Glaucoma
Winter 2024

by Ellen Stodola
Editorial Co-Director

When it comes to treating glaucoma, educating the patient about their disease is a crucial step. In addition to finding an appropriate treatment plan, it’s important for the patient to understand the nature of their disease, which can often be hard because physicians are helping them control their disease, rather than cure it. Alan L. Robin, MD, and Jullia Rosdahl, MD, PhD, discussed how they help patients understand glaucoma and how testing and treatments options play into the discussion.

Dr. Rosdahl said that because she is a glaucoma specialist, most patients that come to her have an idea that they either have glaucoma or are at risk for it. “It surprises me, though, how even some long-standing patients don’t realize that they have a glaucoma diagnosis, even my own patients,” she said. “Glaucoma is tough to understand.”

First, Dr. Rosdahl said you need to find out where the patient is, what they already understand about glaucoma and their condition, and what their concerns and fears are.

Testing is very helpful, she said. “Patients for the most part do understand eye pressure and the need to lower eye pressure,” she said. “The visual field testing and optic nerve imaging (OCT) are helpful, too, especially when there has been a change over time. When patients see those changes on the testing, they understand that their glaucoma is getting worse even if they don’t notice the change symptomatically.”

Dr. Rosdahl said the hardest thing is to explain that vision won’t be getting better with the treatments, and they are only working to preserve the sight they have. “Often, even when patients understand this before surgery, they are hoping/expecting to have improved vision afterward,” she said. “It is a conversation to have multiple times and as gently as possible, especially if someone has advanced glaucoma and a lot of vision loss already.”

While Dr. Rosdahl doesn’t use a formal questionnaire, she does find the discussion with the patient essential for identifying the best treatment program. “We have so many treatment options for glaucoma now—from drops (new classes, preserved and non-preserved) to injectable meds to lasers to MIGS to traditional glaucoma surgeries, plus vision rehabilitation—and the treatments vary so much on how they might affect a patient’s life in the near and long term, what is a good match for the type and stage of glaucoma, the patient’s other ocular and health conditions, and their expectations.”

When a patient seems to be a high risk for needing glaucoma surgery, especially a trabeculectomy or a tube, Dr. Rosdahl often tries to bring it up as early as possible so it is not a surprise for the patient. “We might say something like, “We will start with these eye drops, but we might need to consider incisional surgery to control your glaucoma.” We provide handouts about glaucoma surgery early on, so the patient is learning about it well before they are consenting for surgery and meeting with the surgical scheduler.” She also mentioned handouts from the American Glaucoma Society (AGS) about treatments.

The important thing is understanding and communicating with the patient, Dr. Robin said. If a patient doesn’t understand what’s going on, there’s no way that he or she will cooperate and could be lost to follow-up and potentially go blind.

“I think developing trust with the patient is crucial, and I think the first thing that has to be done is to find out more about the patient,” he said. “What you want to do is get a basic understanding of what they think glaucoma is. It’s a difficult disease to treat because most people feel like they’re doing great. People have no idea they have visual field loss or peripheral vision loss, and you basically have to convince someone who’s totally asymptomatic that there is a problem, and the treatment you’re going to be giving them may cause symptoms itself.” You have to gain the patient’s confidence, discuss the disease, answer any questions, Dr. Robin said. Patients want to know things like what glaucoma is, if they’ll go blind, if they have to take drops, etc.

Dr. Robin said the tests that are needed include gonioscopy, perimetry, and IOP measurements. About half of the patients who have glaucoma have lower pressures, below 21. “You have visual fields to assess the amount of damage to the optic nerve, and the visual fields now are much better than they were when I was a resident,” Dr. Robin said. “They’re black and white, and you can point out black is bad; white is good. It’s always good to repeat visual fields because often on the first time, patients have trouble with it, and you can get a better idea of the amount of damage.” He added that OCTs and slit lamp examinations are crucial to determine the type of glaucoma and any potential adverse effects of medications used to treat the glaucoma.

Treatments and education

If a patient is young and understands what’s going on, Dr. Robin often starts with either eye drops or laser treatment. He will give patients a bottle of artificial tears and see if they can get a drop in their eye. Using drops is extremely difficult, and some people just can’t do it. Additionally, many don’t have a partner or significant person in their lives who can help them.

The second thing that you have to consider, if you decide to go with drops, is what kind of systemic diseases or illnesses the patient has. All topical IOP-lowering medications have different side effects. Some of the prostaglandins can cause eye redness, change the color of the iris, etc., so you have to make sure that a patient understands this. Additionally, Dr. Robin said that beta blockers, like timolol, can cause asthma and exacerbate congestive heart failure. They can also cause a slowing of the heart rate, and a slowing of the heart rate in someone who’s a 25- or 30-year-old track runner whose baseline heart rate is 55 or 60 could cause significant medical issues. You want to make sure you have a full understanding of their systemic health, he said.

“If they can’t put in a drop, my first choice would be a laser trabeculoplasty. You have to explain to patients that this is not a cure; patients always think that there’s a cure,” he said.

The other thing to consider, Dr. Robin said, is how low you want the patient’s pressure to be. You want to make sure that you explain that to the patient. What’s the goal? How do you assess if there’s a change? How do you know you should be more aggressive? You want to ensure that you’re lowering the pressure in a way that prevents visual field loss, so you have to explain the purpose of visual field to the patient. “I have never met a patient who loved taking visual field examinations,” he said.

“I think the important thing is to explain what the treatment is, why you picked that treatment, and what has to be done. Show them how to take drops, and make sure they understand why you’re doing visual fields. Usually, I’ll advance treatment if the eye pressure isn’t adequately controlled, based on the target pressure. I’d either substitute or add a drop or do a laser,” he said.

For patients who can’t put in drops but need a drop, there are some newer devices available. These include Durysta (bimatoprost intracameral implant, AbbVie) and iDose (travoprost intracameral implant, Glaukos). “Both require making a little hole in the wall of the eye and implanting these devices. Durysta is a little pellet that dissolves over time that contains a prostaglandin. It can last for months. iDose is a refillable implant; it’s small, and it’s placed in the area of the eye where fluid leaves slowly over time [and] gives a constant amount of a prostaglandin analog.” Dr. Robin noted the expense of both of these products.

The question is how to decide if a patient needs surgery. He said this depends a lot on the patient’s age. “If they’re young and healthy, I want to be more aggressive in the sense of keeping their pressure low because their life expectancy is longer. If someone loses a little bit of visual field every year, if they’re 90 years old and have a 5-year life expectancy, they’re not going to go blind. But if they’re 40 years old and have a 40-year life expectancy, they could go blind or be visually disabled in their lifetime.”

Depending on the amount of damage and the rate of progression, the surgeon chooses which surgical intervention to go with, he said. There may also be physician preferences at play.

Sometimes a surgeon may need to try multiple treatment options for the patient. The main reason to move onto another treatment, Dr. Rosdahl said, is when what is currently being done is not working due to side effects, documented progression (on visual field or optic nerve imaging), or high risk of progression (for example, if the IOP is higher than the target). Another reason to try a different treatment, she said, is if the patient is having cataract surgery; patients with mild to moderate open angle glaucoma might be able to decrease their eye drop burden if they get a MIGS device along with their cataract surgery.

Challenges in patient education

“I think the most challenging thing for me is to know if a patient is adherent,” Dr. Robin said. We have to improve compliance, he said, adding that this is on both the patient and the doctor. He stressed the importance of physicians instructing patients how to put drops in correctly.

Dr. Robin also emphasized the importance of protecting the optic nerve. There’s a lot of research currently going on looking at the best ways of protecting the optic nerve. There are companies with all different approaches, he said, adding that he hopes there will be a new development soon to make this easier.

Patients are afraid of going blind, Dr. Rosdahl said. “For some people, that is motivating to have surgery, to decrease the long-term risk of vision loss; for other people, that is a huge barrier to having surgery, with the fear of shorter-term risk of postoperative complications and vision loss,” she said. “The hardest part of patient education for glaucoma, though, is not having treatment options to bring vision back that has been lost.” She recommended a number of resources from the American Glaucoma Society, the National Eye Institute, the American Academy of Ophthalmology, and others that offer handouts, podcasts, workshops, educational videos, and more.

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About the physicians

Alan L. Robin, MD
Emeritus Associate Professor of Ophthalmology and International Health
Johns Hopkins University
Baltimore, Maryland

Jullia Rosdahl, MD, PhD
Associate Professor of Ophthalmology
Duke Eye Center
Duke University
Durham, North Carolina

Relevant disclosures

Robin: None
Rosdahl: None

Contact

Robin: arobin@glaucomaexpert.com
Rosdahl: jullia.rosdahl@duke.edu