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Editors Selection IGR 16-4

Medical Treatment: Prediction of medication response

Comment by Anjali Bhorade on:

24091 A Prospective, randomized, investigator-masked evaluation of the monocular trial in ocular hypertension or open-angle glaucoma, Realini TD, Ophthalmology, 2009; 116: 1237-1242

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Realini (1221) prospectively analyzed whether assessment of medication response between two visits using the classic monocular trial or the unadjusted IOP change of the trial eye predicted medication response over a longerterm period (between two pre- and two post-treatment visits). Neither the monocular trial nor the unadjusted IOP change strongly predicted medication response over a long-term period and the author concludes that both short-term methods are inadequate in estimating medication response.

The author should be commended on a well-designed study that alerts us to the inadequacies of our current methods of medication assessment. These results, however, reflect data from 26 Caucasian patients with glaucoma or ocular hypertension with a mean untreated baseline IOP of 20 mmHg. Whether such results are generalizable to patients of different races, more severe disease, or with higher baseline IOPs has yet to be determined.

Medication assessment between two visits may not accurately estimate medication response over a long-term period

The results suggest that while both short-term methods were poor predictors, the unadjusted IOP change was slightly better at predicting long-term IOP response than the monocular trial. Including patients with a lower mean baseline IOP and visits conducted within the same time of day may decrease the nontherapeutic variability of IOP between visits. This may mask the potential benefits of the monocular trial, which theoretically uses the fellow eye as a control for such variability, as compared to using the unadjusted IOP change between visits. In addition, the second visit was included in both the short and long-term analysis which may not only artificially increase the overall correlations but favor the correlation for using the unadjusted IOP change over the monocular trial.

Multiple pre-and post-treatment visits are necessary to better estimate medication response to topical ocular hypotensive medications

Regardless of whether the monocular trial or the unadjusted IOP change is better, this study alerts us to an even more important message: medication assessment between two visits may not accurately estimate medication response over a long-term period. Multiple pre-and post-treatment visits are necessary to better estimate medication response to topical ocular hypotensive medications.

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