Juniper
Publishers- JOJ Ophthalmology
Commentary
A 59-year-old woman is referred to you by her primary
care provider (PCP) for a routine eye examination. She had never
undergone a comprehensive eye exam previously and was looking forward to
the opportunity to have her eyes examined by an ophthalmologist. She
purchased reading glasses for the first time 5 years ago, but now even
those spectacles were not addressing her visual needs. Her complaints to
her PCP prompted the referral. Additional history revealed that this
patient was recently laid off and was now insured on Medicaid, which had
been expanded in her state following the passage of the Affordable Care
Act.[1]
On examination, her visual acuity was 20/40 OD and
20/60 OS. Angles were open OU 360 degrees and IOP measured 25mmHg OD and
32 OS mmHg. SLE revealed clear corneae, deep and quiet anterior
chambers, and 1+nuclear sclerosis. Central corneal thickness
measurements were 550um OD and 555um OS. Optic nerves evidenced moderate
cupping, 0.7OD and 0.8OS.
Patients such as this 59-year-old woman enter our
offices every day. Her visual fields and optic nerve imaging confirmed
mild glaucoma OD and moderate glaucoma OS. Her physician set a target
pressure of 16-18mmHg OD and 14-16mmHg OS. Now that her diagnosis has
been established and a plan discussed with the patient, it is clear
based on her history shared at the beginning of her examination that the
reliance only on topical medication would not be realistic. Although
generic medications may be are affordable options, given the list of
medications that she manages for her diabetes and hypertension, it is
clear that additional options will need to be considered.
This case reminds us of the importance of considering
the whole patient rather than solely the patient's ocular presentation.
Being realistic in the beginning of a patient's relationship with the
provider is critical for establishing the basis for an effective
partnership to slow or halt the progression of disease. It is also
important to understand the healthcare landscape that shapes patients'
choices for coverage of their care. For example, in the United States,
the Affordable Care Act (ACA) that was launched in 2010, expanded
Medicaid coverage to previously uninsured patients in more than half of
the country [1].
This patient had purchased insurance under the ACA, Now that her
insurance may be discontinued, she is concerned that she will be
uninsured again.
Given her circumstance, the physician decided to
begin treatment with generic latanoprost once daily as a monocular trial
in the left eye; the option of selective laser trabeculoplasty (SLT) is
also discussed. The patient returned Measuring and her intraocular
pressures are essentially unchanged, measuring 22 OD mm Hg and 29 OS mm
Hg. The patient admitted not being able to afford the medication and
agrees to proceed with SLT SLT is performed in both eyes and six weeks
later IOP measured 18mHg OD and 20mmHg. Additional SLT treatment is
considered to get her pressures closer to her target.
This case brings up three discussion points the author wishes to highlight:
- The benefits of treatment with SLT
- The importance of understanding the context of care
- Why eye health needs to be a population health priority
The benefits of treatment with SLT in early and advanced glaucoma has been reported by others [2,3].
Notably, in a series of 26 eyes with early glaucoma, investigators
reported greater than a 20% reduction in intraocular pressure and a
reduction in intraocular pressure less than 21mmHg in 62.9% of treated
eyes, and with retreatment an additional 7.4% were noted to evidence a
reduction in intraocular pressure. Among 44 eyes with advanced glaucoma,
an IOP reduction greater than 30% reduction in IOP and an IOP less than
18 mm Hg was noted in 50% of eyes treated. These eyes were followed for
1 year [3]
When compared to either medications or surgery over a 5-year period,
laser trabeculoplasty has been noted to be the most cost effective[4]. Thus, for our patient, given her challenges with the affordability of medications, SLT is a reasonable option.
In the United States, the landscape for patients who
struggle to afford healthcare is currently uncertain, given current
efforts to repeal the Affordable Care Act [1].
Thus, understanding the context in which this patient must consider her
care is important. Personalizing the treatment plan for patients should
consider the realities of the impact of care, in addition to the best,
evidence-based options. At 59 years of age, this patient is not yet
eligible for Medicare and thus, the cost effectiveness of the laser
trabeculoplasty [4]
is an important consideration. In addition, the outcome of the proposed
treatment is critically important. If the patient can be managed on
fewer medications or on no medications, then her quality of life will
benefit.
Consider the evidence of the effectiveness of
surgical intervention if the patient had presented with angle closure
glaucoma. If this patient had presented with angle closure glaucoma,
clear lens extraction may have been an option for her, particularly
given the results of the EAGLE study. The EAGLE study assessed the
effectiveness of clear lens extraction in patients with angle closure
glaucoma. In a randomized controlled study design, randomizing patients
to either laser iridotomy or surgery, the investigators reported clear
lens extraction to be more effective and cost effective than laser
iridotomy [5]. Regardless of the outcome of the debate related to the Affordable Care Act, [1]
it is likely that as a discipline, it will be important to assemble
additional data such as the EAGLE5 and the Cantor evaluation related to
laser trabeculoplasty [3] to support the reimbursement of specific clinical decisions, as metrics for reimbursement move from volume to value [6]. Timing for our patient's procedure is important, given the imminent changes in her healthcare coverage.
The last point highlights a recent report from the
Institute of Medicine (now named the National Academy of Medicine)
released in the fall of 2016, entitled, "Making Eye Health a Population
Health Imperative: Vision for Tomorrow" underscores importance of
preventing irreversible blindness and suggests strategies for minimizing
vision impairment. Nine recommendations are offered addressing public
awareness, the need for greater evidence to guide policy, importance of
expanding access, enhance the capacity of public health resources, and
the need for promoting community action [7].
0ur patient represents a missed opportunity for earlier diagnosis and
intervention. Encouragement by other providers with whom she may have
interfaced even five years prior to her presentation would have given
her a greater likelihood of avoiding irreversible loss of vision related
to glaucoma. 0nly by elevating the eye health in the minds of
nonophthalmic clinicians, the public, and insurers will the needle
significantly move in preventing blindness. Our patient has benefitted
from work of many innovators and researchers, her ability to maintain
her visual lifeline for the rest of her life rests largely with her as
she navigates the healthcare landscape. The provider is her partner in
this journey, effectively guiding her with a focus on the context of her
care.
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