased focus on formulary restrictions, and providers will receive capitated payments for each treatment. Dr. Vold discussed the Ocular Hypertension Treatment Study, a randomized, controlled, multicenter trial supported by the National Eye Institute, National Center on Minority Health and Health Disparities, Research to Prevent Blindness, and Merck Research Laboratories. The trial was designed to identify risks factors for and patients at risk for developing primary open-angle glaucoma (POAG). The researchers were also interested in determining whether reducing intraocular pressure prevents or delays visual field loss from glaucoma and/or optic nerve head damage. The study enrolled 1636 patients who received topical ocular hypotensive medication treatment for a minimum of 5 years. They were between 40 and 80 years of age, had normal visual fields and optic discs, and untreated intraocular pressure. According to Dr. Vold, the study found that patients undergoing treatment had an approximately 20% reduction in intraocular pressure, while patients with ocular hypertension experienced a >50% reduction in POAG incidence. There were few safety concerns reported, Dr. Vold said, although he added that not every patient with ocular hypertension should receive treatment and providers should consider a patient’s age, medical status, life expectancy, and treatment benefit. Investigators from the study as well as those from the European Glaucoma Prevention Study are performing a meta-analysis to determine risk factors for glaucoma. Dr. Vold said the researchers are attempting to whittle down numerous values that examine risk factors into one number that will help patients determine if they are at risk for glaucoma. Dr. Vold also discussed several more studies. The Collaborative Normal Tension Glaucoma Study, a privately funded international trial sponsored by the Glaucoma Research Foundation, examined whether aggressively lowering intraocular pressure halts optic nerve head damage and visual field loss in patients with normal tension glaucoma. Patients were randomized to receive treatment with medication, laser trabeculoplasty, and filtration surgery to lower intraocular pressure by 30% or not receive treatment until they saw slight deterioration. Neither group could receive beta-blockers or adrenergic agonists. The researchers found that patients undergoing treatment can achieve a goal of 30% reduction in intraocular pressure without having filtration surgery at least half of the time. Patients who underwent filtration surgery had slightly better results, according to Dr. Vold, but he said that they were also more likely to have cataract formation. The following are risk factors for progression of normal tension glaucoma: female, migraine, disc hemorrhage at diagnosis, and low systemic blood pressure. In the Early Manifest Glaucoma Trial, patients were randomized to receive laser trabeculoplasty plus topical betaxolol or no treatment. At 3 months, patients who received treatment had a 25% reduction in intraocular pressure. Throughout the 9-year study, patients who had initial treatment displayed a reduction and delayed progression of glaucoma. A 1-mm Hg decrease in intraocular pressure led to a 10% decrease in the risk of glaucoma progression, according to Dr. Vold. The following factors were associated with glaucoma progression: higher baseline intraocular pressure, exfoliation, bilateral disease, worse mean deviation, older age, and disc hemorrhages. The Advanced Glaucoma Intervention Study randomized 591 patients with elevated intraocular pressure and visual field loss who met the standards for undergoing surgery. One group underwent argon laser trabeculoplasty and then received 2 treatments with trabeculoplasty. The other group first had a trabeculoplasty, followed by argon laser trabeculoplasty, and then another trabeculoplasty. Researchers found that a person’s visual field worsens with a higher intraocular pressure and that intraocular pressure <14 mm Hg is associated with a reduction in the progression of a visual field defect. In the Collaborative Initial Glaucoma Treatment Study, 607 patients who were newly diagnosed with open-angle glaucoma were randomized to receive initial therapy with medications or filtering surgery. In an interim analysis at 5 years, both treatments were effective at reducing intraocular pressure: the medication group had an intraocular pressure reduction >35% compared with a >40% reduction in the surgery group. During the first 3 years, the surgery group had a greater visual field loss compared with the medication group, but they had similar visual field loss in years 4 and 5. Dr. Vold said the researchers reported few major complications related to the surgery and few major side effects associated with the medications. When evaluating the success of therapies, Dr. Vold said there are 2 main measures: compliance (using medication as prescribed and adhering to doctor visits) and persistency (remaining on the medication over time). He said compliance is difficult to measure, but it is important because intraocular pressure fluctuates and can affect disease progression. Noncompliance is common for several reasons, according to Dr. Vold, including patients forgetting to use medications, the drugs’ side effects, the drugs’ cost, and a poor understanding of the disease. Dr. Vold said it is easier to measure persistency because data can be gathered through a managed care and pharmacy database and a review of deidentified patient charts. A common term for patients who do not refill their prescriptions is discontinuation rate, which is typically measured as 90 days after the last prescription if dispensing 1 bottle or 180 days if dispensing >1 bottle. He concluded with an overview of the Ex-PRESS glaucoma filtration device, a <3- mm stainless steel implant manufactured by Alcon that reduces intraocular pressure and is inserted under a scleral flap with no tissue removal. He said that there have been >80,000 devices implanted in patients with uncontrolled open-angle glaucoma, combined cataract and glaucoma surgery, or a failed previous glaucoma surgery. The device is as effective as trabeculectomy, the standard filtration surgery, he added. It is also better at reducing postoperative complications and the recovery period compared with trabeculectomy, he said.