(October 11, 2007 - Insidermedicine) Welcome to Insidermedicine's If I Had, where we get a chance to ask an expert what they would do if they had a particular medical condition.
This week, we had the opportunity to ask Dr. Henry Jampel, a world expert in the field of eye disease what he would do if he had glaucoma. Dr. Jampel is a Professor of Ophthalmology at the Wilmer Eye Institute at Johns Hopkins University, and serves as the Associate Editor-in-Chief of 'Ophthalmology,' the official journal of the AAO.
Dr. Jampel gave us his insight into what patients should do if they are told that they have glaucoma.
Dr. Jampel: Well, this is a common question that I get from relatives and acquaintances, and I think it’s important to explain what glaucoma is, what the difference is between being someone who could possible have glaucoma, and who definitely has glaucoma, and then I’d like to give some advice about how to determine whether the person that you’re seeing for your eye care is doing an adequate job of diagnosing and treating you.
So, glaucoma is an optic nerve disease – it’s probably the most common optic nerve disease. And it’s often related to the level of eye pressure within the eye. So, when an eye care practitioner has told you that he thinks that you might have glaucoma, most likely that person has either measured an eye pressure that is abnormally high, or they have looked at your optic nerve and determined that the optic nerve looks like it could possibly be damaged by glaucoma. So, one important question to ask yourself is “Did the eye doctor actually look at my optic nerve?” The best way to know if that was done is by knowing whether or not you had a dilated eye examination. By that I mean eye drops were placed in your eye, you were probably told to sit in the waiting room for a few minutes, and then you came back and the doctor looked again at your eyes with a bright light. If you can’t recollect that having been done, that’s something you can check and see if it was done, but if it was not done, then most likely the doctor simply noted some elevated high pressure and was concerned about that. That is not a diagnosis of glaucoma, and that would not represent an adequate eye examination.
If an eye doctor thinks that you might have glaucoma, then certainly he or she would have either performed a visual field test on you, or would have asked you to come back for a visual field test. The reason for that is that glaucoma, the optic nerve damage that we call glaucoma, is diagnosed by a combination of the appearance of your optic nerve, which is a structural parameter, and a functional test—a visual field test—to determine if you had lost any visual function from the disease. If in fact your eye doctor has done all of those things and has told you that you have glaucoma, then you probably do. Once a diagnosis of glaucoma is made, almost always a decision is made to lower the eye pressure. This can be done with eye drops, medicine, or laser, but it would be unusual for you to be told that you had glaucoma and not have treatment to lower the eye pressure suggested. A much more common scenario, however, is for you to be told that you might have glaucoma, or that you need treatment for glaucoma by lowering the eye pressure, when in fact you don’t actually have the disease, that is optic nerve damage.
There still is a great tendency for eye care practitioners to see an eye pressure that appears to be elevated and feel that that must be treated. We have results from major randomized clinical trials, the highest form of evidence, that if in fact you take a large group of patients with high eye pressure and lower it, you do prevent glaucoma from occurring about 50% of the time. But, the flip side of that coin is that, in these large trials, most patients go for years and years with elevated eye pressure and not develop glaucoma. So there clearly is a risk of overtreatment, and even though our treatments to lower the eye pressure are very good, all treatments have some side effects, cost and inconvenience, that need to be taken into account.
If I had glaucoma…
Dr. Jampel: If I had glaucoma, I would want to make sure that my physician was treating me appropriately and that my diagnosis was correct. I would want to make sure that the appropriate diagnostic tests were done in a timely fashion, and I would want to make sure that I shared with the doctor problems that I was having with the therapy and problems and anxiety that I was having in dealing with the disease. I believe that when the doctor and patient can work together in a chronic disease, such as glaucoma, then outcomes can be optimized.