So I was invited to write a guest blog on the subject of Glaucoma. With the complexity of diagnosis and the multitude of treatments an effort to keep it simple and straight forward was difficult and I quickly hit a writer’s block.
So I thought, what if I had Glaucoma? This is a coincidence as there is a family history or Glaucoma and I have large optic nerves that I monitor from year to year.
Then a few thoughts came to my mind, IF I was the patient and knowing what I know, what would I like to know. First, as a patient, I would like to know what glaucoma is, what the difference is between being someone who could develop glaucoma, and who definitely has glaucoma. Secondly, I would also like to get some professional advice about how to determine if the person that is caring for me is doing an adequate job of both diagnosing and treating me.
First things first, glaucoma is a disease of the optic nerve and probably the most common optic nerve disease and often associated with high pressure within the eye. When an eye doctor tells you that you might have glaucoma, it is likely that two things have happened: the eye pressure is abnormally high and they have looked at your optic nerve and suspect that the nerve appearance could signal possible damaged by glaucoma. Sometimes you might have a mild elevation in pressure with no optic nerve changes and you might just be a glaucoma suspect.
So the first important thing I would ask myself is "Did the eye doctor take the pressure of the eye and look at my optic nerves (yeah most people have two)?"
The best way to start is by knowing whether or not you had a dilated eye examination. Trust me I don’t like using the blinding eye drops as much as you don’t like getting them, I hear my patients complain all the time but it is the single best way to get a good look at the optic nerves.
So, If it was me, and Glaucoma was on the line, I would sit in the waiting room for a few minutes, and then go back to the exam room and have to deal with my doctor shining the bright light in my eyes… As far as I am concerned, this is the only way my doctor can really look into my eye and really evaluate the optic nerves. For my eyes, if glaucoma is on the line a picture is for tracking changes over time but not a tool to diagnose.
If the dilation was not done, then most likely the doctor simply noted some elevated high pressure and was concerned about the pressure. For me, this is not a diagnosis of glaucoma, and that would not represent an adequate optic nerve examination especially if a discussion of signs does not follow.
If my eye doctor thinks that I might have glaucoma, then certainly I would expect to have other test performed to help identify how far along the disease process is and what is the degree of advancement. A visual field test is the test to check for optic nerve damage that we call glaucoma. Glaucoma is diagnosed by a combination of the pressure of the eye, the appearance of the optic nerve, and the functioning of the optic nerve. Visual field test is done to determine if there is any loss of visual function from the pressure. Keep in mind that there are other fancy test known by the acronyms OCT and VEP that could compliment the findings of the dilated exam and the visual field test. Another useful test is called a pachymetry and it measures the thickness of the cornea to accurately reflect the real pressure within the eye. Pictures are very helpful in evaluating structural changes over time.
So the second important thing I would ask myself is "Did the eye doctor have enough information about my optic nerves?"
If in fact my doctor has done all of those things and has told me that I have glaucoma, then I probably do.
When the diagnosis of glaucoma is made, a decision to lower the pressure and the amount to lower it follows. Eye drops, medicine, or laser can help lower the pressure. If I was told to have glaucoma and I did not have any discussion on treatments to lower the eye pressure that would be a big red flag.
I would consider that another common scenario, to be told I might have glaucoma, or that I need treatment for glaucoma when in fact I don’t actually have the disease. For this there have been some studies that look into the tendency for doctors to see an eye pressure that appears to be high and feel that that the pressure must be treated.
In such, I know some results from a major randomized clinical trial (the studies we do in big groups to better understand how to treat diseases over time), provide the best evidence. From this I know that if we take a large group of patients with high eye pressure and lower it, we indeed prevent glaucoma from occurring by about 50% of the time.
Also I know that the flip side of these studies is that most patients can go for years and years with elevated eye pressure and not develop glaucoma. So clearly there is a risk of overtreatment. I know that our current treatments to lower eye pressure are all very good, but I also know that all treatments have some side effects, cost and inconvenience. So at this time I would need to have a discussion where these concerns are taken into account including the frequency of visits, frequency of tests and what values we need to pay attention to evaluate for progression.
So the third important thing I would ask myself is "Does the eye doctor have a plan to evaluate me over time?"
So, to wrap things up, IF I had glaucoma I would follow these simple steps:
1. I would want to make sure that my doctor was diagnosing (dilated eye exam and visual field test as a minimum) and treating me correctly.
2. I would want to make sure that the tests that evaluate for glaucoma are being done in a timely fashion (at least every year a dilated exam, visual fields and photos of the nerves).
3. I would discuss any problems that I was having with the drops.
4. I would seek help if I had any other problems such as anxiety in dealing with the disease. And lastly, I would keep in mind that when I work together with my doctor and we both do our job correctly, my outcome will be positive.