Pre-consultation: Communication issues to bear in mind

As is often the case, adopting a reassuring tone is important when speaking to a patient about their first prescription for glaucoma medication. If the patient has experienced an acute episode and requires ongoing treatment, they are likely
to be anxious about the possibility of a recurrence. Someone who has had COAG or ocular hypertension (OHT) diagnosed at a routine eye test and is starting preventative medication may be wondering what the diagnosis might mean for their future eyesight. 

All patients may have questions about the potential long-term impact of glaucoma and the medication used to treat it, including side-effects and managing topical administration.

NICE updated its guidance on the diagnosis and management of glaucoma last year.1 Patients are generally only provided with medication if they have OHT with intraocular pressure (IOP) at or above 24mmHg and are at risk of visual impairment (defined as a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and reduces a person’s ability to function) within their lifetime. 

However, the IOP treatment threshold is usually lower for patients with normal tension glaucoma (NTG) due to the increased risk of visual impairment. The protocol for pharmacological treatments is as follows (note all are topical):

• A generic prostaglandin analogue (PGA) should be offered to patients if they can’t have or don’t want to have selective trabeculoplasty (SLT), need interim treatment while waiting for SLT, or have had SLT and require additional treatment to reduce IOP
• An alternative generic PGA should be offered to patients with an IOP of 24mmHg who do not tolerate the first product prescribed for them
• A beta-blocker is the next option if neither PGA is tolerated
• Further options include a non-generic PGA, carbonic anhydrase inhibitor, sympathomimetic, miotic or combination of treatments
• For patients who are not experiencing a reduction in their IOP to under 24mmHg, a medicine from another therapeutic class (beta-blocker, carbonic anhydrase inhibitor or sympathomimetic) should be offered. Combinations may be needed to control IOP
• Preservative-free eye drops should be offered to patients with an allergy to preservatives or those with clinically significant and symptomatic ocular surface disease, but only if they are at high risk of conversion to COAG.