Volume 5, Number 2
Fall, 1996
Treatment for Glaucoma:
Not to be Taken Lightly
by George L. Spaeth, MD
Millions of people use eye drops to treat their glaucoma, and
in most cases the drops don't cause serious problems. But heart
attack, impotence, death due to stopping breathing, blood cells
not being manufactured, retinal detachment, kidney failure, eyelids
growing together, and many other problems just as important have
been caused by medications used to treat glaucoma. Patients need
to know this.
Less serious problems such
as fatigue, forgetfulness, red eyes, a bad taste in the mouth,
shortness of breath, bowel spasms occur routinely in people who
to take medications for their glaucoma. In fact, over two thirds
of those using glaucoma medications will have some type of side
effect. In most cases the side effects are tolerable, and are
an acceptable price to pay for the benefit that results from the
medication. But, for that to be the case, patients have to be
aware of the nature of the problems and the nature of the benefits
so they can decide whether the potential benefit is worth the
potential risk.
How Eye Drops Work
Eye drops contain substances
that have powerful effects: adrenaline (affects the heart and
blood vessels), pilocarpine (makes glands secrete and muscles
in the eye, bowel, and bladder contract), beta-blockers (make
breathing harder and blood pressure lower), and carbonic anhydrase
inhibitors (depress one of the widespread enzymes in the body),
etc., etc.
Placing an eye drop in the
eye is not like dropping water on the skin. The surface of the
eye is rich in small blood vessels, so that substances placed
in the eye are quickly absorbed directly into the bloodstream.
In contrast, when a pill is swallowed it has to pass through the
stomach, into the bowel, and then to the liver, where it is often
changed, or "detoxified." Placing a drop in the eye more directly
affects the blood vessels, the heart, the brain, and other tissues
of the body than swallowing a pill.
Can Harm Be Avoided?
One of the principles that's
taught to developing physicians is " primum non nocere," or "first,
do not harm." It was taught 2,500 years ago, and it's still taught
today, although it is an increasingly difficult principle to uphold.
Virtually any action doctors
or others take has multiple effects, some of which are harmful.
We discipline a child because we wish him or her good, yet there
is some harm involved in every disciplinary action. We "harm"
our ability to do what we want by putting funds to be used for
enjoyment into a bank account, or, viewed the other way around,
we harm our bank account (essential for our future well being)
by utilizing funds to enjoy ourselves. We harm fruit trees and
grapevines by pruning them severely in order to cause them to
bear better fruit.
The principle is obvious and
elegantly expressed in the ancient Chinese symbol of the subdivided
circle, one part being yin, and the other, yang, indicating there
are contrasting aspects to everything that exists, including,
for purposes of this discussion, medical treatments (Figure).
There is no "gain" in one aspect without "loss" in another. For
example, there is the potential for harm even in some of our safest
treatments, such as utilizing milk to treat stomach ulcers. When
milk is taken in large doses, especially when combined with the
antacids frequently utilized to treat stomach ulcers, kidney stones
can result.
Since, then, it is virtually
impossible to "do no harm," the challenge is to "make the punishment
fit the crime." While the theoretical goal is to "do no
harm," in practice both the doctor and the patient must realize
they have to accept some risk if they want any benefit at all.
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The ancient
Chinese yin-yang figure symbolizes the fundamental harmony
of opposites. The dark part (the yin) symbolizes the feminine,
dark, receptive, "negative" aspects; and the light part
(the yang), the masculine, light, aggressive, "positive"
aspects. The yin-yang figure indicates that the yin and
yang aspects are absolutely dependent on each other: without
dark there is no light, without light there is no dark.
The dark dot in the light part, and the light dot in the
dark part indicate that nothing is completely yin and nothing
completely yang. The traditional Chinese approach to healing
and life in general is to act to maintain the balance between
yin and yang. By contrast, the typical "Western" approach
to healing and life in general is to act to maintain the
balance between yin and yang. By contrast, the typical "Western"
approach is to attempt to ensure the "victory" of the "positive"
over the "negative". |
Most people are aware of the risk of surgery,
sometimes to such an extent that they choose not to have something
done that would probably help them. Most are aware of the problems
associated with pills and injections. Few people, including doctors,
however, recognize the propensity of little eye drops to cause
big problems. If the patient were aware that the one eye drop
she was using each day might be the reason why she was falling
asleep every time she sat down, or why she had unexplained painful
bowel spasms, attention could be properly directed to the cause.
At that point, the patient might decide to bear
with the fatigue or the bowel spasms as a tolerable cost for the
preservation of vision. But at least both the doctor and the patient
would understand the cause for the fatigue or the bowel spasms,
eliminating the need for other diagnostic tests and potentially
even more damaging treatment.
Patients will sometimes ask what sort of side
effect they should watch for. Different classes or families of
drugs do tend to have similar clustering of side effects. But
each individual is a unique person and reacts uniquely to every
drug. Thus, though it is helpful to know that the beta-blockers
tend to be "downers," slowing the heart, making people fatigued,
making them think less well and lowering their blood pressure,
occasional people will have very different effects from beta-blockers,
for example, high blood pressure.
Eye Drops and the Doctor - Patient Relationship
While the doctor should be aware of the types
of side effects associated with a particular medication, almost
any problem could be caused by one of the medications someone
is taking. Especially if some type of symptom develops shortly
after a new medication is started, it makes sense to attribute
the symptom to the medication.
As hinted earlier, it's not just the serious
side effects that are the problem. Of course, it's a real concern
if a person develops a terrible rash over his whole body, or loses
control of his/her bladder. But people notice such obvious problems
and usually bring them to the attention of their physician. The
less obvious problems are common, and are of real concern, because
they are routinely overlooked. For example, in answer to a question
such as "Are you feeling fatigued," it is common to get the answer
something like, "Yes, but then I'm getting older." Or, in response
to the comment, "It looks as though you've been losing weight,"
the patient will frequently say, "Yes, but you know I live alone
and I haven't been cooking for myself well." These may be minor
difficulties at the start, but they often turn into major concerns
if not recognized.
Appropriate risk-taking is an essential part
of a mature, healthy, joyful, productive life. People who are
considered "competent" by the legal system have the right to make
decisions that affect their well-being. The principle of "informed
consent" is one of the ways our society protects people from having
others inappropriately make decisions for them. One of the physician's
appropriate responsibilities is providing enough information to
a competent person to allow that person to make a decision in
his or her best interest. Physicians, like everybody else, tend
to focus on that segment of life with which they are most familiar
and most concerned. Ophthalmologists know about the eyes and what
damages the eyes, and have as a top priority preservation of the
health of the eyes and of vision. The individual patient is appropriately
focused on what he or she considers best for himself or herself.
The individual's goals and priorities may differ from those attempting
to advise or help the individual, even when the helper is sincere.
Thus, the individual patient should become knowledgeable and should
take appropriate control over decisions that affect his or her
well-being.
Getting the Best Results
The use of any eye drop is going to introduce
some side effect. The side effect may be as minimal as
temporary blurring of vision, or as maximal as causing the person's
death. Because each individual person reacts uniquely, it is impossible
for the physician to predict accurately how any individual person
will react to a medication. The conclusion might then be that
it is, therefore, impossible for a physician to give the patient
adequate information to make appropriate the decisions.
But there is a solution to this apparent dilemma.
The physician can help patients understand their uniqueness, and
their right and their need to make decisions themselves. Because
side effects cannot be accurately predicted, it is essential that
the patient know that side effects cannot be accurately predicted,
and for the patient to be alert to the possibility of all sorts
of side effects and to pass concerns on to the physician, so that
there can be a discussion of whether it is likely it is that the
medication is causing the concern, and what would be the next
appropriate steps to get the information necessary to permit an
informed decision about what to do next: Should the medication
be discontinued; should it be modified; should a new medication
be substituted; should it be continued; what are the risks of
stopping the medication; what are the potential benefits of stopping
the medication, etc.
There are now many highly effective medicines
to use for the treatment of glaucoma. For some patients, it is
appropriate and in their best interest to be treated with medicines;
for some patients, medicines need to be combined with other treatments.
For yet other patients, the treatment of their glaucoma is best
accomplished without medications, either because other approaches
are more likely to be successful, or because the side effects
caused by the medicines are not warranted in view of the potential
benefits.
In every situation, the most appropriate decision
is worked out by an open, honest, and ongoing communication between
the doctor and the patient.
Wills
Eye Hospital Increases Support for Glaucoma Research at the Hospital
The Board of City Trusts, the governing body of Wills Eye Hospital,
meeting in June, committed $1 million to endow research in glaucoma
at Wills. Applauding the Hospital's resolution, Dr. George Spaeth,
President of the Glaucoma Service Foundation to Prevent Blindness,
noted the great impetus these funds will give to the Foundation's
fundraising efforts. He estimates that, in addition to yearly
operating costs, endowment funds of $8 million will be needed
to fund an entity capable of fully realizing the potential for
glaucoma research at the Hospital.
In further shows of support,
the Hospital also earmarked for glaucoma research funds raised
by The Wills Eye Hospital Annual Ball this year, and Alice Lea
Tasman, on behalf of Wills, organized a corporate donor reception
in early October.
Foundation President Dr. George Spaeth provides details of the
glaucoma research under way at Wills at a corporate donor reception
organized by ALice Lea Tasman.
Photo by Bob Curtin
Accolades for Foundation President
Foundation President Dr. George
Spaeth was presented the Derrick Vail Award by the Illinois Ophthalmological
Society in September. This award is given only once each 5 years
to the individual the Society believes has contributed most to
ophthalmology during the preceding five years. The award was given
to Dr. Spaeth because of his work in glaucoma and ethics. Also,
in October, Dr. Spaeth spoke as the Guest of Honor at the 50th
Annual Meeting of the Japanese Ophthalmological Society in Kyoto,
Japan, and was voted one of the country's best ophthalmologists
by the Chairs of the Departments of Ophthalmology in the United
States.
Research Fellows Shine
Research Fellow Tarek Eid has taken on the responsibility of
coordinating the Foundation's research program. In a recent report
Dr. Eid outlined 18 ongoing projects, 9 studies to be initiated,
and 12 investigations completed or nearing completion. Dr. Eid's
own research was selected for presentation at the American Academy
of Ophthalmology's recent annual meeting in Chicago.
The Lions Eye Bank of Delaware
Valley awarded Research Fellow Dr. Lavkumar Panchal $15,000 to
conduct a study on the relationship between myopia and glaucoma.
Dr. Panchal's poster on the subject also was selected for presentation
at the American Academy of Ophthalmology's annual meeting.
Glaucoma Service Fellows (left to right) Tarek Eid, Augusto Azuara,
and Lavkumar Panchal in the WIlls Library.
Photo by Jamie Nicholl
Glaucoma Support Group Meeting
The next meeting of the Foundation-sponsored
Glaucoma support group will be on Sunday, January 12th, 1997,
from 3:00pm to 5:00pm, in the Glaucoma Service (third floor) of
the Wills Eye Hospital. The meeting is free and refreshments will
be served.
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