
8th March 2008 2pm to 4pm - Talks on glaucoma in Mandarin (open to public - 150 seats available)
Peer to Peer Sharing : In the sea of knowledge, we seek to establish a connection between those seeking for information and those who have the answers sought. Together we may come to a better understanding of the "newly discovered" knowledge that makes the difference.
What is neuroprotection and how does it apply to glaucoma treatment?
Neuroprotection is a broad term to cover any therapeutic strategy to prevent nerve cells called neurons from dying, and it usually involves an intervention, either a drug or treatment. There is significant amount of scientific work that is currently going on in this area, but much more research is needed to identify the best pathways to target for neuroprotection. - Dr. Moses Chao, Glaucoma Research Foundation
FOR MORE INFORMATION VISIT THE LINK BELOW:
The Society’s Objectives are:
Website: http://www.amd-singapore.org
emails : admin@amd-singapore.org or amdsg.sg@gmail.com
GLAUCOMA CARE: LOOKING BACK, LOOKING AHEAD - A PATIENT'S HOPE
DON’T FALL VICTIM TO THE SILENT SNEAK THIEF OF SIGHT
by Sam Fong, Alpha-C Support Group, Glaucoma Society (Singapore)
Once-a-day eye-drops such as the prostaglandin analogs for glaucoma introduced at the turn of this century and more combination-drops coming on stream will improve the problem of medication compliance through greater convenience to the patient. Improved and refined surgical techniques together with better understanding of pre- and post-operative care greatly reduced the risks of surgical failures.
From the patient’s perspective, we hope the future will bring more effective treatments for glaucoma than merely reducing Intra-ocular Pressure (IOP). We hope that breakthroughs in neuroprotection, which can safeguard the optic nerve, will not be too far away. Beyond that - Stem Cell Therapy for optic nerve regeneration may become a possibility. These will all enhance the prognosis of future patients to preserve their vision, if not “cure” their condition.
12th Mar 2007 : Latest from Tan Tock Seng Hospital - LASIK PUBLIC FORUM ... please call 6357 8266 for Registration and it is FREE!!!
Hi Sam,
Thanks for diseminating the info to your group. We have decided to make out LASIK public forum free. Also, the number to call for registration will be 6357 8266. FYI. Thanks! :)Regards,
Eugene Kwek, Executive, Ophthalmology Department DID: 6357 7736
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11th March 2007
Dear Friends,
This month, March 2007, there are 2 Public Forums organized by the Hospitals, each will be held at Tan Tock Seng Hospital and Alexandra Hospital. It looks like it is possible, with some time management, to attend the morning session at AH, take a leisurely lunch and go to TTSH in the afternoon for the next session. Those who are interested to attend may contact the respective organizing personnels:-
TAN TOCK SENG HOSPITAL
LASIK Public Forum
Date: 17 March 2007
Time: 1.30 to 3.30pm
Venue: TTSH Theatrette, Level 1
Registration Fee: $5
For registration or enquiries,
please contact Ms Lim Sing Yong / Mr Eugene Kwek at 6357-2678 / 7736 or email: Sing_Yong_Lim@ttsh.com.sg
ALEXANDRA HOSPITAL
Eye Bags & Sags
Ever wonder what causes eye bags, sagging upper eyelids or sagging eyebrows? Ever dream of removing them to see clearer and look more youthful?
Date: 17 March 2007 Time:
10 am - 11am (English Session) |
Venue: Auditorium For registration or enquiries,
please contact Ms Alice How at 6379 3741 or email: Alice_How@alexhosp.com.sg
Yours truly,
Sam Fong
Pro-Tem Committee
AMD Support Group
Is glaucoma eye-drops compliance that difficult?
A patient's perspective
By Sam Fong, Alpha-C Support Group, Glaucoma Society (Singapore)
Far too many glaucoma patients have lost too much of their sight, much too early and unnecessarily, due to non-compliance on the use of their eye-drops. The correct use of eye-drops is surprising low even among the educated population. What are the reasons?
Glaucoma Eye-drops - a pressure regulator
However, with glaucoma, it is not quite the same story. It is not a common experience and the normal technique does not apply. This is because, when you have glaucoma, your eye’s auto-regulation system has failed. Eye-drops are no longer a symptom-reliever but now acts as a regulator of intra-ocular pressures (IOP) in the eye. You can say it is like the pace-maker used to regulate the heart beat and stopping the pace-maker will cause the faulty heart to function erratically. So it is with the eye. When your application of IOP-lowering eye-drops are stopped or not regular, the unregulated glaucomatous eye pressure may fluctuate diurnally by as much as +10 mmHg from its low.
First, we need to try to understand how glaucoma is treated with the use of eye-drops. Currently, the only available treatment for glaucoma is by lowering the IOP. We can do this by taking medicine in the form of tablets, using eye-drops or by surgery where an alternate drainage path is created for AH (aqueous humor) outflow. It is quite obvious that tablet intake is probably the least effective means for lowering IOP in the eye because the medicine is not directly applied to the eye and that surgery is the most effective because it directly and physically creates a vent in the eye for pressure relief.
No feedback indication
What makes it difficult for the patient to understand the usefulness of the eye-drops is that the pressure in the eye is awfully low. Take a drinking straw and fill it with water to 150mm height and hold it against your arm and you will feel nothing; double it to 300mm water height and again you will feel nothing pressure-wise. This represents the limits of the range of pressures between 11 and 22mmHg. The eye-drops in most instances are trying to regulate the IOP in the patient*s eye within this range and to find a "safe" level required by the patient. And because the patient cannot feel the effects physically, the patient cannot appreciate the usefulness of the eye-drops. The process is unable to provide a system of positive feedback that can be measured by the patient. In the case of diabetes, the patient is able to measure daily his blood-sugar level and gauge his compliance but this is not quite the case with glaucoma. With glaucoma, the patient can only get the performance-feedback at his next clinic visit, which may be 5 to 6 months later.
There are various causes of non-compliance in the use of eye-drops. Broadly we may classify them into two groups:-
1) failing to take prescribed doses at recommended intervals
2) failing to dispense the correct dosage due to wrong techniques
Unclear Prescription Convention
It is traditional in medicine prescription to use the day to represent the interval of dosage and then specify the number of times they have to be taken, often before or after food. Thus this practice is also applied to glaucoma eye-drops - do you apply nightly, twice a day, three times a day, or four times a day? The day is taken as the yardstick. What then about the night? Does one sleep through it without medication? If the patient sleeps 10 hours a day, what happens to the 3 or 4 times a day dosage interval? It is possible in such instances that the eye-drops would have over-regulated the IOP during the wake-hours and under regulated the IOP during the sleep-hours. This can only lead to undesirable results for patients with "spiked-up" IOPs during the night.
If the traditional prescription methods are confusing, then change them. Perhaps it may be better to base the application times on a 24-hour day (inclusive of the night) - applying eye-drops 12 hourly, 8 hourly, or 6 hourly - instead of the 2x, 3x or 4x per day convention. In this way, the time of dosage each day will be the same and much easier to remember. This makes the exact dosage times clearer and helps the patient to be more disciplined. The patient will also have a better idea of the dosage interval and plan ahead. Thus, if adherence to a 6-hourly dosage schedule is not possible for the patient because his work, age, health etc, it would be better that the ophthalmologist prescribe eye-drops which have longer effectiveness. Studies show that greater compliance is seen with lower-dose frequency and falls sharply as the frequency is increased. With once-a-day dosage, 75% of patients use their drops regularly. But, the patients' compliance falls to 40% when the dosage ís increased to a 6-hourly schedule.
Consumption rates of common dosing schedules are around 80% when the drops are taken by patients who are on a once-a-day dose; and falls to 50% when patients are placed on 6-hourly dosages.
Though the consumption rate looks better, the time interval of application has often been compromised. Often non-compliance may be due to:-
1) some over-flow the rim of the eye
2) some gets drain out through the tear duct
3) some gets absorbed by the eye - the only useful portion
Depends on Patient, his Patience and Persistence
The objective is to allow as little of (1) and (2) to happen and as much of (3), which is the only useful portion of the eye-drop, to take place. The eye-drop must get to the eye to do its job. How much of the drop is going to be effective depends on the patient, his patience and his persistence. Too little of (3) would result in partial compliance or lack of efficacy. How much of the drop should do useful work i.e. (3) is a chicken-and-egg issue. The test is, if by maximizing the usefulness of the drop will maximize the IOP lowering, the maximum usefulness should logically be targeted. It saves money, it gives less side effects.
Consider a Case Study. Let us say that a control patient needs a 35% IOP reduction to reach the target pressure. Assuming that, with this patient, the prescribed eye-drop is capable of lowering the IOP by 40% if optimal efficacy is practiced but only 20% was obtained due to poor but consistent application. As a result, on examination of the optic nerves and visual field results, the ophthalmologist prescribes to add on another eye-drop so as to lower the IOP further by another 20% and the target IOP was met. Note that this could actually be achieved with the first drop if there was good compliance. Thus, with good compliance, it is possible to reach the target pressure with less cost, a less frequent dosing regime and less side effects. Trying to get everyone to achieve the maximum benefit from the drop may not be practical but some good practices may yield better results than haphazard applications.
Some Good Techniques for Good Compliance
Let us consider some of the better techniques adopted for good compliance. In a workshop study of 20 patients some good practices were introduced and the performance gauged after the next visit. The results of the initial visit and subsequent visit are tabled: The results showed that with proper instructions and practice, the procedures could be taught and learnt by patients.
Let us try to understand how each of these steps helps to improve the procedure of application. Getting the eye-drops properly absorbed by the eye requires time and it varies with different eye-drops and from person to person. Generally, 5 minutes would be sufficient but with the carbonic anhydrase inhibitors (CAI) they might take as much as 10 minutes because of their more waxy and viscous nature. Keeping still for 5 minutes in the tilted head back and the eye gently closed position will keep the drop at optimum instilment mode. Closing the eye gently without blinking and squeezing will improve the dosage. The action of blinking will cause fluid to drain down the tear ducts and together with some of the medicine. Applied pressure-lacrimal puntae, a procedure of applying slight pressure to the inner corner of the eye with the finger, will physically close the tear duct blocking drainage through this channel temporarily. The patient should try to apply drops to one eye at a time instead of both eyes simultaneously if difficulties are experienced in preventing over-flowing. A delay of 1 or 2 minutes between instilment of drops to each eye often helps. Similarly, if more than 1 drop is instilled to the same eye at close interval, a minimum of 5 to 10 minutes between applications will ensure that the second drop does not wash out the first drop.
Even the most conscientious patient forgets or misses the time to take a medication occasionally. But, immediately upon realizing it, he should take the medicine as soon as possible unless the time is so close to the next scheduled medication, that he should skip the dose and carry on according to his normal schedule.
One must safeguard against the folly of being fully compliant just before the next clinic review with the objective of obtaining good IOP readings, with the hope that the ophthalmologist would not increase the dosage of eye-drops and thus save cost. This will not work, as the optic nerves and visual field results will reveal the long-term consistency or inconsistency of eye-drops compliance. But it is only when the patient understands the importance of being consistent, that the patient would want to be compliant.
Conclusion
Finally, the patient should remember that the IOP-lowering eye-drop acts as an IOP regulator. In order that it can function in this role, the interval of application should be regular, as prescribed, and consistently maintained over long periods of time. The ability to apply each dose with maximum effectiveness to the eye will enable maximum benefit to be obtained from each drop and avoid additional medicine. By being compliant the benefits to the patient are:-
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Am I at RISK for GLAUCOMA?
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ASK YOURSELF THESE QUESTIONS :
SEE: Wills Glaucoma Service : Chat Highlights: Glaucoma Risk Factors and Their Significance
http://www.wills-glaucoma.org/supportgroup/20030625.php
Risk Factors for Glaucoma:
You need not answer all the questions. Just state the Question No. in your comments with your Answers.
Alpha-CARE for U
Speed up the treatment, spread the word - compliance, compliance, compliance ......
How to use your eye drops
Some General Information
If you experience any discomfort when using the eye drops please contact your eye doctor
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How to put your eye drops in
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Also see : Is eye-drops compliance that difficult? http://alphacian.blogspot.com/2007/02/is-eye-drops-compliance-that-difficult.html
Now that I've been told I have glaucoma, what can I expect?
By George L. Spaeth
"Now that I've been told I have glaucoma, what can I expect? " This question has to enter the mind of every person who has just learned that he or she has glaucoma. It may be a sufficiently frightening question that the person never speaks it aloud. But it's the sort of question that most physicians dread, because it asks for projections that are extremely difficult to make. It asks the ophthalmologist to "play God," and, while physicians may be respected for their knowledge, they are usually aware that they have no unique ability to see into the future. Nevertheless the question is the right one for patients to ask, and it is an essential one for the ophthalmologist to address with a patient.
The first thing that a person who has been told that he or she has glaucoma ought to do is to ask the doctor what he or she means by the word "glaucoma." The word "glaucoma" is still used in so many different ways, and it means so many different things to different people, that the question about what it means for the person to have glaucoma can't really be addressed at all until there's some agreement on what the word "glaucoma" means.
Expect the Unexpected
The first thing that the patient with glaucoma should expect is the unexpected. Some types of glaucoma seem so serious that the physician worries that the affected person is likely to go blind. Other glaucomas seem quite mild, and the doctor may wonder if any treatment is necessary at all. But the patient with what appears to be a serious glaucoma may respond wonderfully to treatment and not have any further significant visual loss, while the one with the seemingly mild glaucoma may end up visually incapacitated because glaucoma in this case proves very resistant to all sorts of treatments.
Does this mean that the individual affected with glaucoma can't make any plans? No. While unexpected things are routine, the changes that occur in most people with glaucoma, once the initial diagnosis has been made and the initial treatment started, usually occur slowly over a period of many years. If the patient is alert and the physician is alert, the different directions in which the glaucoma is going can be spotted, and new and more appropriate projections made.
For example, the first patient mentioned above needs to be counseled at the start that there's a reasonable chance that he will lose his vision due to glaucoma. But as soon as it becomes apparent that the response to treatment is better than expected, a new counseling session is necessary in which the patient comes to understand that he's doing very well and the outlook for the future is far more favorable than had initially been considered. In a similar vein, when it becomes apparent to the physician that the second patient is not responding well to therapy, it's essential to share that information with the patient so the patient have a more accurate idea of where he or she can expect to be 20 years later.
Remain Vigilant
Except for a few types of glaucoma, the tendency for glaucoma to cause continuing damage remains with the person for the rest of the person's life. Thus, the person must not think that he or she is "cured" and stop being vigilant. There's a great difference between being vigilant and being a hypochondriac. To be vigilant means to be alert to warning signs and to exercise appropriate "preventive maintenance." To take care of a car properly does not require that the owner spend an hour a day inspecting the car. It does mean that periodically the car needs to be checked to make sure that the operating systems are working appropriately and that, if they don't seem to be working properly, that they are checked out promptly.
Warning signs that should alert the patient to call the doctor are symptoms of any kind that make the patient wonder if everything is OK. Of course, the most worrisome symptom is any sense that visual function is worse in any way. These symptoms would include:
It's appropriate for the person to test each eye individually periodically. This need not be time-consuming or threatening. One way, for example, is on the first of each month for the person to check each eye individually to see if there's been a change in the smallest print that the person can read, and to check each eye to see if there's a change in the sense of the visual field, i.e., the awareness of all the things that surround a person. If one uses the same printed material each time to check vision, it becomes immediately apparent if the vision is becoming worse. If one looks at the same general scene, such as at a specific picture on the far side of the wall, then major changes in the visual field are easy to appreciate on repeated testing.
There are, of course, a wide variety of other visual symptoms that indicate that something might be wrong, such as "seeing double" or marked problems with glare. These symptoms, however, usually point to concerns other than glaucoma.
It's also important for the person to be vigilant regarding his or her general health. A person's general health has a profound effect on his or her glaucoma, and the glaucoma can have a profound effect on general health. Changes in the person's sense of well-being, the person's sense of energy, level of general fatigue, stress, and important events in the individual's life should be noted and relayed to the physician.
Prepare for Battle or Be Wary of Treatment?
Eyes that have far-advanced damage have demonstrated that the person's glaucomatous disease is the type that causes damage. Eyes that don't have much damage have demonstrated that they have the type of condition in which damage is much less likely to occur. The person, then, who at a relatively young age is found to have far-advanced glaucoma damage has to be prepared for a real battle. On the other hand, the person who's really doing quite well and isn't showing signs of progressive deterioration is more likely to be damaged by methods used to prevent further damage than he or she is likely to be damaged by the glaucomatous process itself.
Value Your Own Assessment of What You're Feeling
The person with glaucoma has to realize that the system of medical care which has come to be considered to be the best medical care is based on science, and science is based on unbiased, objective measurements which are analyzed in an unbiased, objective way. This means that the concerns of patients, which are never objective, and are always biased, are always considered with skepticism by the scientist. But in fact every individual person is unique and different from every other person. The patient wants a physician to be scientific, objective, and knowledgeable, but the patient must be prepared to do battle with physicians who don't appear to value what the patient feels about himself or herself. For example, when a patient says to the doctor that he's getting worse, by definition the patient is getting worse. The doctor may not be able to find manifestations of that deterioration but that doesn't mean the deterioration isn't occurring. The glaucoma patient, then, must pay a great deal of attention to his own sense of well-being and must be prepared to communicate that convincingly to his or her physician.
Be Ready for Repeated Optic Disc and Visual Field Assessments
The two most important tests done on the glaucoma patient are evaluation of the optic disc and visual field. Patients need to be prepared to have serial, repeated tests of these two functions. The patient also must be prepared for the huge amount of variability that exists between testing sessions and must not conclude that he or she is either getting worse or stable just on the basis of an apparent change in a photograph or on a visual field. The determination of whether a test really does represent a deterioration or an improvement is frequently an extraordinarily difficult determination and should not be made lightly by either the physician or the patient.
Be Prepared to Make Trade-Offs
The person who has a serious glaucoma, in which the optic nerve already has become damaged must realize that he or she is going to have to make trade-offs. Using drops is a nuisance; the vision is temporarily blurred, it's not comfortable to have to leave a meeting to go into the bathroom to use one's drops, it's a nuisance to make sure that one always has one's drop with one, etc. But if one has the type of glaucoma that is going to get worse, and the glaucoma is being controlled with medications, either one uses the drops or the glaucoma gets worse.
The two most important tests done on the glaucoma patient are evaluation of the optic disc and visual field. Patients need to be prepared to have serial, repeated tests of these two functions. The patient also must be prepared for the huge amount of variability that exists between testing sessions and must not conclude that he or she is either getting worse or stable just on the basis of an apparent change in a photograph or on a visual field. The determination of whether a test really does represent a deterioration or an improvement is frequently an extraordinarily difficult determination and should not be made lightly by either the physician or the patient.
Similarly, when glaucoma surgery is done, the eye is not returned to normal. The pressure may be controlled by the surgery, but the surgery usually substitutes one problem of less magnitude for the greater problem of losing vision. It is essential that the patient understand that there will be such trade-offs and it is the job of the patient and physician together to decide how to prioritize the problems so that the patient is most likely to accomplish those things which are of most importance to the patient.
Source: Wills Glaucoma Service