Glaucoma is a silent disease that always results in blindness if not properly treated. There are several types of glaucoma, but all are a result of increased pressure within the eye, and a corresponding decrease in blood flow to the optic nerve. Like most diseases, treatment of glaucoma has evolved over the years, and knowing what must be done and considered when therapy is administrated can make the difference between life long vision and ultimate blindness.
There are 10 considerations that should always be kept in mind when treating and suffering from glaucoma.
1) Prostaglandins are one of the newest medications that are employed to treat glaucoma. They are extremely efficacious, and have a low rate of side affects. Therapeutically, Travatan and Lumigan are a little more affective the Xalatan in lowering intra-ocular pressure, but Xalatan has fewer side affects. Travatan lowered pressure and average of 8.7 mm Hg, and Lumigan 5.5 mm Hg while Xalatan was at 4.8 mm Hg. There is no ethnic difference with prostaglandins efficacy. The major issue when prescribing these medications are their tremendous expense.
2) Pachometry, or measuring corneal thickness; is a must when evaluating and treating glaucoma patients. The importance of Pachometry was clearly shown during the Ocular Hypertension Treatment Study, (OHTS). Corneal thickness will affect both the actual measurement of the Intra Ocular Pressure(IOP) using Goldman Tonometry and the target IOP. Corneal rigidity greater the 520 um will result in higher than actual IOP readings and thinner corneas will display lower than actual IOP. The problem is how much higher or lower as a result of this rigidity issue. Therefore a patient being treated for glaucoma with thicker corneas is at greater risk of vision loss then one with thinner corneas. The greater the thickness, the greater the danger, and the converse occurs for thinner corneas.
3) Strong patient-doctor relationships are essential. Glaucoma is a life long disease that will be asymptomatic until the later stages of the disorder. Therefore the patient must trust his/her doctor despite not feeling any different while under going therapy. The patient must be well educated by the eye doctor and shown the results of each test be they Visual Fields, IOP readings, and OCTs. Trust and follow up is the key.
4) Gonioscopy is a must. Anterior angle measurement will help diagnose some forms of glaucoma and follow any changes in this important structure as therapy continues. If laser treatments are done, gonioscopy should be performed more frequently.
5) The patient must understand that their treatment is for life. The most important component to the success in glaucoma therapy is patient compliance. If all is done perfectly well, but the patient fails to take the medication as prescribed, then failure is inevitable. With the new medications that require single daily administration, compliance has improved, but contact reminders are required at each follow up visit.
6) Ethnicity is an important factor that must be considered. Based on the Baltimore Eye Study, African Americans are twice as likely as Caucasians to go blind in both eyes as a result of glaucoma. While there are many other factors that must be included in the diagnosis and therapeutic process, ethnicity and race must never be over looked or minimized.
7) The optic nerve heads must be studies stereoscopically at the onset of the diagnostic process, and continued as the condition evolves. An even subtle change in one quadrant of the nerve head is significant in the progression of the disease.
Is Diabetes a risk factor? While Diabetes is pretty much a risk factor for most diseases, and complicates; there is no direct evidence to support the relationship between Diabetes and glaucoma. In addition, while the OHTS data suggested that Diabetes was a protective factor against glaucoma, recent studies have failed to prove that factor as well. Basically, having Diabetes is neither good nor bad with regard to glaucoma.
9) Compliance depends on how many drops, and how often they must be taken. A recent study demonstrated that 49% of patients took their eye drops regularly when required to do so once per day, but that number dropped to 39% when patients were required to use more then one drop or administer them more then twice per day. The compliance dropped like a rock in a pond the more frequently the drops had to be used. Therefore, to improve compliance the doctor must use the least number of drops, the least number of times per day. Cost was a major factor especially in the fixed income group of patients as well.
10) Finally, glaucoma therapy is always evolving and improving. It is incumbent upon the doctor to keep abreast of all new therapies, and also keep an open mind as to different types of therapies. The Age Related Eye Disease Study, AREDS, suggested that nutraceuticals were effective in combination therapy for glaucoma. This concept is controversial, but must not be ignored. Combination drugs and new innovative treatments should be considered in all cases, and the need may arise.
Glaucoma is a difficult disease to treat and manage over the many years that a patient must deal with it. Therefore all options and developments must be kept on the table.
This article is written by Dr. Jay Stockman, contributing author to
VisionUpdate.net. Dr. Jay Stockman, with his partner Dr. Brian Lewy have co-managed a significant number of refractive surgery patients. Advise, and medical questions can be directed to
New York Vision Associates
