Glaucoma and Wildlife??

 Retinal Nerve Fibre layer shares its characteristic appearance from wildlife.........The fibres just fan out like the wings of a white peacock and the "double hump pattern" on an OCT scan resembles the humps of a Bactrian camel.
You may think that its a crazy thought but I am just in awe of the wonders of nature and of course, science and scientific correlation.

Check this out folks!! My first book.

Eye drop instillation: What’s the big deal?

What’s the big deal? Ask Monica how much tough time Rachel gave her (in Friends).

Think about the people with chronic diseases like glaucoma, who require multiple medications.

Here is the correct way for instilling eye drops, trust me.

^·          Wash both hands prior to instillation, sit down on a chair or lie on a bed. If seated, the head is tilted slightly backwards while gazing upward.

^·          The lower lid is gently pulled down with the nondominant hand to form a small concavity in which the drops will be placed. With dominant hand, the dispenser is held above this concavity. The bottle should be near enough to make sure that the drop will enter the eye and far enough so as not to touch it (2-5 cm).

^·          Avoiding blinking, the body of the bottle is pressed so that a single drop falls into the eye.

^·          After application, lids should be kept closed (or digital compression be applied to the punctum) for 1-2 minutes to minimize systemic absorption.

^·          The bottle cap should be replaced and any excess fluid wiped from the skin, especially when using prostaglandin medications that may darken the skin colour.

^·          When the eyedrop is a suspension, shake the bottle before administration.

^·          Wait at least 5 minutes between instillation of two different eyedrops.

For people with limited field, who cannot see the tip of the bottle:

Ritch Sussman technique:

·         Hold the bottle between thumb and index finger of your dominant hand.

·         Place the index finger of the other hand in the centre of lower eyelid to hold it open; point it towards the eye creating a right angle with the knuckle closest to your finger tip.

·         Place the first knuckle of your right thumb on the left index finger, point the bottle down and stop it at the knuckle of left finger.

Practical points regarding topical medications:

·         The human tear volume is approximately 7µl with a turnover rate of approximately 1 µl per minute.The use of topical drugs in the eyes doubles this rate.

·         The spontaneous tear flow will cause complete washout of medication from conjunctiva sac within 5 minutes.

·         The volume of an eye drop is 30 µl to 50 µl. Once a drop has been instilled into the eye, only 20% manages to enter the eye, will the rest either runs down the cheek or is drained through nasolacrimal duct.

·         A substantial systemic absorption takes place through highly vascularised nasal mucosa.

Hope this helps save you from the wastage and frustration due to “runny drops over the cheeks”.

Happy drop instillation.

What's in a name? Does it matter if it's a Branded or a generic drug?

Juliet:
"What's in a name? That which we call a rose
By any other name would smell as sweet."

Romeo and Juliet (II, ii, 1-2)

Romeo Montague and Juliet Capulet meet and fall in love in Shakespeare's lyrical tale of "star-cross'd" lovers. They are doomed from the start as members of two warring families. Here Juliet tells Romeo that a name is an artificial and meaningless convention, and that she loves the person who is called "Montague", not the Montague name and not the Montague family. Romeo, out of his passion for Juliet, rejects his family name and vows, as Juliet asks, to "deny (his) father" and instead be "new baptized" as Juliet's lover. 

But when it comes to medicines, do you say to yourself: What’s in a name? How does it matter if it is a branded drug or a generic? Xalatan or latanoprost hydrochloride?

Many people become concerned because generic drugs are often substantially cheaper than their branded counterparts. The cost difference makes one wonder if the quality and effectiveness have been compromised to make the less expensive products.

Why are generics cheaper than branded drugs?

Actually, generic drugs are cheaper because the manufacturers did not spend for developing and marketing the new drug. When a company brings a new drug onto the market, the firm has already spent substantial money on research, development, marketing and promotion of the drug. A patent is granted that gives the company that developed the drug an exclusive right to sell the drug as long as the patent is in effect. Once the patent expires, other manufacturers can also make and sell generic versions of the drug; and without the startup costs for development of the drug, other companies can afford to make and sell it more cheaply. When multiple companies begin producing and selling a drug, the competition among them can also drive the price down even further.

 Is there a difference in the effectiveness or side-effect profile of the generic medications?

The drug authorities of all countries require generic drugs to be equivalent to the original brand name product. Unfortunately the generic drugs do not undergo the same rigorous testing that is undertaken when the original patented product is released, so in some cases doctors may experience dissatisfaction in terms of IOP reduction or slight exacerbation of adverse effects such as increased hyperemia with the generic drug. But one cannot generalize that all branded drugs are better than all generics.

An Indian patient on Xalatan is now switched to generic latanoprost by his doctor as his dispensing pharmacy no longer provides Internationally marketed brands, and he is very apprehensive about the changes in his IOP profile. What needs to be explained to him to reduce his concerns?

Three alternatives should be discussed with the patient.

First, that he can try the generic drug and review its effects with his ophthalmologist, 3- 4 weeks after starting it.

Alternatively, he can pay the additional cost of continuing on the brand name, Xalatan itself, although the cost difference may hurt his pocket.

Lastly, he should be told that there are two other similar products that are available in case the generic does not work and he cannot afford Xalatan. These medications are Lumigan (bimataprost, Made by Allergan, Inc.) and Travatan (travoprost, made by Alcon, Inc.) and he can be switched to these, if need be.

In general, patients who are switched to a generic product should be told that the eye drop size delivered from the bottle and the amount of product in the bottle itself may vary in generic products. Hence, they should keep a note about how long the generic bottle lasts so that a timely refill can be taken.

Back to the key question: What may account for differences between generic and Branded? 

Some differences will have a scientific explanation while others will be anecdotal in nature. IOP is a very difficult parameter to assess due to the significant fluctuation over the diurnal and nocturnal periods. When a patient is switched to a new medication or generics, it is often difficult to determine whether the switch or the fluctuation in IOP is the primary reason for a change in IOP relative to the previous visit.

Ocular tolerability, in contrast, is easier to assess as patients will commonly bring side effects to the physician's attention.

Generic- Branded drug scenario across the globe

Even the most developed nation, USA, has one of the highest levels of generic drug use relative to total prescription volume among developed nations. So, it is logical that a similar scenario would exist in developing nations.

In India more than one-third of the population is below the poverty line (earn less than 10 rupees per day) and a 2007 report by the state-run National Commission for Enterprises in the Unorganised Sector (NCEUS) found that 77% of Indians, or 836 million people, lived on less than 20 rupees (approximately US$ 0.50) per day. This fact must be kept in mind and the income of the family noted before prescribing expensive glaucoma medications which are to be taken lifelong.

Generic low cost versions of prostaglandins which are free of BAK preservative are now available in India (eg. Xovatra – Travoprost by  Cipla Inc., Latoprost RT- Latanoprost  by Sun Pharma, Travo Z – by Micro Vision Inc.)  which may be used as cost is a very important issue in developing countries.

How to establish whether a generic is working or not?

When any generic version is used where field trials on efficacy are not published, one must check the percentage drop in IOP (atleast 20%), size of the drop/nozzle of the bottle to ensure only 1 drop comes out with each squeeze of the bottle and the availability of the drug in the native place of the patient to ensure a good compliance.

Well, in a nutshell our challenge as eye care providers is to be cognizant of the unknowns regarding ophthalmic generic medications

Peripapillary halo and atrophy in Advanced Glaucomatous optic neuropathy

" Oops I forgot my Glaucoma med today....Never mind I will just lie to my doc."

C. Everett Koop, the former U.S Surgeon General, has rightly remarked,

“Drugs don’t work in patients who don’t take them.”

Simply prescribing anti glaucoma drops and telling the patient, "See you in three months . . . next patient, please!" is not the right approach when we are dealing with “glaucoma”.

Remember:

      Communication, Communication, Communication: Optimal treatment of patients with a chronic condition such as glaucoma requires a detailed conversation between the patient and the ophthalmologist that continues over the years. These conversations must regularly reinforce the benefits of ocular hypotensive therapy and regular follow-up visits.

In patients with multiple medical conditions who tend to be less compliant, polypharmacy, can lead to deletion of medication that patients think are less important. For example, if given a choice between affording or remembering to take a heart medication or an eye drop, the patient may logically choose the heart medication. Therefore a proper patient counseling about the disease process, the rationale for treatment and how drugs act, and the need of life long medication and follow up cannot be over emphasized.

     Regular assessment of the medication regimen: Consider the simplest feasible medication regimen that will meet the patient’s needs. Be alert to side effects that might reduce compliance and persistency and consider changing the regimen if problems arise.

      Ensure patient understanding of correct drop instillation technique: When starting a patient on drops for the first time, consider a ‘‘practice bottle’’ of artificial tears. At each visit, have a staff observe the patient instilling drops in the office. Instruct patients regarding the timing/spacing of drops and, depending on the regimen, consider a device to administer the drop. 

Be attuned to cost issues: Patients may be embarrassed to admit they cannot afford the medication  or  follow-up visit fee, and ophthalmologists need to be sensitive to the possibility that cost is an issue. Patient assistance programs from pharmaceutical companies can be offered to patients having difficulty paying for medications.

Help patients remember eyedrops into their routines: Cues such as teeth brushing, morning coffee, or administration of other medications may help patients remember to instill the eyedrops. Ask patients to keep a calendar and check off when drops are instilled.

 Advise patients who work, especially those who work shifts, to consider keeping an extra bottle at the work site.

Example of a drug dose reminder chart:

Drug	Morning	Noon/Evening	Night/Bedtime
Betablocker (Timolast™)	Ö	Ö
Dorzolamide (Cosopt™)	Ö	Ö	Ö
Travoprost (Travatan Z™)			Ö

Practical tips:

The most common techniques for detecting non-compliance are:

· Patient interview: Use open ended questions rather than statements,

· Clinical outcome

· Calculation of number of bottles used per month.

Tips on Instructing Glaucoma Patients

By Dr George L Spaeth

Louis J. Esposito Research Professor

Wills Eye Institute/Jefferson Medical College

Philadelphia, PA, USA

           

Perhaps the most important key to instructing patients and answering their questions effectively is for the physician to consider himself or herself primarily a teacher and fundamentally interested in educating in the broadest sense of the word.  This does not mean “filling up” with so-called “facts” or pieces of medical information.  It does mean literally “leading forth.”  It means helping the individual control his or her life in a way that will lead to the greatest likelihood that what that particular patient wants will be able to be achieved.

1.    Believe everything the patient says.  The words may be inappropriate, or even wrong, but underneath the words will be a fundamental truth that the patient is trying to get across to you.  It is our responsibility as physicians to translate those words so we can understand that message.  And we need to speak back to the patient in ways in which we address that core issue with all the aspects of successful communication:  body language, touching, and speaking that is meaningful to the patient.    

2.   It is essential to be honest.  One can be completely honest and yet not be cruel.  Lying is almost always disrespectful and arrogant.  Remember that a truth can be a lie.  A lie is an intent to deceive.  “Bullshit” is one of the most venal types of lying, because when we speak bullshit, we fool ourselves at the same time we are trying to fool the patient.

3.   Speak in terms the patient can fully understand.  Never use abbreviations or jargon.  It is deeply disturbing to hear doctors speaking to each other in front of patients about the patients’ CRVO or their decreased MD or the “CME in the OD.” There is no place for such language with patients.  Use “the pressure inside your eye,” or “your eye pressure,” rather than “intraocular pressure.”  After you have said something to a patient, ask him what he understood you to say.  You will be shocked.  You think you have said something so clearly that everybody would understand it fully.  But when the patient says it back to you, it is a totally different story from what you had in mind.  A routine part of communicating meaningfully with patients is asking, “What does X mean to you?”  “What did you understand that I just said?”

4.   Try to avoid phrases such as, “Unfortunately. . .” or “I am sorry to tell you. . .”  Just saying “unfortunately” will turn off the patient’s ability to hear.  Simply put the facts out in a way which are understandable, but phrased so as always to leave hope, because there is always hope.  It is always, always, always possible to do something that will make the patient’s life better.

5.   Do not confuse the patient with the patient’s condition.  Do not say, “You are worse.”  Rather say, “Your visual field has gotten worse in your right eye.”

6.   Always consider the future.  Think in terms of a video, not a snapshot.  Remember that no treatment of any kind is justified unless you know that without the treatment the patient will have a decrease in quality of life or develop some type of disability.  If you cannot be sure of that then there is no justification for starting the treatment, because every treatment causes problems.  With that in mind, then, it is easy to instruct the patient to say, “I am starting this drop because without it I believe that you are going to have a decrease in your ability to “X” (drive, read, play tennis, whatever is important to the patient).”

7.   Remember that your words and gestures will instruct.  For example, when you have measured the intraocular pressure and you say in a definitive, authoritative tone, “Your intraocular pressure is 15,” the patient will conclude that you really know that the pressure is 15.  (That is bullshit.)  Of course you do not know the pressure is 15 mm Hg.  Furthermore, the pressure could easily have been 10 or 20 one hour earlier, or 10 or 30 that evening.  On the other hand, if you say something like, “As I measure your eye pressure just now, it is somewhere around 15,” you will be instructing the patient in the difficulty of determining exactly what intraocular pressure the person has.  When one looks at the second visual field and says, “Your visual field is worse.  You had 4 decibels of loss last time, and you have 8 this time,” the patient concludes that they are twice “as bad” as they were before.  Of course that is nonsense.  A field change from 4 to 8 decibels may not even be significant.  Indicating to patients the softness of all these values is a critically important part of educating them.  Everything we do or say educates patients in some way.

8.   When you think you have said something especially brilliant, ask the patient what she understood you to say.  Then be prepared for a huge deflation.  But do not take it negatively.  Recognize it as an opportunity to clarify, to engage the patient more fully, to understand the patient better and to have them understand you better so that at the end of the conversation they feel that they have really moved ahead in being able to control their own lives.

9.   Finally, remember that your final comments to your patients will remain with them for months or years.  Consider a patient who has had a guarded filtration procedure three months before, and at this three-month visit you note that the visual acuity is one line worse, and the person has mild bleb dysethesia, and an intraocular pressure around 12 mm Hg (which is where you wanted it).  The parting statement to that patient could be, “I am sorry your eye is so uncomfortable and that your vision is worse.  Let’s hope it clears up.  It is important that I see you again in six months.”  That patient will leave discouraged and will be apprehensive for the entire six months.  On the other hand, the parting comments to the same patient could be, “I am very pleased with the result of the surgery.  I know that you now have mild irritation, but I also know that you can tolerate that.  When the eye feels irritated, blink several times and that will almost certainly make the eye feel better.  Your sight is still excellent, and the likelihood is great that you will keep your vision for the rest of your life.”  (As you say that you hold their hand and look them directly in the eye, because you are genuinely pleased.)  “I am eager to see you again in six months.  You are a real inspiration to me.”