Evidence-Based Medicine: Glaucoma Surgery, Essay Example

Evidence-based medicine is a medical tool that facilitates an effective treatment procedure by providing the doctor with data for determining the best alternative to use for this case Evidence-based medicine was used to determine the best alternative for treating glaucoma between Baeveldt implant surgery and trabeculectomy in a patient with the previous history of suffering from open-angle glaucoma. Determining the procedure to use for the treatment followed the results of a Tube Versus Trabeculectomy (TVT) study. The evidence from the study was carefully evaluated. The evidence on the actual clinical factors was used to calculate the impact of using either of the treatment regimes on the patient. Absolute risk rate factor was computed by subtracting the estimated rate of having a surgical failure from the calculated risk level for a surgical failure. The inverse of this result provides the doctor with the alternative that needs to be used. These procedures should be used to help prevent an adverse outcome. The study was done to determine the balance between harming the patient and helping the patient.

Other alternatives that could be used for acute appendicitis cancer may include using precision medicine such as anti-biotic, surgery and target therapy.  These methods offer alternatives for the patients at different stages where they cannot be put through the usual medical procedure that is chemotherapy as it is one of the main factors that contributed to her current state. Many appendix patients have benefited from surgery, but the current situation requires the acquisition of a different medical approach. Suggested alternatives include the use of precision medicine, an approach that allows the doctor to selectively apply different treatments for glaucoma patients with genetic properties of the disease.  The procedure is executed with the help of biopsy. The other procedure involves surgery where the affected body organ is removed completely. The other option is the use of targeted therapy that focuses on the changes in disease development. The non-pharmacological option is the use of the psychological and behavioral intervention.

Patient Characteristics

The following is a medical procedure for an 82-year-old female patient (Mss. M) who was admitted to the hospital with a history of open-angle glaucoma.  Mr. M has been re-admitted to treat acute lack of sight due to the deterioration of the condition.  Initially, the patient has been using beta blocker prostaglandin analog alpha-2 stimulator and carbonic anhydrase inhibitor. The patient has previously been treated for keratopathy using hyaluronic acid, and an additional medication and therapy to manage the blood pressure. Further examination of the patient revealed that she was also suffering from lung disease, heart disease, diabetes mellitus and she had a malignant tumor. The corrected visual acute was recorded as 0.5 for the right eye and 0.3 for the left eye. The 30-2 Humphrey visual field analyzer provided a mean deviation value of -25.0dB for the left eye and -18.7dB for the right eye.

The current status of the patient indicates superficial keratopathy at grade A2D3 in both eyes due to multiple treatment agents that were previously used to treat glaucoma. For example, she had undergone a cataract surgery in both eyes that was meant to clear the pupils He was also suffering from severe malnutrition which made use of surgery a risky alternative as the treatment for acute appendicitis.  Also, he showed effects of previous theatre visit, which was an indication that it was dangerous to use another surgical procedure or radiation as treatment procedures of choice.  His age was also presented a major challenge by disqualifying application of normal treatment procedures.

EBM research questions

• Is the old age an issue in choosing the type of treatment to use?
• How serious is the problem?
• Is the problem related to any other previous procedures?
• Are there any other complications that may hinder a successful treatment or application of a specific treatment regime?

Evidence-Based Medicine EBM on the Patient

Further analysis was necessitated to help determine specific concerns raised about Barvedlt implant surgery and trabeculectomy or any other medical procedure.  These factors were analyzed by assessing several features, for example, the p-value and the risk factor related to the procedure.  Findings showed that women who were above the age of 40 years were at greater risk when acute glaucoma surgery procedure treating glaucoma having presented symptoms of surgery were used on them.  For example, more than 70% risk factor was recorded while using surgery on an elderly acute appendicitis patient.

Table 1: EBM data

Women aged below 40 years have better chances of a successful procedure when surgical treatment procedures are used on them, as the associated risk factor is less than 30%.  Also, it was also necessary to determine the number of times the patient has been to surgery before the current treatment.  The patient’s exposure to surgery, for example, had a risk factor of 78.5%, suggesting that it was a better alternative to use surgical procedures on her. Specific incidence for CIA, produced p value<0.0001 while Kaplan-Meier method was used to determine the time of onset of permanent surgical complications with the p value<0.05 found to have had statistical significance.  Therefore, putting the patient through surgery was deemed a bad option since it comprised of some risks.

Analysis of the Alternative Procedures

Application of Precision Medicine

To have a successful EBM. All the available evidence should be considered in the current medical status of the patient. The circumstances of the disease and decisions and views from medical experts in the medical team handling the case. The patient has been subjected to surgery previously; this is suspected to have been the cause of her current health condition. The best option should be the one that is less likely to worsen the health condition of the patient. The method of precision medicine using trabeculectomy is a modern approach used to treatment of glaucoma. Adoption of this technique will be helpful for treated the 82-year-old patient. The technique is also known as personalized medicine involves a person diagnosed with glaucoma being given the same treatment to those having similar stage and type of the disease.

After the TVT study, it was decided that trabeculectomy was the most appropriate mode of treatment while the tube surgery approach was set aside as a control procedure. It was established that where trabeculectomy was used on the patient instead of on tube surgery implant procedure, the risk factor dropped considerably. The use of these approaches helps reduce the probability of an adverse outcome.

Baerveldt implant surgery

This is one of the best alternative treatment procedures for our patient as she was previously subjected to the same process implying she has fully recovered. The blood-forming stem cells are involved in the formation of different blood cell types. The patient will be injected with blood-forming stem cells in her veins. The stem cells may be acquired in three different ways. Autologous is one method where the stem cells will come from the patient herself.

Similarly, these cells may be acquired from her relative through a process known as allogeneic, or if she has a twin, she can also be offered her stem cells through a process known as syngeneic. The treatment will enable the patient to produce stem cells after being previously subjected to surgery.

Use of Targeted Therapy

Targeted therapy is a type of treatment method that focuses on the changes presented by the disease-carrying cells that facilitate, spreading and division mechanism. The treatment using targeted therapy forms the foundation on which precision medicine method is built. Both precision and targeted therapy methods employ same mechanisms in treating glaucoma-related issues. It is important to understand and determine the changes presented by the infectious bacteria. Doctors use this information on appendices tissue trends to define the treatment and therapy solution aimed at blocking the changes in the disease-carrying cells.

Based on our patient’s characteristics, she has undergone surgery before which is not advisable to undergo as he has not fully recovered from the previous surgical procedure. Thus, the method of targeted therapy is also a suitable solution for treating the patient. One primary challenge associated with using surgery is that it may expose the patient to further harm as she has shown symptoms of side effects of theatre drugs. Targeted therapy is, therefore, one of the best solutions we can use on the patient to ensure her recovery.

Non-Pharmacological Therapies for Open Angle Glaucoma (POAG)

POAG causes blindness and other comorbidities and it the only lifelong use of medication and surgical treatment. Therefore, it leads to multiple side effects. This can be overcome using drugless approach using Myofascial Release (MFR) and Muscle Energy Technique (MET). MET is utilized traditional muscle energy principles to balance extra-ocular muscle tone. It involves the physiotherapist applying resistance against the patient’ ocular globe while the patient looks in a particular direction. MFR will be used to release fascia and muscles of Mrs. MET will be used to M. MFR will be designed to lower IOP by relaxing the muscle and normalizing their tone. On the other hand, MET will help Mrs. Benefits of M to Mrs. M will include emotional relief, general feelings of well-being and relaxation (Kuchera, Kuchera, 1994; Misischia, 2002; Alguire, 1990). The two non-pharmacological therapies applied simultaneously will help Mrs. M manage pain.

Analysis of the Evidence

There are peer-reviewed studies showing the effectiveness of MFR and MET in managing pain in patients with POAG, back pain, post-partum coccydynia and temporomandibular joint dysfunction (TMJD).

Varghese (2012) demonstrated that the MET could be used to effectively reduce disability and pain in patients with sub-acute and acute low back pain. Varghese (2012) hypothesized that patients with a limited or reduced range of motions and treated with MET would show statistically and significantly reduced pain and increased the lumbar range of motion than those treated using specific passive mobilization. ANAVO was used to test the effect of the treatment on muscle energy technique for each measurement outcome over three-time points. Results demonstrated the effectiveness of using MET to treat low back pain and pain management and disability in patients presenting with chronic LBP.

Pandey et al. (2017) examined the effectiveness of MFR and MET on POAG. Pandey et al. (2017) used 12 patients with POAG recruited from tertiary care teaching hospital using a convenient sampling technique. Nine out of these 12 patients completed the study. Their age range was between 15 and 30 years. Patients were given MFR and MET for six days/eek, 30 min/day for three weeks. Ophthalmologist assessed intraocular pressure (IOP) with Tonometer. Change in Post and pre IOP was established. Post and pre IOP results were found as 20 ± 1.4 mmHg for post IOP and 3.1 ± 1.9 mmHg for pre IOP with P=0.002 significant difference confirming that MFR and MET are effective in reducing IOP. Pandey et al. (2017) concluded that MFR and MET could serve as the cost-effective Non-Pharmacological Therapies for POAG and affirmed that MFR and MET could provide effective relief from a headache, strain, eye irritation eye ache, and minimize intraocular pressure in patients with POAG.

In a randomized controlled trial, Trivedi et al. (2016) compared the effectiveness of MET and MRT on a range of motion and pain in patients with temporomandibular joint dysfunction. The study involved 36 patients with chronic temporomandibular joint dysfunction randomly assigned into three groups (Control, Myofascial Research Technique (MFR) and Muscle Energy Technique (MET). Following the treatment of the patients with MET and MRT for four weeks, results revealed a significant increase (P<0.05) in the range of motion and pain reduction (NPRS<0.05) in TMJD patients. No improvement in either pain or range of motion was reported in the control group. Of the two techniques, MET proved more clinically effective than MFR in reducing pain and increasing the range of motion. It was concluded that MFR and MET are effective in increasing ROM and reducing pain in chronic TMJD subjects.

Embaby, Elgendy and Hasanin (2017) examined the effectiveness of MET in treating pain associated with post-partum coccydynia. Participants recruited included 40 multi-parus females with postpartum coccydynia aged between 25 and 35. These patients were randomly allocated to study group and control group. The study group received MET with PP (phonophoresis) for four weeks in three sessions per week. Following the treatment with MET, there was a significant improvement (p<0.05) in plasma cortisol levels, functional ability, and pain level confirming that MET is effective in treating pain.

Discussion

The patient 82 years old was found to have advanced glaucoma complications due to the previous eye treatment procedures/. At this stage, it was identified that she would not go through the normal procedure for treating glaucoma, which is usually through surgery. However, the patient would have to go through other medical procedures that would protect him from any further harm associated with undergoing one medication many times.

It would, therefore, be relevant to avoid such procedures that caused the patient to have CIA as a side effect. Thus, taking on procedures such as prescription medicine, Baerveldt implant surgery, trabeculectomy and targeted therapy are among the options that the patient should be given to treat her cancer problem. Similarly, the non-pharmacological procedures are usually relevant for such cases.

For instance, the patient would be subject to psychological and behavioral intervention where psychiatrist addresses her psychiatric disorders and any other factor that may contribute to managing complications associated with glaucoma treatment. Thus, as a medical expert, looking at the condition the patient was brought in presenting symptoms of CIA and was leukemia, suggestions would be to avoid the normal acute appendicitis treatment procedures and adopt different mechanisms that would protect the patient from any harm.

Implementation

The procedures suggested above are among the best treatment options the patient should be subjected to treat her glaucoma. Therefore, the best implementation procedure would be to first, take the patient through biopsy to determine the genetic changes presented in his appendix. This should be done using the DNA sequencing machine, which will inform of the molecular behavior of her infected cells.

The next step will involve selecting one among the three pharmacological treatment options, which for our patient’s case we choose either stem cell transplant if there is donor available or stick to precision medicine. The procedure for either of the two options should be carried out with a qualified professional expert in the related field. The patient should then be offered some social assistance, which involves the fourth option constituting of psychological and behavioral intervention.

The non-pharmacological option will assist the patient in dealing with any social or psychological challenge brought about by the disease. Some of these challenges may include fear, which usually rises among patients with glaucoma. The other problem is a psychiatric disorder, which can also be adequately addressed by the psychiatrist. Therefore, a combination of the options presented above will lead to successful treatment of the patient.

References

Alguire, P.C. (1990).Tonometry. In: Walker H.K., Hall W.D., Husrt J.W., editors. Clinical methods: the history, physical, and laboratory examinations. 3rd ed. Butterworths; Boston; 581–584.

Embaby, H., Elgendy, S., & Hasanin, M.E. (2017). Effect of muscle energy technique in treating post-partum coccydynia: A randomized control trial. Physical Therapy and Rehabilitation, 2055-2386. Retrieved on 24th Nov 2017 from http://www.hoajonline.com/phystherrehabil/2055-2386/4/5.

Kuchera, M., Kuchera, W. (1994). 2nd Rev ed. Greyden LLC; Dayton, Ohio: 1994. Osteopathic consideration in systemic dysfunction; 13–15.

Misischia P.J. (2002). The evaluation of intraocular tension following osteopathic manipulation. JAOA; 80:35–43.

Pandey, R., Samuel, A.J., Aranha V.P., Pandey, A., & Narkeesh, K. (2017). Non-pharmacological therapies for primary open angle glaucoma: A quasi-experimental pilot study. Saudi Journal Ophthalmo, 31(2): 95-98.

Trivedi P., Bhatt, P., Dhanakotti, S., & Nambi, G. (2016). Comparison of Muscle Energy Technique and Myofascial Release Technique on Pain and Range of Motion in Patients with Temporamandibular Joint Dysfunction: A Randomized Controlled Study. International Journal of Physiotherapy and Research; 4(6): 1788-92.

Varghese, S. (2012). A study on the effectiveness of muscle energy technique (MET) as compared to manuplation therapy in chronic low back pain. Internatioanal Journal of Latest Research in Science and Technogy, 1(2): 214-217.

 Appendix

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