Annette L. Giangiacomo

Diagnosing glaucoma progression: current practice and promising technologies.

Purpose of review An update on recent work is provided that has broadened our understanding of the evaluation of visual function and structure, and their use in evaluating glaucoma progression. Recent findings The challenge of determining visual-field progression and the implications of long-term fluctuation are reviewed and data to support the magnitude of the fluctuaion are cited. The use of confirmatory testing can limit the over diagnosis of glaucoma progression. Focusing visual-field testing on the locations of present scotomas or using frequency doubling technology may provide new approaches to assessing visual function. New standardized techniques to interpret visual fields, including neural networks, unsupervised machine learning and pointwise linear regression, may provide more quantitative means for visual-field interpretation. These techniques, along with structural evaluation of the optic nerve and nerve fiber layer, are essential in glaucoma management. Optic-nerve-head photography is still a mainstay in evaluating glaucoma progression, although many technologies including scanning laser tomography, scanning laser polarimetry and optical coherence tomography offer more quantitative means to follow structural change. These modalities, in different ways, show promise in providing additional information regarding the stability of glaucoma. Summary Identifying the functional visual component as well as structural changes is essential in evaluating glaucoma progression. New techniques of testing and evaluating visual fields, the optic-nerve head, and the retinal nerve fiber layer offer exciting opportunities to more accurately identify glaucoma progression, and are likely to become more central as imaging devices and software support develop further.

Development of an instrument to measure glaucoma medication self-efficacy and outcome expectations

PurposeThe purpose of this study was to develop and evaluate the psychometric properties of (a) a glaucoma medication self-efficacy scale and (b) a glaucoma outcome expectations scale.Patients and MethodsTwo instruments were developed: a glaucoma medication self-efficacy scale and a glaucoma outcome expectations scale. Packets containing (a) the instruments and patient demographic questions and (b) a letter explaining the study were distributed to 225 glaucoma patients from three ophthalmology practices between August and December 2007. The instrument was completed by 191 patients for a response rate of 85%. Principal components factor analysis with a varimax rotation and Cronbachs α reliability were used to analyse the data. To assess discriminant validity, we administered the scales and two self-reported measures of adherence in a separate sample of 43 glaucoma patients who were currently using at least one glaucoma medication.ResultsOur results yielded a 21-item self-efficacy in overcoming barriers that might interfere with the use of glaucoma medications scale, a 14-item self-efficacy in carrying out specific tasks required to use eye drops correctly scale, and a four-item glaucoma outcome expectations scale. Results of the Cronbachs α reliability indicated that the scales are internally consistent. The self-efficacy scales were both significantly associated with two patient self-reported measures of glaucoma medication adherence, which show discriminant validity.ConclusionsEye care providers and researchers can use these scales to identify patients with low self-efficacy in using their glaucoma medications and patients who do not believe that following their eye care providers’ advice can help their vision.

Detection of visual field progression in glaucoma with standard achromatic perimetry: A review and practical implications

Detection of visual field progression remains a challenging task despite the recent advances for better handling of longitudinal visual field data, some of which are incorporated in currently available perimeters. Standard achromatic perimetry remains the gold standard for detection of visual field progression. The authors present a practical and clinically relevant review of the main issues involved in detection of early glaucoma as well as detection of visual field progression in eyes with pre-existing glaucomatous damage. After discussing some basic concepts in perimetry, the authors present evidence-based recommendations for criteria to detect earliest evidence of glaucomatous damage with perimetry. The authors will review different event- and trend-based criteria and present data with regard to comparative performance of such criteria. Relevance of using absolute versus corrected threshold data with regard to different criteria is also addressed. At the end, the authors provide practical guidelines for detection of visual field progression in a clinical setting and review issues related to clinical trials.

Determinants of Self-Reported Barriers to Glaucoma Medicine Administration and Adherence A Multisite Study

Background: Many factors influence glaucoma medication adherence. A better understanding of the relationships between health literacy, depressive symptoms, and patient-reported problems in using glaucoma medications may reveal opportunities for intervention that could improve patients’ clinical outcomes. Objective: To examine the relationship between patient characteristics (demographics, health literacy, and depressive symptoms) and patient-reported problems in using glaucoma medications and to assess factors related to patients’ self-reported adherence to glaucoma medications. Methods: Patients diagnosed with primary open-angle glaucoma (n = 228) currently taking intraocular pressure–lowering medications were recruited at 6 ophthalmology clinics. Patients were interviewed to identify problems using glaucoma medications, and self-reported medication adherence was determined using a Visual Analog Scale. Questionnaires were administered to assess health literacy, depressive symptoms, outcome expectations, and medication self-efficacy. Results: Younger patients (P = 0.03), patients with depressive symptoms (P = 0.02), and patients who reported more medication problems (P = 0.005) were significantly less adherent to their glaucoma medications. Patients with higher glaucoma medication self-efficacy adherence scores (P = 0.003) and higher outcome expectations (P = 0.03) were significantly more adherent. Conclusions: Providers should consider using tools to screen glaucoma patients for depressive symptoms and for problems in using medications to identify patients who are at higher risk of nonadherence to treatment and who might benefit from follow-up with primary care providers.

Accuracy of Patient-reported Adherence to Glaucoma Medications on a Visual Analog Scale Compared With Electronic Monitors

PURPOSE Glaucoma medications can improve clinical outcomes when patients adhere to their medication regimen. Providers often ask patients with glaucoma to self-report their adherence, but the accuracy of self-reporting has received little scientific attention. The purpose of this article was to compare a self-reported medication adherence measure with adherence data collected from Medication Event Monitoring Systems (MEMS) electronic monitors. An additional goal was to identify which patient characteristics were associated with overreporting adherence on the self-reported measure. METHODS English-speaking adult patients with glaucoma were recruited from 6 ophthalmology practices for this observational cohort study. Patients were interviewed after their initial visit and were given MEMS contains, which recorded adherence over a 60-day period. MEMS percent adherence measured the percentage of the prescribed number of doses taken. MEMS-measured timing adherence assessed the percent doses taken on time. Patients self-reported adherence to their glaucoma medications on a visual analog scale (VAS) ~60 days after the baseline visit. Bivariate analyses and logistic regressions were used to analyze the data. Self-reported medication adherence on the VAS was plotted against MEMS adherence to illustrate the discrepancy between self-reported and electronically monitored adherence. FINDINGS The analyses included 240 patients who returned their MEMS containers and self-reported medication adherence at the 60-day follow-up visit. Compared with MEMS-measured percent adherence, 31% of patients (n = 75) overestimated their adherence on the VAS. Compared with MEMS-measured timing adherence, 74% (n = 177) of patients overestimated their adherence. For the MEMS-measured percent adherence, logistic regression revealed that patients who were newly prescribed glaucoma medications were significantly more likely to overreport adherence on the VAS (odds ratio, 3.07 [95% CI, 1.22-7.75]). For the MEMS-measured timing adherence, being male (χ(2) test, 6.78; P = 0.009) and being prescribed glaucoma medications dosed multiple times daily (χ(2) test, 4.02; P = 0.045) were significantly associated with patients overreporting adherence. However, only male sex remained a significant predictor of overreporting adherence in the logistic regression (odds ratio, 4.05 [95% CI, 1.73-9.47]). IMPLICATIONS Many patients with glaucoma, especially those newly diagnosed, overestimated their medication adherence. Because patients were likely to overreport the percent doses taken and timing adherence, providers may want to ask patients additional questions about when they take their glaucoma medications to potentially detect issues with taking these medications on time.

Patient Question-Asking About Glaucoma and Glaucoma Medications During Videotaped Medical Visits

We applied the ecologic model of communication in medical consultations to examine how patient, physician, and situational/contextual factors are associated with whether patients ask one or more questions about glaucoma and glaucoma medications during visits to ophthalmologists. Patients with glaucoma who were newly prescribed or already on glaucoma medications were recruited at six ophthalmology clinics. Patients’ visits with their doctors were video-recorded and patients were interviewed after visits. Generalized estimating equations were used to analyze the data. Two hundred and seventy-nine patients participated. Patients asked one or more questions about glaucoma during 59% of visits and about glaucoma medications during 48% of visits. Patients who were newly prescribed glaucoma medications were significantly more likely to ask one or more questions about glaucoma and glaucoma medications. Whether providers asked patients if they had questions was not significantly associated with patient question-asking. Patients were significantly more likely to ask older providers questions about glaucoma medications and female providers questions about glaucoma. Eye care providers should encourage glaucoma patients to ask questions during their medical visits.

A Comparison of Sequential Glaucoma Drainage Device Implantation Versus Cyclophotocoagulation Following Failure of a Primary Drainage Device

Purpose: To compare sequential glaucoma drainage device (GDD) implantation with transscleral diode cyclophotocoagulation (CPC) following failure of a primary GDD. Materials and Methods: A retrospective review of all patients who underwent GDD implantation at a single institution over 10 years. Patients who required an additional GDD and/or CPC were analyzed. Success was defined as absence of loss of light perception, reoperation for glaucoma, and intraocular pressure (IOP) >21 or <6 at 2 consecutive visits after an initial 3-month period. Results: Thirty-two patients received sequential GDD. Twenty-one underwent CPC. Cohorts were statistically similar in regards to age, sex, race, and number of previous surgeries. Preoperatively, the GDD cohort had a lower IOP and better visual acuity. The mean length of follow-up was 37.9 months for the GDD group and 46.3 months for CPC. Both procedures significantly reduced IOP; however, CPC led to a greater reduction (P=0.0172). Survival analysis found the 5-year probability of surgical success to be 65.3% for sequential GDD and 58.0% for CPC (P=0.8678). No cases of phthisis occurred in either group. There were 2 cases of endophthalmitis (6.3%) in the GDD group, and none in the CPC group. In eyes without preexisting corneal edema, estimated corneal decompensation probability at 3 years was 31.6% for GDD and 6.7% for CPC (P=0.0828). Conclusions: Sequential GDD and CPC are both effective at reducing IOP following the failure of a primary GDD. CPC after GDD failure warrants further investigation as it led to a greater reduction in IOP with fewer serious adverse events.

Pediatric glaucoma: review of recent literature.

Purpose of review The purpose of this review is to update the clinician on the recent work in the field of pediatric glaucoma. Recent findings Using the iCare tonometer to measure intraocular pressure (IOP) in children is highly successful. New data from the Infant Aphakia Treatment Study show that after 5 years of follow-up the risk of developing glaucoma is similar between patients that receive initial intraocular lens implantation and those who are left aphakic. New data show effective lowering of IOP using either approach to trabeculotomy: treating the angle partially with trabeculotomes or circumferentially with a suture or iTrack microcatheter. Recent data on an updated approach to trabeculectomy in children show success in lowering IOP with few complications; however, visual outcomes continue to be suboptimal. A separate study shows that the addition of tenonectomy may not increase surgical success, but may increase survival time and reduce bleb encapsulation. Glaucoma drainage devices in general, and the Ahmed implant in particular, continue to be found to be moderately successful to control IOP, and are therefore employed, especially after initial angle surgery has failed. Summary Continued work to evaluate the techniques used in the clinical and surgical management of pediatric glaucoma patients supports that both newer and older approaches remain standard of care.

Communication predicts medication self-efficacy in glaucoma patients

Purpose Medication self-efficacy, or patients’ confidence that they can perform medication-related behaviors, is associated with better glaucoma medication adherence. Little is known about how to enhance glaucoma patients’ medication self-efficacy. Our purpose is to examine whether patient-provider communication increases glaucoma patients’ medication self-efficacy. Methods During an 8-month cohort study of 279 glaucoma patients and 15 providers, two office visits were videotape-recorded, transcribed, and coded for six patient-provider communication behaviors. A validated scale was used at baseline and 8-month follow-up to assess patients’ confidence in overcoming adherence barriers (adherence barriers self-efficacy) and carrying out tasks to use eye drops correctly (eye drop task self-efficacy). We ran two generalized estimating equations to examine whether more frequent patient-provider communication during office visits predicted increased patient adherence barriers self-efficacy and eye drop task self-efficacy at 8-month follow-up. Results For each additional topic providers educated about, patients reported an average increase of 0.35 in self-efficacy in overcoming adherence barriers (p < 0.001). Patients also reported an average increase of 1.01 points in eye drop task self-efficacy when providers asked about patients’ views of glaucoma and its treatment versus not (p < 0.001). Patients who asked more medication questions (p < 0.001) and African-American patients (p < 0.05) reported lower adherence barriers self-efficacy by 0.30 and 2.15 points, respectively. Women had a 0.63 lower eye drop task self-efficacy than men (p < 0.05). Conclusions When providers educate glaucoma patients and assess patient views about glaucoma and its treatment, patients report higher medication self-efficacy. Providers should be aware that patients who ask more medication questions may have less confidence in their ability to overcome barriers to adherence.

The Effect of Eye Drop Technique Education in Patients With Glaucoma

ABSTRACT Education about how to administer eye drops may improve a patient’s ability to instill his or her eye drops correctly. Our objectives were to (a) document the methods providers use to educate glaucoma patients about eye drop technique; (b) determine whether eye drop technique education varies by provider and patient characteristics; and (c) evaluate whether education predicts improved patient technique. We conducted an 8-month longitudinal study of 279 glaucoma patients and 15 providers in which we recorded on videotape the content of glaucoma office visits at two time points (baseline and 4- to 6-week follow-up) and videotaped patient eye drop technique at three time points (baseline, 4- to 6-week follow-up, and 8-month follow-up). Mann–Whitney rank sum tests were used to determine whether education was associated with improved patient eye drop technique over time. Ninety-four patients (34%) received technique education at either visit; 31% received verbal education and 10% received a technique demonstration. Only 24 patients (47%) who were new to eye drops received technique education at the baseline visit. Patients who were new to drops at baseline (p = .008) and patients who asked a question about drops (p < .001) were more likely to receive technique education. Education was not associated with improved technique. Eye drop technique education occurs infrequently during glaucoma office visits. Future studies should compare the effectiveness of different educational methods, such as patient demonstration versus provider verbal instruction, to determine which method is best at improving patient eye drop technique.