Volume 14, Number 2
August 2005
Foundation Planning Elegant Fundraiser
Planning for the Foundation’s upcoming fundraiser, Appreciating
Vision – Celebrating the Arts, is underway. Steering committee
co-chairs, Dr. Zeff Lazinger and Joe Watson, with the help of
Board member Stan Tuttleman, have reserved the Tuttleman Sculpture
Gallery of the Pennsylvania Academy of the Fine Arts. This elegant
evening of cocktails, concert and confections will take place
on Saturday, October 8, 2005 at 7:30 PM.
The glass enclosed Tuttleman Sculpture Gallery and the Samuel
M.V. Hamilton Building, recently opened to the public, complement
the beautifully renovated historic galleries, leading the New
York Times to call it the Academy’s “Museum of Contemporary
Art.”
The evening will also feature a concert by the Delaware Valley
Celtic Harp Orchestra. The Orchestra will present an exciting
and varied program with a large repertoire of 17th and 18th century
traditional Irish and Scottish dance music. With seven harps,
a fiddle, flute and tinwhistle, the orchestra will regale guests
with fast-paced music from the heyday of the Irish harp.
Patrons of this event will receive a private reception with complementary
champagne in addition to a special tour of the major modern works
in the Tuttleman Sculpture Gallery with a representative of the
Pennsylvania Academy of the Fine Arts, as well as name recognition
in the program.
For more information about the event, or to receive
an invitation, please contact the Foundation office at 215-928-3191.
YOUR INVITATION TO AN ELEGANT FUNDRAISING EVENT
FOR THE GLAUCOMA SERVICE FOUNDATION
Canadian Medical Student Nearing
Completion of Study: The effect of personality
on measures of quality of life related to glaucoma patients.
One way to determine the type and extent of a
person’s vision problem is to ask him or her to read an
eye chart, take a visual field test, take some other such test,
or be examined by an eye doctor. Such tests and examinations,
however, do not tell us much about how the person’s visual
deficit affects their quality of life. A better way to get at
this question is to ask them specific questions about how well
they can perform vision-related tasks and how their visual handicap
affects their performance of those tasks. If a doctor takes this
second approach, he or she may ask the patient about his vision
and how it affects his life.To do this in a systematic way, the
doctor could administer the National Eye Institute’s Visual
Functioning Questionnaire (VFQ-25), which asks questions such
as:
“Do you accomplish less than you would like because of your
vision?
a. All of the time
b. most of the time
c. some of the time
d. a little of the time
e. none of the time.
“How much difficulty do you have reading ordinary print
in newspapers?” Or “Because of your eyesight, how
much difficulty do you have doing things like shaving, styling
your hair, or putting on makeup?
a. no difficulty at all
b. a little difficulty
c. moderate difficulty
d. extreme difficulty
e. stopped doing this because of your eyesight
f. stopped doing this for other reasons or not interested in doing
this
As helpful as the responses to such questions might be to the
eye doctor in deciding on an appropriate treatment, he or she
needs to take seriously the fact that the patient’s perception
of his/her quality of life related to vision may or may not match
reality. Just because a person says that he has no trouble recognizing
friends on the street does not necessarily mean that a person
actually observing him would come to the same conclusion. Another
example is the results of a scientific survey of drivers in which
over 80% said they thought they were better-than-average
drivers.
Medical student Kevin Warrian is completing a research project
on the Glaucoma Service in which he is studying the effect of
a person’s personality on his/her self-reported quality
of life as related to vision as assessed by the NEI-VFQ 25 survey.
A third-year medical student at the University of Manitoba who
plans to use his participation in this clinical science research
project to fulfill the research requirement for obtaining a Bachelor
of Science degree (B.Sc.Med.) in Ophthalmology, Mr.Warrian plans
to finish this project in this, his second summer spent on the
Glaucoma Service of Wills Eye Hospital.
It may seem intuitively obvious that a patient’s personality
will affect how he responds to the above kinds of questions. For
example, we may well think that if a person is very anxious, he
will generally perceive his visual handicap as a great detriment
to his quality of life, much worse than a person observing him
might think. But a tendency to be anxious is only one aspect of
personality.
The NEO Personality Inventory
To get the full spectrum, Mr.Warrian is using another questionnaire,
The NEO Personality Inventory. This questionnaire comprises 240
questions ranging, for example, from ranking the statement, “I
am not a worrier,” “I really like most people I meet,”
“I have a very active imagination,” to “I’m
an even-tempered person,” “I like to have a lot of
people around me,” and “I am sometimes completely
absorbed in music I am listening to.” How does the fact
that a person perceives himself as “even-tempered”
affect his response to the NEI-VFQ 25 question, ““Because
of your eyesight, how much difficulty do you have doing things
like shaving, styling your hair, or putting on makeup?”?
The relationship here is not very intuitive. Perhaps there is
no relationship. But in his study Mr.Warrian is trying to determine
whether such relationships exist.
Mr.Warrian is also trying to understand how glaucoma patients’
personalities affect how they take glaucoma medications. Thus,
he is also matching up questions about patients’ use of
medications with the NEO Personality Inventory. For example, do
outgoing people take their medications more consistently than
more introverted people?
Certainly not all, if any, glaucoma patients are going to take
the NEI-VFQ 25 and the NEO Personality Inventory tests as a routine
part of their care. Nor will they be asked detailed questions
about taking their glaucoma medications. The point, explains Mr.
Warrian, is to sensitize physicians, especially, to the fact that
patients’ personalities do affect how they perceive their
quality of life related to vision as well as to how they take
their glaucoma medications. “Taking into account the personality
of the patients they are treating is perhaps something all physicians
do to some extent,” explains Mr.Warrian. “The point
of my study, however, is to develop data to guide their intuitions
with solid empirical evidence as they make treatment recommendations.”
Glaucoma patient Marietta Taylor with Kevin
Warrian. A patient of Drs. Rhee and Spaeth, Ms. Taylor has graduate
degrees in public health and has administered public health surveys
throughout Pennsylvania. She noted that her background made her
particularly amenable to participating in Mr. Warrian’s
quality-of-life research project.
Photo by Ken Parker, PhD
 Note
from Board Chairman Andy Medcalf, PhD
The Glaucoma Service and the Glaucoma Service Foundation are
busy with many exciting and productive activities, as you will
see as you read this issue of Searchlight on Glaucoma.
One event I would like to highlight is our upcoming fundraising
event, Appreciating Vision – Celebrating the Arts, An Elegant
Evening of Cocktails, Concert and Confections. This event is being
held in the Tuttleman Sculpture Gallery in the Samuel M.V. Hamilton
Building of the Pennsylvania Academy of the Fine Arts.
In addition to the post -1945 contemporary American art and sculptures,
guests will enjoy a concert by the Delaware Valley Celtic Harp
Orchestra. The proceeds of this event will support the Foundation’s
many programs, including glaucoma research, patient and physician
education, public awareness and community outreach. The event
will, once again, explore the idea that the practice of medicine
is an art involving the same types of knowledge, technical excellence,
dedication and attention to spirituality that are essential in
the other arts.
I do hope you will plan to join us on Saturday, October 8, 2005
for a wonderful evening celebrating the physicians on the Glaucoma
Service and the Glaucoma Service Foundation, and the impact they
are making in the lives of glaucoma patients everywhere.
 Volunteer
Norma Devine’s Skills Keep the Glaucoma Service Website
Chat Room Humming
1. Could you give us a synopsis of all the things you
do in connection with the Glaucoma Service Foundation website?
Mainly I help with the glaucoma chat room and revise transcripts
of the Wednesday night "doctor" chats. I also look after
the Bionic Eye (B.E.), a message forum for glaucoma patients that
is linked to the Glaucoma Service Foundation web pages. “Mort,”
a glaucoma patient and the owner of B.E., started the forum in
July 1998. Since Wednesday nights were not convenient for some
patients, I also spent two hours on Monday nights in the chat
room for five years. I still stop by the room on many Monday nights
and Saturday mornings.
2. When did you start participating in the Glaucoma Service
Foundation chat room?
The Glaucoma Service Foundation website went online in January
of 1998, the chat room opened in March, and I found it a few months
later. Vivian Werner, a glaucoma patient in need of support, asked
Dr. Rick Wilson if she could start a chat room. To Vivian's surprise,
Dr. Wilson started showing up on Wednesday nights, chatting with
her and a few other glaucoma patients and answering their questions.
Vivian said she “never expected “Dr. Rick” to
come every week or at all. He really made a big difference.”
3. How did you get started doing the Chat Highlights?
More interesting, I think, is how the chat highlights began and
evolved. As the number of glaucoma patients finding the chat room
grew, cross-talk increased accordingly. While Dr. Rick was typing
a response to a patient’s question, other patients kept
typing messages to him and to one another. It was chaotic and
hard for patients, even those with good vision, to keep up with
the rapidly rolling screen.To better provide information to meet
the various needs of glaucoma patients, we decided to discuss
a specific topic every Wednesday night for the first 30 minutes
of the hour, with the rest of the hour free for patients to ask
the doctor questions about their own concerns.
The chat program recorded everything that transpired in the chat
room. Vivian, the Webmaster, kept copies of the transcripts. But
a couple of the patients learned to use their own computers to
make copies of the chat, which they then sent to friends, including
some who lived abroad. That practice, I felt, had the potential
to cause problems, because the transcripts contained personal
information. Vivian switched to a different software program that
made it much more difficult for participants to capture the chats.
To give readers only relevant information from the chats, I edited
the lengthy transcripts to create highlights of them. The first
one appeared online in February 2000.
Chaotic as the chats were, some participants vigorously opposed
switching to moderated chats. Finally, in April and May of 2001,
Vivian conducted a survey of the participants. One of the questions
was, "Would you be willing to try a moderated chat during
the discussion of the topic?" To my relief, 82% favored a
moderated chat.
In December 2001, I posted a notice on the Bionic Eye, which
said, in part: "If you participated in the chat last Wednesday
night, you helped break new ground in cyberspace with a moderated
medical chat in real time.” The moderated chats also reduced
the time it took me to create the highlights of a chat by several
hours.
4. Have you worked professionally as
an editor, or does this just come naturally to
you?
Actually, in 1983 I was working as a freelance
writer, using an IBM Selectric typewriter, when I became one of
the so-called pioneers in home computing. I spent $2,000 for a
Morrow computer and $1,000 for a Daisywriter printer. To increase
my income, I started editing Ph.D. dissertations and other scholarly
papers.
Part of my responsibility as a Patient Advocate on the Institutional
Review Board of the JAEB Center for Health Research from 1993
until October 2004 involved editing patients’ informed consent
forms and other material. The JAEB Center is a nonprofit entity
whose primary interest is in the design, conduct and analysis
of clinical trials, most of which concern ophthalmology and are
funded by the National Institutes of Health.
5. Why do you contribute so much of your
time and energy supporting the Glaucoma Service Foundation website?
First, the chat room and chat highlights are unique in all of
cyberspace. Glaucoma patients and their loved ones, not only from
all time zones in the U.S. and Canada, but also from many countries
abroad, come to the Glaucoma Service Foundation chat room and
website seeking and finding support and information. One of them,
a young Brazilian engineer in Rio de Janeiro, has seldom missed
a chat since the Wednesday night chats started seven years ago.
The chat highlights alone, of which there are over 270, contain
a wealth of information that is easy for glaucoma patients to
understand and is not readily available elsewhere. Further, glaucoma
patients can get their questions answered free of charge in real
time by highly respected specialists.
Second, when my normal-tension glaucoma was diagnosed in 1988,
I didn’t know anyone who had glaucoma. Although I had a
home computer, the World Wide Web did not exist. Eager to learn
about the glaucomas, I was fortunate to have access to the library
of a university’s medical school. Now any glaucoma patient
with access to a computer also has access to the resources of
the Web, the greatest library in the world and, of course, the
Glaucoma Service Foundation web pages.
With computer-literate baby boomers reaching their sixties, many
more glaucoma patients will be discovering the Foundation’s
chat room and the dedicated doctors who generously give of their
time and expertise. I like to think those patients will find the
same support and information that has made glaucoma more bearable,
less frightening for many of us.
6. Is there anything else you would like to add?
Yes. Years ago, a bad skiing accident kept me hospitalized for
a long time, over a thousand miles from my husband and four young
children. One day in the orthopedic hospital, I asked an elderly
visitor how I could ever repay her and the many other strangers
who did so much for us during that difficult time.
She smiled and said: “You can’t repay us. But someday
when you walk again, you will find a way to help others.”
What she neglected to mention was how rewarding helping others
can be.
 Board
Member Bonnie Long: Contributing her skills to
prevent blindness from glaucoma
As a board member, I have had the opportunity to learn more about
the work of the physicians on the Glaucoma Service at Wills.
I know that this group of physicians and fellows are some of the
best in the world… and if anyone is going to advance diagnosis
and treatment of glaucoma… this is the group that will do
it. The Glaucoma Service Foundation supports that work. Giving
my time and whatever skills I can is one way, andI hope a productive
way that I can contribute and help make a difference. I have a
long family history of glaucoma beginning with my maternal grandmother,
my mother, maternal aunts and cousins. What is most disturbing
is that we are now seeing glaucoma in my cousins' children...and
their children. Not all of them have been as fortunate as I have
been with successful surgery that preserved my vision. Many are
dealing with vision loss and difficulty controlling the disease.
I have a brother and a niece who are at risk. My husband's mother
had glaucoma, so there is another family of brothers, sisters,
nieces and nephews who are at risk.We have to learn more, to understand
more aboutglaucoma and find better treatment, not only for them,
but for millions around the world.
I believe The Glaucoma Service Foundation offers one of the best
chances we have to advance our knowledge and treatment of glaucoma.
This Foundation can make a difference, but only with our support.
Money is certainly important, critical in fact. But so is the
support and involvement of volunteers. I give my time and whatever
talents I can bring because I know the work of this Foundation
will have an impact and it is an opportunity to help that effort.
The Stress of Glaucoma:
A Chat with Dr. Elliot Werner
Norma Devine, Editor
On Wednesday, July 20, 2005, Dr. Elliot Werner, a former member
of the Wills Eye Hospital Glaucoma Service now in private practice
in Wyomissing, Pennsylvania, led a discussion with the chat group
on "Stress and Glaucoma."
Moderator: Welcome back to chat, Dr. Werner. Our
topic tonight is stress and how it affects us glaucoma patients.
But, first, how does stress affect the doctors who take
care of us?
Dr. Elliot Werner: Taking care of glaucoma patients
can be very rewarding, but also very stressful. Although
the treatments for glaucoma are pretty good, they still have a
measurable failure rate. When things don't go well with
a patient, it can be very hard on the doctor. I've spent
many a sleepless night worrying about a patient who was not doing
well.
Moderator: Are the complications of treatment the
main cause of stress for you in your work?
Dr. Elliot Werner: Yes. When you do something to
a patient and instead of helping the patient it makes them worse
or increases their suffering, that is really hard to deal with.
Also, unlike many other eye conditions, the vision loss
from glaucoma is usually not reversible, so you don't have a lot
of wiggle room when making decisions.
Moderator: How do you handle glaucoma patients who
may be feeling overstressed from bad news?
Dr. Elliot Werner: It's tough. You try to give them
the best possible outlook. Never destroy hope. I always
try to find some good news to give the patient, even if I have
to search real hard for something to say.
Shutting up and listening to the patient for a while also seems
to help. It's also important to find out what is bothering
the patient. For example, the doctor can get all involved
with IOP (intraocular pressure) or cupping (of the optic nerve),
but the patient may be more concerned about red eyes.
When people think about stress and glaucoma,
they are wondering if stress causes or makes glaucoma worse. In
fact, many studies have shown the opposite. Glaucoma causes stress,
not the other way around.
Dr. Elliot Werner
P: Does being nervous or stressed increase the IOP
(intraocular pressure) as it does blood pressure?
Dr. Elliot Werner: Not as far as we know.
P: Learning anything new has been shown to beat
stress. A new study at the Mind-Body Wellness Center in
Pennsylvania found that playing music significantly reduces stress.
I knew an orthopedic surgeon who sang in a barbershop quartet.
Said it helped him relax. Several in our group play
musical instruments. Two sing in choirs. One fellow
seems to know the lyrics to hundreds of new and old popular songs.
Dr. Elliot Werner: Music is great. A lot of
surgeons play music in the operating room for that reason. If
someone has a strong religious faith, prayer also helps. I
have sometimes prayed with patients when it seems appropriate.
P: Can stress that leads to depression be harmful
for someone with glaucoma?
Dr. Elliot Werner: Stress is hard to measure. Depressed
patients often do not take their medications and do not keep their
follow-up appointments, which can hurt their glaucoma. Psychiatric
illness generally can interfere significantly with treatment of
other problems, such as glaucoma.
P: What are some ways to relieve or reduce stress
levels?
Dr. Elliot Werner: That's hard for me to answer
since I am not a psychotherapist and really don't have any training
in that area. Exercise is a good one. Many people
say that exercise is a great stress reliever.
P: When Harvard University researchers followed
people over the age of 65, they reported that people who enjoyed
games, such as bridge, found as much stress relief and prolonged
life expectancy as did those who exercised regularly. I
wonder if that also holds true for people under age 65.
Dr. Elliot Werner: That is probably true. Something
that is truly pleasurable and not harmful stimulates the production
of endorphins in the brain and that relieves stress at the biochemical
level.
P: I still feel that a good laugh works wonders.
P: That's a good point. According to research
from Western Illinois University, people who can appreciate humor
are less stressed and anxious.
Dr. Elliot Werner: Laughter, of course, is a pleasurable
activity that is not harmful.
Moderator: I have heard it is the best medicine.
I went to a funny movie this weekend, just for a good laugh.
I was able to forget troubles and feel good and laugh.
P: This chat room has probably relieved a lot of
stress for many of us.
Dr. Elliot Werner: Support from others in the same
boat also helps. Another good stress reliever is a glass
(that is ONE glass) of red wine, but not if you have an alcohol
problem.
P: How does stress affect glaucoma?
Dr. Elliot Werner: Generally, when people think
about stress and glaucoma, they are wondering if stress causes
or makes glaucoma worse. In fact, many studies have shown
the opposite. Glaucoma causes stress, not the other way around.
A recent study found that the biggest problem newly diagnosed
glaucoma patients face is anxiety and depression about their diagnosis,
not vision loss.
P: What about the role of cortisol, a natural stress-related
steroid, in open-angle glaucoma? I seem to recall reading
that it's over-produced in times of stress, weakens collagen structures
in the body, and may affect the eye.
Dr. Elliot Werner: That is undoubtedly true. The
release of endogenous cortisol during periods of stress can raise
the IOP. That has been shown.
P: I get stressed at an office visit with my glaucoma
specialist, but not when I visit my other doctors. My six-month
checkup is in two weeks and already I'm feeling stressed. I
think I worry about my eyes more than any other part of my body.
Dr. Elliot Werner: Why do you think seeing the glaucoma
doctor stresses you?
Depression can be a side effect of several glaucoma
medications. Doctors need to keep that in mind. Dr. Elliot Werner
P: He can be abrupt and dismissive and I get nervous
and forget to ask him questions.
Dr. Elliot Werner: In other words, it is the doctor
who is causing the stress, not the situation or your condition.
I hate to say this, but maybe you should consider switching
doctors. The other option is to talk to the doctor frankly
and tell him or her what the problem is from your point of view.
P: I've seriously thought about that, Dr. Werner,
but he has taken very good care of my eye.
P: Write your questions down ahead of time.
P: When doctors go to symposia, are there ever any
presentations on how they can hone their people skills when dealing
with patients?
Dr. Elliot Werner: No. It's not something that particularly
interests the people who sponsor symposia. I'll have to
check again, but I don't think the next American Academy of Ophthalmology
meeting is offering a single course on that subject. It
is a great deficiency.
P: Dr. Werner, don't you think it's not so much
the amount of stress that matters, but how we manage it?
Dr. Elliot Werner: Again, I am no expert on stress.
Stress is almost impossible to measure and quantify, so it's hard
to know what the "amount" of stress is in any individual.
Some situations like being sent to jail or the death of
a close loved one are obviously more stressful than others like
breaking a glass in the kitchen, but it is the ability of the
individual to cope that matters.
P: Doctors don't mention that glaucoma eye drops
can cause depression. I wonder how many people are stressed
or depressed from their drops? Cosopt and Alphagan P are
two drops that list depression as side effects.
Dr. Elliot Werner: Depression can be a side effect
of several glaucoma medications. Doctors need to keep that
in mind.
P: Dr. Werner, do you or your technician show your
patients how to occlude the puncta to maximize the effectiveness
of the drops and minimize the amount draining into the system?
I had to learn how and why to do that years ago by reading
the literature.
Dr. Elliot Werner: Yes, our techs are trained to
do that, and I usually ask patients if they are doing punctal
occlusion.
P: What is punctal occlusion?
Dr. Elliot Werner: You hold you fingers over your
tear ducts for a couple of minutes after putting the drops in
so the drops don't go down your tear duct into your throat. That
reduces the risk of side effects. You doctor should teach
you how to do it.
P: I use punctal occlusion despite my doctor saying
to use passive lid closure. He says that's the general thinking
among clinicians currently. Supposedly, most people don't
do punctal occlusion properly, so it's better to have them do
something else, that is, passive lid closure.
Dr. Elliot Werner: Gently closing the eyes is quite
effective at occluding the tear puncta. I usually tell patients
to do both, close the eyes and compress the medial corner of the
lids. That seems to be pretty easy for most people.
P: I didn't know that I should do that, but know
that now. I learned the hard way. Wish the doctor
would have told me.
P: People don't read the Patient Information sheets.
Dr. Elliot Werner: You are absolutely right. A doctor
is legally obliged to make a patient aware of potential side effects
of medications or other treatments.
Moderator: Thank you, Dr. Werner. We look
forward to your next visit.
Dr. Wilson Helps Patient Think
About Whether to Have Surgery or Not
Dear Doctor:
I just spent time at your web site and would like to ask you some
questions. I am 68 years old and have open-angle glaucoma.
I went to an ophthalmologist for 7 years and he never did a visual
field test. I knew nothing about glaucoma, no family history,
etc. I kept complaining of worsening vision. Finally I went to
a new doctor in our little town, an optometrist. He does visual
field testing. He said he suspected something and had me come
back in a month. He said he felt I had glaucoma and started me
on drops. A few months later he sent me to an ophthalmologist.
I had quite a bit of damage already. About five years later now
I have had two laser procedures on my left eye. This is the worst
eye, not much vision left.
I have had one laser treatment on the right eye. None of these
has had a significant effect on my pressure. My pressure stays
around 14 - 16. Both doctors have been urging me to have surgery
and I am very close to that. It will be in my left eye first,
then the right.
I am very concerned. I have read a lot of information about the
surgery and the possible complications. I am not as concerned
about my left eye, but if the right eye were to be damaged during
surgery I would be in real trouble.
If I could have reassurance that this surgery is totally necessary
(both doctors tell me it is), and that it will be successful in
slowing progress of my glaucoma I would feel better. I am a widow
and getting to the hospital and for follow-up will be a problem.
I am so thankful to my local doctor for discovering
my problem.
Thanks for any response.
A Glaucoma Patient
Dear Glaucoma Patient:
While it is certainly understandable and correct to be concerned
about the possible complications of the surgery, the other side
of the coin is the probable complication of not having the surgery.
If you have been getting worse, you will continue to until your
vision is lost. The success rate of glaucoma surgery is close
to 90% if success is defined as adequate pressure control with
or without medications.
Most of the time when the surgery fails, the vision is not much
affected but you are back where you started on many medicines
with a pressure that is too high. If surgery is successful, patients
with cataracts usually notice a faster progression of their cataracts
after surgery and patients with too low a pressure after surgery
may not have as crisp vision as they did preoperatively. So the
decision may hinge on having slightly less clear vision postoperatively
but maintaining it for life versus continued slow loss of vision.
While I cannot comment on your particular situation
without seeing you, I trust you are going to a glaucoma specialist
for your surgery. With only one eye, I think this is a must. A
list of glaucoma specialists is on the American Glaucoma Society
website at www.glaucomaweb.org/patients/.
Good luck with your surgery.
R. Wilson, M.D.
Drs. Wilson, Katz, Spaeth, and Eight
Former Fellows Contribute to World Glaucoma Congress
Drs. Richard Wilson, L. Jay Katz, and George Spaeth, were among
the luminaries of the glaucoma world who made presentations at
the Association of International Glaucoma Societies’ first
World Glaucoma Congress, held in Vienna, Austria, July 6-9th.
Virtually every topic relevant to the diagnosis and treatment
of glaucoma received attention in lectures and posters.
- Dr. Wilson discussed the nature of the evidence ophthalmologists
use to make patient care decisions and present better approaches
in his presentation, “Evidence-Based and Value-Based Medicine,”
taught two courses, “Limbus-Based Trabeculectomy,”
and “The Use of Releasable Sutures in Glaucoma Surgery,”
and was one of a group of glaucoma specialists teaching yet
another course, “Managing Cataract and Glaucoma.”
- Dr. Katz gave a presentation titled, “Argon Laser Trabeculoplasty
and Selective Laser Trabeculoplasty are the Same.”
- Dr. Spaeth, working with Allergan, presented a poster, “Literature
Review of Glaucoma Patients' Quality of Life.”
Fellows trained on the Wills Glaucoma Service presenting lectures
included
- Augusto Azuara-Blanco, Consultant Ophthalmic Surgeon at the
Aberdeen Royal Infirmary and Honorary Senior Lecturer at the
University of Aberdeen, Scotland
- James Brandt, Professor and Director of the Glaucoma Service
at the University of California, Davis
- Joseph Caprioli, Professor of Ophthalmology at the UCLA School
of Medicine
- Ronald Gross, Professor of Ophthalmology at the Baylor College
of Medicine, Houston
- Roger Hitchings, Professor of Ophthalmology at the University
of London
- Clive Migdal at the Western Eye Hospital, London
- Richard Parrish II, Professor, Department of Ophthalmology,
University of Miami School of Medicine, and Carlo Traverso,
of the Clinica Oculistica, Department of Neurosciences, Ophthalmology
and Genetics, University of Genova, Italy
Normal-Tension Glaucoma from a Neuro-Ophthalmologist
Point of View
Norma Devine, Editor
On Wednesday, May 4, 2005, Dr. Mark Moster and the glaucoma chat
group discussed "NTG from a Neuro- Ophthalmologist Point
of View."
Moderator: Welcome, Dr. Moster. Thanks for joining
us again. For those who are not familiar with your background,
will you please tell us a little about it?
Dr. Mark Moster: I am a neuro-ophthalmologist, first
trained in neurology and then neuro-ophthalmology.
Moderator: As a neuro-ophthalmologist, what are
you looking for when you first examine someone diagnosed with
normal-tension glaucoma (NTG)?
Dr. Mark Moster: I will usually see someone with
NTG when an ophthalmologist questions whether there may be a cause
for the NTG other than glaucoma. My goal is to be sure there
is not another problem that should be treated in a different manner.
P: Under what circumstances would a general ophthalmologist,
or even a glaucoma specialist, have an NTG patient examined by
a neuro-ophthalmologist? Do you think that occurs as often
as it should?
Dr. Mark Moster: I think it likely does occur as
often as it should. When there is something atypical about
the clinical presentation or course, I think that is an appropriate
circumstance.
P: Does every NTG patient you see undergo the same
kinds of tests and examinations, or does that depend on individual
symptoms?
Dr. Mark Moster: I think the clinical examination
is the same for all patients. It includes a thorough history
and an examination that looks for findings that may not be typical
for glaucoma. Depending on the results of the exam, the testing
may be different.
P: Will you please give a couple examples?
Dr. Mark Moster: Patient A has typical optic disc
cupping, but has headaches and mainly temporal-sided visual field
defects. An MRI (magnetic resonance imaging) is performed
that shows a pituitary tumor. Patient B has had a gastrectomy
(stomach removal) for ulcers. There is progressive visual
loss. A blood test for vitamin B12 reveals a very low level.
The patient is treated with vitamin B12 shots.
P: If I had a bout of optic neuritis that was undiagnosed
at the time, would it be possible to tell now?
Dr. Mark Moster: It is usually possible to tell
that the optic nerve has been affected by some illness. In
some, but not all, cases, it is easy to tell that it was optic
neuritis.
P: Could a glaucoma specialist tell, or would I
need to see a neuro-ophthalmologist?
Dr. Mark Moster: A glaucoma specialist is typically
good at knowing who should see a neuro-ophthalmologist, since
glaucoma specialists are comfortable assessing the optic nerve.
P: Are there other neurological conditions that
could be misdiagnosed as NTG?
Dr. Mark Moster: The most important neurologic condition
that can be missed is a mass lesion pressing on the optic nerve
or further back in the visual pathway. It could be a tumor
or an aneurysm. Other things that can be missed include
a prior episode of a loss of blood flow to the optic nerve, prior
inflammation, vitamin deficiencies, degenerative diseases, etc.
P: You mentioned prior inflammation. Would that
be the same as being told that "your optic nerve is very
enlarged?"
Dr. Mark Moster: “Enlarged” can mean
several things. It may just be large, which isn't bad at all.
It may be elevated or swollen, which is not good, due to
inflammation, infection, loss of blood flow, high blood pressure,
compression from tumor, or elevated pressure in the brain.
P: Are there other glaucomas besides NTG that could
have neurological causes?
Dr. Mark Moster: Well, a lot depends on how people
define diseases. For instance, many people feel that NTG
and POAG (primary open-angle glaucoma) are really the same. If
that is the case, and we believe that NTG is neurological, then
POAG by definition also would be neurological, although intraocular
pressure may play more of a role in NTG.
P: Wouldn't something atypical include sudden vision
loss? What about damage in only one eye (monocular)?
Dr. Mark Moster: Yes, sudden visual loss is atypical,
except in acute-angle closure glaucoma. Monocular damage
occurs in NTG, but I would be a little more careful in considering
neurologic causes if it is monocular.
P: We have heard that a diminished blood flow and
oxygen supply to the optic nerve may be a factor in the development
of NTG. If that is so, wouldn't you have to classify NTG
as an ischemic optic neuropathy (ION)? If NTG is a form
of ION, why would treatment focus on lowering intraocular pressure?
Dr. Mark Moster: The key to what you said is "may
be." Although blood flow may be diminished, it may
be secondary to the loss of nerve fibers in the optic nerve and
not the cause of the problem. Also, treatment of blood flow
has not been proven to really help. IOP is lowered because
it does help.
P: Has the treatment of blood flow not been proven
to really help because of the difficulty of actually improving
microcirculation at the level of the optic nerve head, or because
such improvement, even when achieved, does not seem to help?
Dr. Mark Moster: I think it may be both.
P: Is there any way to detect a prior episode of
loss of blood flow to the optic nerve?
Dr. Mark Moster: The changes in the optic nerve
are typically optic pallor, that is, paleness of the nerve. There
may be cupping of the optic disc as well, particularly if the
blood loss was due to an illness know as giant cell (or temporal)
arteritis.
PATIENT SUPPORT GROUP MEETING
Meetings are from 1:30 to 3:00 PM on Sundays in the 8th floor
auditorium of the “new” Wills Eye Hospital, southeast
corner of 9th and Walnut Streets, with the entrance on Walnut
Street, near 9th Street.
September 18th
Dr. Jeffrey Henderer
A Refresher Course in Glaucoma with Some Notes
on Accumap
For information on future, as yet unscheduled,
meetings please call the Foundation office (215-928-3283) and
ask to be put on the support group mailing list.
CHAT SUPPORT GROUP
www.willsglaucoma.org
Wednesdays, 8:30-9:30 pm
Hosted by a Wills Glaucoma Specialist
Mondays, 8:00-9:30 pm
Saturdays, 10:00-11:00 am
Patients and family members only
FROM THE “CHAT HIGHLIGHTS”
OF THE GLAUCOMA SERVICE WEBSITE
Decisions in Combined Cataract-Glaucome Surgery
Participant: If the visual outcome of the cataract
surgery is always the same, does your decision for or against
combined surgery hinge on the trabeculectomy portion?
Dr. Rick Wilson: Yes. The surgeon opts for a
combined procedure if the IOP (intraocular
pressure) control is not adequate, or if the patient is already
on so many glaucoma medicines that if the IOP increases after
surgery, there will be little to add to bring it down.
How Often Are Visual Fields Necessary?
Participant: How often should a patient ask for
a visual field test to help allay fears of rapidly losing vision?
Dr. Rick Wilson: If field loss is mild to moderate
and the IOPs seem controlled, then yearly. If the IOP is above
normal and the glaucoma is mild, then every 9 to 12 months. If
the loss is moderate to severe, then every 6 months. I rarely
get visual field tests more than every 6 months, unless the patient
develops new symptoms that may be related to visual field loss.
Blood Pressure and Glaucoma
P: Is high blood pressure or low blood pressure
worse for glaucoma patients?
Dr. Rick Wilson: Low blood pressure is worse.
The heart pumps blood into the eye against the pressure in the
eye. When the eye pressure is up and the blood pressure is down,
it is a double whammy. If the blood pressure is allowed to remain
up, it causes changes, like narrowing of the arteries (a protective
reflex that becomes chronic).
How Can a Patient Get the Most Benefit from
a Doctor’s Visit?
Participant: Both the doctor
and the patient have external stresses. In a perfect world, they
would be left outside the door, but that's easier said than done.
Do you have any suggestions about how the patient can get the
most benefit from a visit, such as getting answers to questions?
Dr. Rick Wilson: In order to get the most information
in the shortest amount of time, write down your questions succinctly
and hand the list to your doctor, so he or she can quickly and
directly answer them. A short introduction like "I am sorry
to take so much of your valuable time, but I would feel so much
better if I could get the answers to these questions. Can you
help me?"
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