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| ORIGINAL ARTICLE |
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| Year : 1991 | Volume
: 39
| Issue : 3 | Page : 91-93 |
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Medical and socio-economic aspects of long term therapy of open angle glaucoma
NN Sood, Harsh Kumar, ND Patil, AC Aggarwal, Ramanjit Sihota
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi- 110 029, India
Correspondence Address:
Harsh Kumar
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All Institute of Medical Sciences, Ansari Nagar, New Delhi- 110 029
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 1841899 
Hundred patients of open angle glaucoma (OAG) who were on any one of the three drugs pilocarpine, timolol and epinephrine--for an average period of 3.3 years were chosen. Proforma regarding socio-economic status and the patients' reaction to long-term medication were recorded. Though the objective and subjective effects of long term medication were negligible the financial constraints were considerable. More than 70% patient would prefer laser's and surgery because of the cumbersome schedule and financial burden. The visit to the clinic was a time consuming process suggesting a lack of adequate glaucoma follow-up at the peripheral level. The study reflects a need for reorientation of glaucoma management.
How to cite this article:
Sood N N, Kumar H, Patil N D, Aggarwal A C, Sihota R. Medical and socio-economic aspects of long term therapy of open angle glaucoma. Indian J Ophthalmol 1991;39:91-3 |
| Introduction | |  |
The list of complications for any single antiglaucoma drug makes an impressive reading [1][2][3][4]. However, drugs are still the mainstay of treatment of primary open angle glaucoma in most parts of our country.
We undertook a study to evaluate ocular and systemic discomfort encountered by a patient on long term antiglaucoma drug therapy, as well as his financial restraints; understanding of the disease, compliance for usage of the drug and willingness to change to surgical or laser therapy.
We thus wanted to study the acceptability of long term antiglaucoma medications in face of financial restraints and the numerous possible side effects.
| Material and methods | | |
The study comprised 100 patients of primary open angle glaucoma and ocular hypertension selected from the glaucoma clinic of this centre. The diagnosis was based on elevated applanation intraocular pressures (IOP), disc and field changes in the presence of open angles on gonioscopy.
Those patients who were using only one of the three antiglaucoma drugs, namely, Pilocarpine 2%, Timolol maleate 0.25% or 0.5% and Epinephrine bitarterate 1 %, for an average period of 3.3 years (range 3 months to 5 years) were selected.
A detailed history regarding the socio-economic status, education, expenditure on drugs, time spent in attending clinics, regularity of drug use, systemic and local side effects encountered and the availability of the drugs in the market was recorded.
A detailed routine ophthalmic examination was carried out and a proforma was utilised to find the local and systemic side effects of the drugs. Schirmer's test was carried out in patients on timolol and the criteria for presence of dry eye included the Schirmer's value of less than 5 mm along with the presence of mucous shreds and filaments.
Anterior chamber depth measurements were done by pachometer attached to Haag Streit slit lamp in case of patients using pilocarpine. Those with a chamber depth of less than 2 mm in the centre were termed shallow chambers.
| Results | | |
Of the 100 cases 65 were male patients, their average age being 52.4 (range 32-81) years and that of females was 50.5 (range 41-72) years.
Of the 100 cases, 7 were ocular hypertensives while the rest were of primary open angle glaucoma.
Economic status
Forty-five of these patients had a monthly income below Rs.1000/-, 37 were earning between Rs.1000/to Rs.2000/- and the remaining 18 were in the income group of more than Rs.2000/- per month. The same is depicted in [Figure - 1].
Cost of drugs
On an average, the patients using Timolol maleate spent 40 to 50 rupees per month on their drugs and those using Pilocarpine or Epinephrine spent Rs.20/- to Rs.30/- per month.
Education status and awareness
Twenty of these patients were well educated and had a clear idea about the usefulness of the drugs and the consequences of neglect. Another 50 patients were aware of the benefit of regular use of drugs to some extent and desired to have more information. Thirty patients were putting the drug solely because they were told to do so and showed little interest in finding out more about their disease.
Time spent for follow-up
Twenty-three patients spent around 3-4 hours per month in the clinic, on an average, inclusive of travel time, 12 patients required upto 6 hours, while the rest 65 had to spend anywhere between half a day to two days for attending the clinic. The same is depicted in [Figure - 2]. More than 90% of the patients used their medicines regularly.
Mode of medication
About 70% of the patients instilled their drops themselves while the rest 30% got them put by family members.
The complications encountered in the Pilocarpine group are enumerated in [Table 1], while those of Timolol and Epinephrine are depicted in [Table 2][Table 3] respectively. The willingness to shift to other modes of therapy is depicted in [Table 4].
| Discussion | | |
The number of patients chosen for the study was small because it was difficult to find persons who were continuously using only a single drug for a long time. Most others had either changed their drugs intermittently or were using a combination of drugs both of which would defeat the basic purpose of the study, i.e., to elucidate the actual percentage of patients suffering from side effects of each topical antiglaucoma drug and to find out the acceptability of long term medical therapy of glaucoma.
The small number of patients in higher income group perhaps reflects their tendency to go more often to the private practitioners and also the fact that our catchment area has fewer people of higher income group in this category. Thq fact that some of the drugs may cost almost 5% of the monthly income of lower strata highlights the need for surgery in such patients. The data on motivation factor compels us to have a second look at our health education programme.
The amount of time spent by patients for the clinic clearly reflects that around 80% of the patients either came from the outskirts of the city or from outside. This may be attributed to the popularity of the clinic and the faith of the patients in the institution, it also reflects the need for better peripheral services. If the primary health centres and other district level hospitals offer good follow-up care, which is indeed an inexpensive proposition, then the patients will be saved the hardship of long travel. Also the specialised clinics will then be able to concentrate more on the complicated cases
It is interesting to note that 10% of the patients were so used to pilocarpine that any discontinuation caused optical and ocular discomfort. This specifically occurred in presbyopes who could read better after pilocarpine. The side effects of nausea, sinking feeling and headache were transitory and wore away after constant use for one to two months. The local side effects of watering and burning were noted more in the beginning but were not serious enough to warrant discontinuation of the drug.
Induced myopia occurred in 22.5% patients usually in the younger age group -as reported by other workers also, We could detect cyst in the iris in only 1.25% of the eyes, which disappeared after dilation of pupil.
We did not encounter retinal detachment, band shaped keratopathy or any complaint regarding the urinary system.
The systemic side effects were seen overall in 11.2% of the patients using Timolol. Depression was found in 2.8%, angina in 2.8% and problems in breathing in 5:6% of cases. In all these cases the drug was stopped. CNS side effects with Timolol are reported to be around 6.07% [4]
The symptom of depression was detected mostly on direct questioning. This suggests that the patients on long term timolol therapy should be specifically questioned to detect such side effects in the early stages. Cardiac and respiratory problems also must be enquired into thoroughly. The low rate of these abnormalities in our study perhaps reflects the precaution taken to rule out these conditions initially. Despite this caution, development of such problems reflects the need for utmost care while initiating the therapy.
Many patients held back the information regarding their having cardiac or respiratory problems since they thought that they were adequately controlled for the same. This invariably led to precipitation of such symptoms after use of Timolol.
The local ocular complications encountered in our patients were dry eye, superficial punctate keratitis and congestion of the eyes, all of which are well known problems [4]The presence of persistent dry eye resulted in discontinuation of therapy in one case.
Maximum ocular side effects were seen with Epinephrine. Burning, irritation and conjunctival pigmentation were severe enough in 8% of the cases necessitating discontinuation of the drug and change to other drugs despite acceptance for a few years. The discoloration was a cosmetic blemish for a few patients while others tolerated it well. The conjunctival pigmentation though present did not cause any significant corneal problem as reported [3]It was surprising that no systemic side effects were noted with Epinephrine, mainly perhaps due to discontinuation of the drug in most patients at the earliest appearance of symptoms.
[Table 4] indicates that only 5% of the patients, mostly presbyopes on pilocarpine, were interested in continuing medical therapy. Another 25% were indifferent enough to let the doctor choose their therapy though it does point to the fact that drugs would not be inconveniencing them too much. However, the rest 70% patients wanted alternative therapy because of side effects of long term ways of antiglaucoma drugs, financial restraints or the problems in maintaining the strict schedule of the drugs[5].
| References | | |
| 1. | Axelsson U and Homberg A. Acta Ophthalmol 44, 421, 1966.  |
| 2. | Pape LG and Forbes M. Am J Ophthalmol 85, 558, 1978. |
| 3. | Corusin ME and Spancer WH. Arch Ophthalmol 69, 73, 1963. |
| 4. | McMohan CD, Shaffer CN, Hoskins HDJ, Hetherington JJ. Am J Ophthalmol 88, 736, 1979. |
| 5. | Shields MS (1982). William & Wilkins, London, 1st edition, P 391. |
[Figure - 1], [Figure - 2]
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