Discovery 2.2 Glaucoma PDF

Discovery 2.2: Glaucoma Week Week 2 Notes Need to Review and Complete the Activities Overview Glaucoma Key Concepts Introduction to Glaucoma What is Glaucoma...

Discovery 2.2: Glaucoma Week Week 2 Notes Need to Review and Complete the Activities Overview Glaucoma Key Concepts Introduction to Glaucoma What is Glaucoma Risk factors for glaucoma Pharmacology of glaucoma therapy options Mechanism of action of glaucoma therapy Treatment options for open-angle glaucoma Combination Products Open-angle glaucoma monitoring and ongoing management Role of the pharmacist in managing open-angle glaucoma Administration of eye drops Assessing and improving compliance Overview Glaucoma is a group of diseases that can cause loss of vision if left untreated due to damage to the optic nerve (Glaucoma Australia, n.d.). This Discovery will refer a lot to the Glaucoma Australia website that has useful information for health professionals and people that have glaucoma. Glaucoma Website: https://www.glaucoma.org.au/ Living in a rural area is associated with various factors that mean there is a greater incidence of glaucoma than in urban areas (National Rural Health Alliance, 2012). These include exposure to UV light, diabetes, and an older population. Pharmulary Medicines Latanoprost (Glaucoma & Ocular hypertension) Timolol (Glaucoma & Ocular hypertension) Dorzolamide Brimonidine Glaucoma Key Concepts What are the different types of glaucoma? What causes glaucoma? What are the risk factors for glaucoma? What are the clinical presentations of open and closed angle glaucoma? What are the treatment options for open-angle glaucoma? What are the predominant mechanisms of action of treatments for open-angle glaucoma? When would the following medications be used in the management of open-angle glaucoma? And when should they be avoided? 1. Beta-blockers 2. Prostaglandin analogues 3. Carbonic anhydrase inhibitors Discovery 2.2: Glaucoma 1  4. Alpha 2 agonists 5. Cholinergic agents What are the goals of therapy when treating open-angle glaucoma and how can progress with this condition be monitored and managed? How can a pharmacist optimise the patient response to eye drops for open-angle glaucoma? Introduction to Glaucoma What is Glaucoma (Glaucoma Australia, n.d.; The Pharmaceutical Journal, 2017). Glaucoma is generally characterised as damage to the optic nerve and a build-up of intraocular pressure (IOP) which is the fluid pressure inside the front part of the eye. Aqueous Humour (AH) is a fluid which bathes and nourishes the eye, keeping it firm and maintaining optimal eye pressure. AH flows from the ciliary body, through the anterior chamber and drains out of the eye via the trabecular meshwork (see figure 1 below). If this draining process becomes blocked, the AH levels in the eye can build-up, resulting in increased IOP. IOP normally ranges from 10-21mmHg. Intraocular pressure is caused due to aqueous humor production ≥ aqueous humor drainage This means that the AH cannot be drained properly and remains in the eye, coupled with aqueous humor production, this means more aqueous humor remains in the eye and increase intraocular pressure. The increase in IOP can cause optic nerve damage, vision loss (generally with peripheral vision going first) and ongoing damage will lead to permanent blindness. IOP levels can vary between different people so it's important to find what the baseline level of the person is. Some people with high IOP do not develop nerve damage whereas others with normal eye pressure can develop nerve damage. There is no cure for glaucoma and loss to vision cannot be reversed, however, early detection and adherence to treatment can halt or significantly slow progression. Around 2 in 100 Australians will develop glaucoma in their lifetime. Open angle glaucoma can affect one or both eyes, progression to two eyes from one eye occurs in up to 80% of people in a 5-10-year period. There are two main types of glaucoma: 1. Open angle glaucoma 2. Closed angle glaucoma Discovery 2.2: Glaucoma 2  Figure 1. Aqueous flow within the eye (Glaucoma Australia, n.d). Other types of glaucoma that are not as common Normal tension glaucoma Secondary glaucomas due to inflammation, trauma, tumors, cataracts and prolonged ophthalmic corticosteroid therapy Primary open angle glaucoma (POAG) is asymptomatic and 50% of people with POAG can remain undetected Closed angle glaucoma is a medical emergency characterized by severe pain as a result of a rapid increase in Intraocular pressure (IOP) to >50 mmHg. If a person comes to the pharmacy with excruciating eye pain (can be accompanied by nausea, vomiting and visual disturbances), please send them to the emergency department as these symptoms may relate to closed angle glaucoma. This discovery focus on open angle glaucoma Risk factors for glaucoma Refer to Glaucoma Australia website Family history of glaucoma (First degree relatives of people with glaucoma have an up to 10-fold increased risk of developin the disease High Intraocular Pressure (IOP) Age over 50 (1 in 8 Australians aged over 80 years will develop glaucoma) African or Asian descent Diabetes mellitus Short or long sighted Treatment with prolonged course of cortisone (steroid) medication History of migraines Eye operation of eye injury Try this glaucoma risk factor calculator from Glaucoma Australia to calculate the risk for you or one of your family members. https://glaucoma.org.au/what-is-glaucoma/risk-factors-for-glaucoma Best way to manage glaucoma is to test eyes regularly and receive treatment early. Optometrist may be the first to pick up signs of glaucoma as they are continually screening for damages to optic nerves during regular eye tests. Discovery 2.2: Glaucoma 3  Optometrist will routinely check IOP (intraocularessure) in any patient over 40 years old. If they suspect glaucoma, they will perform a visual field test and will refer on to an ophthalmologist The ophthalmologist will do an examination and full patient history, and perform further eye tests. Diagnosis will always be based on a combination of tests. The most common glaucoma tests are: Tonometry (measures pressure within the eye) Optical Coherence Tomography (measures the retinal nerve fiber layer thickness in glaucoma and can detect damage) Ophthalmoscopy (a visual examination of the optic nerve) Perimetry (also known as a visual field test and checks your peripheral vision) Gonioscopy (examines the introcular fluid outflow drainage angle) Pachymetry (measures the thickness of the cornea) Diagnostic tests are not examinable. Activity 1 Watch the following video by Dr Ahmara Gibbons Ross to learn more about the different types of glaucoma https://youtu.be/-Bq28tU-ODc Types of Glaucoma Primary Types of Glaucoma: Open-Angle Glaucoma (Primary Open-Angle Glaucoma) Angle-Closure Glaucoma (Narrow-Angle Glaucoma) (Primary Angle-Closure Glaucoma) Other Types of Glaucoma: Exfoliative Glaucoma (Pseudoexfoliative Glaucoma) Neovascular Glaucoma Uveitic Glaucoma Traumatic Glaucoma Glaucoma → group of disease. Summary from ChatGPT Glaucoma Fast Facts: Types of Glaucoma with Dr. Ahmara Gibbons Ross Key Points: Introduction: Dr. Ahmara Gibbons Ross discusses different types of glaucoma. Glaucoma as a Group of Diseases: Glaucoma is not a single disease but a group of diseases characterized by visual field defects and structural changes in the eye. It can be diagnosed using tools like optic coherence tomography. Types of Glaucoma: Discovery 2.2: Glaucoma 4  Primary vs. Secondary Glaucoma: Primary Glaucoma: No identifiable cause for the disease. Secondary Glaucoma: Has identifiable causes such as pseudoexfoliation (weird material clogging the drainage system) and pigmentary glaucoma (pigmented cells clogging the drainage system)Types of Glaucoma (2:41-4:11) Glaucoma is categorized into open-angle and closed-angle types. Open-Angle vs. Closed-Angle Glaucoma: Open-Angle Glaucoma: Includes primary (no identifiable cause) and other types with identifiable causes. Closed-Angle Glaucoma: Can be due to narrow angles from birth, inflammation, or changes in the lens with age (phacomorphic glaucoma). Types of Glaucoma: Open-Angle Glaucoma: Primary: No identifiable cause. Secondary: Specific causes identified. Closed-Angle Glaucoma: Primary: Narrow angle due to anatomy or inflammation. Secondary: Lens changes with age that push the angle closed. Common Type of Glaucoma: Primary open-angle glaucoma is the most common type. Glaucoma Suspect: Patients may be identified as glaucoma suspects due to family history, routine exams showing nerve cupping, or other signs seen during an exam. Glaucoma often doesn't present symptoms until it's too late, making regular check-ups essential. Importance of Regular Check-Ups: Regular eye exams are crucial, especially as one ages, to catch signs of glaucoma early. For more information, visit Glaucoma Research Foundation and download their free booklet, "Understanding and Living with Glaucoma." Important Points Glaucoma is a group of diseases with characteristic visual field defects. It is categorized into primary and secondary types, with secondary having identifiable causes. Primary open-angle glaucoma is the most common type. Regular eye exams are essential for early detection, especially for those with a family history of glaucoma. Glaucoma is often asymptomatic until it has progressed significantly. Important Timestamps: 00:36: Introduction and overview of glaucoma. 01:56: Explanation of primary vs. secondary glaucoma. 03:07: Discussion on open-angle vs. closed-angle glaucoma. 04:59: Importance of regular check-ups and early detection. Additional Summary of "Glaucoma Fast Facts: Types of Glaucoma with Dr. Ahmara Gibbons Ross" Introduction (0:36-0:47) Dr. Ahmara Gibbons Ross introduces the topic of different types of glaucoma. Discovery 2.2: Glaucoma 5  Understanding Glaucoma (0:47-1:08) Glaucoma is a group of diseases characterized by visual field defects and structural changes in the eye. These changes can be detected using optic coherence tomography and other high-tech machinery. Primary vs. Secondary Glaucoma (1:08-2:41) Primary Glaucoma: No identifiable cause for the visual defects after examining the eye. Secondary Glaucoma: Identifiable causes, such as: Pseudoexfoliation: Material from the lens surface clogs the drainage system. Pigmentary Glaucoma: Pigmented cells clog the drainage system. Types of Glaucoma (2:41-4:11) Glaucoma is categorized into open-angle and closed-angle types. Open-Angle Glaucoma: Primary: No identifiable cause. Secondary: Specific causes identified. Closed-Angle Glaucoma: Primary: Narrow angle due to anatomy or inflammation. Secondary: Lens changes with age that push the angle closed. Most Common Type (4:11-4:14) Primary open-angle glaucoma is the most common type. Glaucoma Suspect (4:14-5:54) People with characteristic changes in visual fields or structural changes in the eye are termed "glaucoma suspects". Regular eye exams are crucial, especially with a family history of glaucoma, as the disease is often asymptomatic until it is advanced. Conclusion (5:54-6:05) For more information, visit the Glaucoma Research Foundation website and download their booklet on understanding and living with glaucoma. Important Points Glaucoma is a group of diseases with characteristic visual field defects. It is categorized into primary and secondary types, with secondary having identifiable causes. Primary open-angle glaucoma is the most common type. Regular eye exams are essential for early detection, especially for those with a family history of glaucoma. Glaucoma is often asymptomatic until it has progressed significantly. For more details, you can watch the video here. Turbolearn AI Open Angle vs Closed Angle Glaucoma Glaucoma can be separated into open angle and closed angle causes. Open Angle Glaucoma Primary Open-Angle Glaucoma: No identifiable cause can be found despite a thorough examination of the eye. Secondary Open-Angle Glaucoma: Caused by enlarged blood vessels, pseudoexfoliation (a flaky material that comes off the lens surface), pigmentary glaucoma (additional pigmented cells), or other identifiable causes. Closed Angle Glaucoma Discovery 2.2: Glaucoma 6  Primary Closed-Angle Glaucoma: Caused by a person's natural anatomy, often due to a small eye with a narrow angle. Secondary Closed-Angle Glaucoma: Caused by inflammation and scar tissue, or a phacomorphic lens that pushes the angle closed. Glaucoma Classification Type Description Primary Open-Angle Glaucoma No identifiable cause Secondary Open-Angle Glaucoma Caused by enlarged blood vessels, pseudoexfoliation, pigmentary glaucoma, etc. Primary Closed-Angle Glaucoma Caused by natural anatomy (small eye with narrow angle) Secondary Closed-Angle Glaucoma Caused by inflammation, scar tissue, or phacomorphic lens Glaucoma Suspect A person identified as a glaucoma suspect has characteristic changes in visual fields or structural changes in the eye, but no clear diagnosis of glaucoma. This may be due to a family history of glaucoma, cupping of the nerve, or other suspicious signs. Note: Glaucoma is often asymptomatic, and vision can be affected only when the disease has progressed significantly, making regular check-ups with an ophthalmologist crucial for early detection and prevention. Pharmacology of glaucoma therapy options Previously learned basic physiology of the eye and function of key structures within the eye. The following diagram summarizes the basic structure of the eye. Figure 2. The basic structure of the eye (Glaucoma Australia, n.d.). The two main ways that aqueous humor leaves the eye are: What is Aqueous Humor (AH) Aqueous Humour (AH) is a fluid which bathes and nourishes the eye, keeping it firm and maintaining optimal eye pressure. 1. Through the trabecular meshwork into the Schlemm’s canal (80-85% AH flows this way). 2. Around and between tissues including ciliary muscle, sclera, lymphatic vessels, etc (15-20% of AH flows this way. Flow of AH other than through the trabecular meshwork is called the uveoscleral (US) flow (Pfeiffer & Thieme, 2015). Discovery 2.2: Glaucoma 7  a. With US flow, AH can normally move between the ciliary muscle bundles into the subciliary and suprachoroidal spaces then drain through the sclera because there is no epithelial barrier between the anterior chamber and the ciliary muscle (Nilsson, 1997). Mechanism of action of glaucoma therapy Medications for glaucoma can be mainly characterized in 2 distinct categories which target the 2 pathways of how AH exits the eye as explained above: 1. Those that reduce AH production or synthesis from ciliary muscle (e.g. β2 antagonists, α2 agonists and carbonic anhydrase inhibitors). 2. Those which increase AH outflow (e.g. prostaglandin analogues, and cholinergic agonists). Prostaglandin analogues also relax ciliary muscle, decreasing resistance by widening the spaces in the US (uveoscleral) pathway and increasing the internal angle to allow for more US outflow of AH a. Cholinergic agonists contract ciliary muscles but when the ciliary muscle contracts, it opens up the trabecular meshwork to facilitate a higher rate of AH leaving the eye (National Center for Biotechnology Information, 2020). Uveoscleral outflow (Maharjan, 2016). Treatment options for open-angle glaucoma Topical drug therapy is the first line treatment for open-angle glaucoma with prostaglandin analogues and beta blockers being first line agents (AMH). Prescribers will generally start with one agent and add on agents from a different class after monitoring the affected eye. As glaucoma is asymptomatic, compliance to treatment is a major issue. This is why many prescribers opt for combination or once daily dosing to improve compliance. Some eye drops offer preservative free options as well for patients who are sensitive to to benzalkonium chloride (most common preservative in eye drops). All drops have some risk of causing stinging or ocular irritation. Some eye drops may cause less irritation than the others which may lead to a aptient switching drops. Prescribers sometimes recommend using lubricant drops to relieve ocular irritation. Comorbidities and concomitant medications are important factors to consider when deciding which drops to prescribe. If topical treatment and oral treatment (e.g. acetazolamide) fail, management will generally escalated to laser or surgery Activity 2 Activity 2 To address the key concept tasks for this topic review and summarise information from resources such as the Australian Medicine Handbook to determine the advantages and disadvantages of the different treatment options for open-angle glaucoma. Use the table below to complete your summary of the different drug classes. Click here to download an editable table and complete your summary. This article about the management of glaucoma from the Medical Journal of Australia is another useful resource to help complete this activity. Discovery 2.2: Glaucoma 8  https://www.mja.com.au/system/files/issues/210_04/mja250020.pdf Drug class Drugs (with brands) Advantages Disadvantages Bimatoprost (e.g. Lumigan, Lumigan PF) Can cause iris hyperpigementation (which can be Bimatoprost with undesirable for those with light coloured eyes) timolol (e.g. Ganfort, Can cause periorbital changes which can be more Ganfort PF) Once daily dosing noticeable in those who have glaucoma in only one Latanoprost (e.g. Most effective at reducing affected eye Prostaglandin Xalatan) IOP Need to ideally take it in the evening (This is because analogues Latanoprost with Bimatoprost comes in the peak efficacy takes place at 8-12 hours, and timolol (e.g. Xalacom) preservative free preparation intraocular pressure is highest in the morning. And Travoprost (e.g. therefore best time to take at the night to get the best Travatan) efficacy) Travoprost with Can't take two prostaglandins together timolol (e.g. Duotrav) Betaxolol (e.g. Betoptic, Betoquin) Timolol (e.g. Timoptol-XE, Timoptol) Betaxolol may be less effective at reducing IOP and Bimatoprost with more likely cause stining compared to tomolol timolol (e.g. Ganfort, Can cause asthma exacerbation due to acting on Ganfort PF) beta-2 receptors. Brimonidine with Once or Twice Daily dosing Contraindicated in asthma timolol (e.g. Combigan) Prefer dosing in the morning Can cause nocturnal systemic hypotension and thus Beta blockers Brinzolamide with optic nerve hypoperfusion which may induce glaucoma timolol (e.g. Azarga) progression despite apparent IOP control. Dorzolamide with Can mask symptoms of hypoglycemia in patients who timolol (e.g. Cosdor, are on insulin for diabetes Vizo-PF Dorzolatim) Latanoprost with timolol (e.g. Xalacom, Xalamol) Travoprost with timolol (e.g. Duotrav) Brinzolamide (e.g. Azopt, BrinzoQuin) Brinzolamide with Oral preparation Twice to three times daily - compliance issue Brimodine (e.g. (acetazolamide) is more Contraindicated for patients with allergy to Simbrinza) effective oral preparation with sulfonamides Carbonic Brinzolamide with poor systemic safety profile Feel uncomfortable for little while after put the eye anhydrase timolol (e.g. Azarga) Second Line drops inhibitors Dorzalamide (e.g. Least effective Trusamide, Trusopt) Side effects include peripheral tingling, nausea, Dorzolamide with dysgeusia, general weakness, electrolyte syndrome timolol (e.g. Cosdor, and SJS syndrome Vizo-PF Dorzolatim) Least tolerated IOP lowering agents due to high rates Apraclonidine (e.g. More gentle preservative of conjunctival hyperaemia and localized allergic Iopidine) (Brimonidine purite 0.15%) changes Alpha 2 Brimonidine (e.g. compared to Benzalkonum Can cause dry mouth and drowsiness agonists Alphagan) chloride. Allergies can developed Brimonidine with Second Line Apraclonidine is indicated for short-term use (up to 3 timolol (e.g. Combigan) months) as its effect usually declines over time Pilocarpine – Last line → initially 1 eye drop of 1% 3 or 4 times daily, then increase concentration slowly according to response and tolerability. Counselling → These eye drops may sting and make your eyes water, which may dilute and reduce the effectiveness of subsequent eye drops. If you are using more than one type of eye drop, put pilocarpine drops in last. These eye drops may cause blurred vision. Do not drive or operate machinery if you are affected. Take particular care in poor light. Discovery 2.2: Glaucoma 9  https://prod-files-secure.s3.us-west-2.amazonaws.com/c94beed1-a278-4c75-926e-db65b5ab75bb/99bca3d0 -6864-46b8-84fa-f2fadc683f11/PHR4042_D2.2_Activity_2.docx Discovery 2.2: Glaucoma 10  Doing so will allow you to consider the optimal treatment options and the options to avoid in the following scenarios: 1. Pui has trouble with compliance. Pui has no other medical conditions. She has open-angle glaucoma in the right- eye. a. Prostalglandin analogues (recommended). Avoid other eye drops as they usually are twice daily 2. Elka is quite embarrassed about having a diagnosis of open-angle glaucoma. She has open-angle glaucoma in her left eye only. She would prefer a treatment that will not irritate her eye as much and will not draw attention to her diagnosis. Elka has no other medical conditions. a. Can recommend Prostaglandin Analogues (Travoprost - as this contain a different preservative than benzalkonium chloride 3. Reba has open-angle glaucoma in both eyes. She has mild asthma (reversible airways disease). She has no allergies or medical conditions. a. Avoid Beta Blockers for this patient Discovery 2.2: Glaucoma 11  Combination Products Discovery 2.2: Glaucoma 12  Treatments for open-angle glaucoma also exist as combinations. If a patient requires more than 1 type of eye drops, using a combination product can help improve compliance. Below are examples of some of the combination products that can exist. Examples of combination products for open-angle glaucoma. Drugs Date Frequency Status Bimatoprost + Timol Once Daily Not started Latanoprost + Timolol Once daily Not started Travoprost + timolol Once daily Not started Brinzolamide + Timolol Twice Daily Not started Brimonidine + Timolol Twice Daily Not started Brinzolamide + Brimonidine Twice Daily Not started Note: One brand image has been provided for each combination. Please note there may be other brands available. Open-angle glaucoma monitoring and ongoing management Glaucoma guidelines recommend that patients with chronic glaucoma are monitored at least yearly even if target IOP has been achieved and there is no progression of damage (Prum et al., 2016). If target IOP has not been achieved, it should be monitored every 1-2 months Before starting treatment, a baseline IOP is established (this varies from person to person), the response to treatment will be based on the person’s baseline IOP (intraocular pressure) Initial treatment is normally reviewed within 2-8 weeks to monitor efficacy and adverse events. Similarly, if a patient has had a change in their eye drops they should be reviewed again 2-8 weeks after the change. Table 2. Recommended follow up intervals (adapted from Prum et al., 2016). Target IOP Progression of Duration of control if IOP target is achieved and no Approximate follow up achieved damage progression of damage interval Yes No ≤6 months 6 months Yes No >6 months 12 months Yes Yes N/A 1-2 months No Yes N/A 1-2 months No No N/A 3-6 months Discovery 2.2: Glaucoma 13  The following diagram provides a useful summary of the typical management approach to glaucoma. Figure 12. Glaucoma management summary (Lusthaus & Goldberg, 2019). Surgical intervention is necessary when a patient’s visual independence is at risk, despite the use of medical and/or laser treatment options. Surgical intervention can also be used if patients have trouble tolerating medical treatment or have poor adherence. Trabeculectomy is the main type of suergery that reduces intraocular pressure in the eye by draining aqueous humor. Selective Laser Trabeculoplasty (SLT) enhances conventional aqueous outflow and can be used as a step before surgery. More information on the type of surgery for glaucoma SLT: https://glaucoma.org.au/path-file/133 https://glaucoma.org.au/path-file/133 Minimally Invasive Surgery (MIGS) https://glaucoma.org.au/news-details/treatment/migs-whats-happening-now-and-on-the-horizon https://glaucoma.org.au/news-details/treatment/migs-whats-happening-now-and-on-the-horizon Note: Not tested on the types of surgeries and what’s involved but need to know when they have a place in therapy Optional Reading NHMRC glaucoma.pdf Role of the pharmacist in managing open-angle glaucoma Administration of eye drops Discovery 2.2: Glaucoma 14  Pharmacological treatment of open-angle glaucoma relies on eye drops and therefore an optimal response to therapy relies on correct administration of eye drops. See below from the The Royal Eye and Ear Hospital Melbourne about a pamphlet on administering eye drops https://prod-files-secure.s3.us-west-2.amazonaws.com/c94beed1-a278-4c75-926e-db65b5ab75bb/254d70cc-e5d 6-4052-800c-7433c8ed5fbd/PF2_How_to_administer_eye_drops.pdf Other particular critical points to consider that may influence the efficacy of ocular treatments are: Storage (some eye drops require refrigeration prior to opening but can be left out of the fridge for 28 days once opened (e.g. Xalatan, Xalacom)). Expiry (most eye drops will have a limited expiry once you open the drops, preservative free drops will generally have a shorter expiry than those with preservatives). It is important for pharmacists to counsel patients on eye drop storage and expiry as it will affect drug potency. Assessing and improving compliance As with medications for any chronic illness, pharmacists have a role to assess patient compliance with therapy and develop strategies to improve compliance. Some tips that are relevant to improving compliance with ocular therapies for open-angle glaucoma include: Reducing the complexity of the regimen (e.g. could a combination product be used? Could a therapy with once daily administration be recommended?). Reducing irritation associated with instillation (e.g. could a preservative free product be used instead? How is the eye drop being administered? Using lubricant eye drops after instillation or changing products could sometimes address this). Patients may be reluctant to express concern with administering eye drops. Pharmacists will need to engage with them and assess signs that may indicate progression of damage (e.g. worsening peripheral vision). This may elude to issues with compliance. Activity 3 In preparation for Interactive Lecture 2.1, consider the following case scenario and respond to the associated questions. You are the community pharmacist in a rural town. Your regular patient Jim (52-year-old male) comes in for his prescription repeat refill for Xalatan eye drops. You have noticed he hasn't come in 3 months to have this prescription filled. Upon questioning him, you realise his compliance is poor because he finds the eye drops irritating which affects his work on the farm, what strategies can you offer Jim to improve his compliance? Medication history: Timoptol® 0.5% twice daily – last filled 2 months ago Timolol → Xalatan® 0.005% daily – last filled 3 months ago Lantonoprost + Timolol Medical history: Glaucoma diagnosed 2 years ago You may find it useful to read this publication (see below) from Keeffe et al regarding utilisation of eye care services by urban and rural Australia that outline some of the challenges Jim may face. Keeffe et al.pdf https://glaucoma.org.au/sites/default/files/inline-files/2020.07.02 Glaucoma and eye drops.pdf Discovery 2.2: Glaucoma 15  Things to improve compliance Changing to preservative eye drops → single-usage eyedrops, in small, clear plastic dispensers Change to just a single eyedrop instead of using 2 eyedrops Applying before bed, to help reduce the irritation and will not help with your work on the farm. Taking glaucoma eye drops can reduce redness in the morning → https://glaucoma.org.au/news-details/news/side- effects-of-glaucoma-medication#:~:text=Glaucoma eye drops can exacerbate,care than regular red eyes. Soothe your eyes before adding the glaucoma eye drops to reduce irritation. Use an artificial tears before administer glaucoma eye drops (preservative free). Wait 5 minutes after putting the artificial tears drop before put glaucoma eye drops. Soothe your eyes Many of the eye drops used for glaucoma treatment are irritating to the eye, and some eye drops also burn when they are instilled. One way to help with this is to use artificial tears BEFORE you instill your glaucoma eye drops (preferably preservative-free if you have sensitive eyes or are using many different types of glaucoma eye drops). You should wait 5 minutes after putting in the artificial tears before starting your glaucoma eye drops. There are also over-the-counter gels or ointments used at nighttime (often they are labeled “PM”) that are thicker and can help soothe your eyes overnight. If you do choose to use these formulations, make sure they are preservative-free, wait 5 minutes after your last glaucoma drop goes in, and use the gel or ointment last. And as always, tell your ophthalmologist all of the eye drops that you are using, including over-the-counter products such as artificial tears. https://www.brightfocus.org/glaucoma/article/10-tips-using-glaucoma-eye-drops# Discovery 2.2: Glaucoma 16