Glaucoma Awareness
Chat Highlights
January 9, 2002

Norma Devine, Editor

On Wednesday, January 9, 2002, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma Awareness."

Moderator:  Welcome, Dr. Rick.  The topic tonight is "Raising Glaucoma Awareness."  January is Glaucoma Awareness Month.  

P:  Is there a glaucoma awareness group that promotes knowledge of the disease?  I recently saw a TV show where that was mentioned.  I think that is a good way to educate people.

Dr. Rick Wilson:  Yes, the American Academy of Ophthalmology (AAO) is promoting glaucoma awareness, especially among those most at risk:  family members, African Americans and the elderly.

P:  Over the years, what have you seen as the most successful ways to raise awareness of glaucoma?  

Dr. Rick Wilson:  When famous people are known to have glaucoma, that is the greatest boon for glaucoma awareness, especially if they talk about it.

P:  Is the actor Harry Belafonte the spokesperson for the International Glaucoma Association?

(Note:  The IGA (http://www.iga.org.uk/) is a registered charity which offers advice and support to glaucoma sufferers, campaigns for improved glaucoma services for glaucoma patients and greater public awareness of glaucoma.)

Dr. Rick Wilson:  Belafonte has retinal problems and is the spokesperson for Eye Care America, the Glaucoma Project. (http://www.unitedwaydenver.org/iris/4n0hhz8v.htm) John Glenn, who has glaucoma, is the spokesperson for the National Eye Care initiative.  (http://www.laurelhs.org/guideline/ax0xig9k.htm)  You should have seen him on television.  I understand Bill Cosby has glaucoma.  

P:  How about Kirby Puckett?

Dr. Rick Wilson:  Kirby Puckett, a Hall of Fame baseball player from the Minnesota Twins, had to quit playing baseball because of vision problems in one eye caused by glaucoma.  Most sports fans knew about him.

P:  My father-in-law is an example.  He refused to use his glaucoma eye drops regularly until Kirby Puckett had to leave major league baseball.  That made an impression on him.

P:  Do you know of other famous people with glaucoma?

Dr. Rick Wilson:  We mentioned John Glenn, Bill Cosby, and Kirby Puckett.  I have seen a Broadway star, but professional ethics prevent me from saying her name.  George W. Bush, Sr., had trabeculectomies in both eyes.

P:  Is there some kind of screening test?

Dr. Rick Wilson:  You may have heard of the OcuGene^tm test.  It is claimed to identify many people who will get glaucoma.  What isn't mentioned is that it will only pick up fewer than four percent of the people who will later develop open-angle glaucoma as adults and less than six percent of those who will develop juvenile glaucoma.  In my view, that's a small return for the $200 cost. 

(Note:  OcuGene^tm is the brand name for the ISV-900 test, the commercialized genetic test that screens for the presence of the promoter region mutation and several coding region mutations of the TIGR gene.  The presence of mutations in the coding region has been associated with a greater likelihood of developing the disease.)

P:  Is screening of any kind effective?

Dr. Rick Wilson:  As it turns out, just screening for glaucoma, even when done by ophthalmologists, is inefficient and a poor use of limited resources.  That is why the latest Eye Care America project is concentrating on those who are already at high risk -- to get them seen.

P:  If a primary care physician had two minutes to screen each of his patients for glaucoma, what would you advise him to do, other than write a referral to an ophthalmologist?

Dr. Rick Wilson:  Give the patients the brochure by Eye Care America -- The Glaucoma Project that describes for patients the risk of developing glaucoma.  

Circle one number in each category:

• I am less than 50 years old.   0
• I am 50 to 64 years old.   1
• I am 65 to 74 years old.   2
• I am more than 75 years old.   3

• I am African American.   2
• I am Spanish American.   1
• I am not one of the above.   0

• None of my immediate family (i.e. parents or siblings) has glaucoma.  0
• One or both or my parents has glaucoma.   2
• One or more of my siblings has glaucoma.   2
• One or both of my parents and one or more of my siblings has glaucoma.   3

• Within the past two years. 0 
• Between two and five years ago. 1 
• More than five years ago. 2 

Total Score
Then your risk for glaucoma is:  4 High;  3 Moderate;  2 Low

P:  How effective are the glaucoma screenings in malls?  

Dr. Rick Wilson:  Those glaucoma screenings have many false positives; that is, too often they "detect" glaucoma where it doesn't exist.  

P:  If air-puff tonometers are used, they are unreliable.

P:  Most of the time when people hear about glaucoma, they think of high intraocular pressure.  What percent of people have normal-tension glaucoma?  

Dr. Rick Wilson:  One out of six patients with open-angle glaucoma have normal pressures.  

P:  How can we convince Medicare and HMOs that visual field tests are needed even in the absence of high pressure?

Dr. Rick Wilson:  The only way is to have hard study data on how frequently visual field tests are needed and apply public pressure.

P:  My HMO has been paying for my visual field test every six months.

P:  My HMO has paid for my visual field test every three to six months with no problems.

Dr. Rick Wilson:  You have a good HMO.

P:  Do you think U.S. public interest and awareness about glaucoma are less than they might be because glaucoma disproportionately affects African Americans?

Dr. Rick Wilson:  To some extent, yes.  Older Hispanics also are disproportionately affected.

P:  You said high-risk patients should be screened.  Do you mean middle-aged African Americans and Hispanics?  

Dr. Rick Wilson:  Yes.  

P:  Are women disproportionately affected, too?

Dr. Rick Wilson:  Yes, but not nearly to the same extent.  (Note: At the end of this chat highlight you will find some epidemiological information.) 

P:  I think a lot of people just think glaucoma is no big deal.  I have a friend who has an intraocular pressure of 25 mm Hg, was put on drops, but could not tolerate them.  The doctor told her to return in six months for a pressure check, but she didn't.

Dr. Rick Wilson:  One study I saw reported that 25 to 40% of patients who turned in a prescription for their first glaucoma medication at a pharmacy never picked it up.

P:  The reason some people do not pick up prescriptions is probably sticker shock when they see the price for the little bottles of medicine.  I was shocked -- and my HMO paid for it.

Dr. Rick Wilson:  I agree.  It is very difficult for patients on a fixed income to pay for the medication.  However, as someone with arthritis in my knees, I have mixed feelings.  I want the pharmaceutical company to make enough money to plow their profits back into research for better medications.  If all prices were at the generic level -- i.e.,  cost plus small profit paid to stockholders and no research, then there would be no new medications.

P:  Do you think non-compliance with medications is worse for glaucoma than for other (painless, non-acute) conditions?

Dr. Rick Wilson:  Yes.   It's a huge problem.  People with glaucoma often can't tell whether they have the disease, and when they take the medication they can't tell that it helps them. It's not like taking anti-acids for upset stomach or antibiotics for a cold.  The doctor has to tell glaucoma patients whether or not their medication is working.  

P:  That is so true.  When I was a teenager I thought, "Do I really need these drops?"  Luckily, I had a great family who made sure I took my drops.  I read of someone who was not as lucky.

Dr. Rick Wilson:  When I see a new baby with glaucoma, the first thing I look at is the family. Without good family support, the baby's chances of seeing well as an adult are greatly reduced. 

P:  How often are medicine costs factored into treatment decisions?  I saw a study from Brazil where the patients preferred pilocarpine because it's the cheapest of the drugs.

Dr. Rick Wilson:  I often ask patients if cost is an issue and then it does affect my prescribing.

P:  Don't you give samples when you're starting a patient on a new drop?

Dr. Rick Wilson:  Yes, but you need to be sure that they can continue on the therapy if it is effective.

P:  Why will Social Security pay for meds for some diseases but not for glaucoma?  

Dr. Rick Wilson:  I don't know.  

P:  It is so sad to think people do not get medicine in the U.S. because of costs.  We are fortunate in Canada.  People 65 and over receive their medication free. 

Dr. Rick Wilson:  True, but Canadians and Europeans don't pay for the research and development that goes on. Without the high costs that Americans pay, research would dramatically slow down.  It's a real double-edged sword.  

P:  Dr. Rick, here in Canada we have a 20-year patent protection for drug companies.  We do pay for it.  

P:  Is my homeoatropine cheap because it is not a popular drug?

Dr. Rick Wilson:  No.  It's cheap because it has been around way too long to be under patent protection, and it is cheap to make. Drugs that are not popular face an uncertain future, because the company may not have enough of a market to make the medication profitable. These drugs are often called "orphan" drugs.

P:  Are there any promising new medications in the works?

Dr. Rick Wilson:  None in the very near future, but new classes in the future that may be dramatically better than those that have gone before.

P:  My eye doctor has a chart showing the progression of glaucoma on the optic nerve in 10 steps.  I think the chart was by a drug company.  Do you know which one?  

Dr. Rick Wilson:  No, I don't.  I think Merck put one out way back, but I can't be sure.  I must leave now.  You can check out the epidemiology information below.  Good night, everyone.

Note:  Two and a half million Americans have glaucoma; half are unaware of it.  Approximately 130,000 Americans are blind (best-corrected visual acuity less than or equal to 20/200) from primary glaucoma.  It is the second leading cause of blindness overall (U.S.A.)

African Americans are four times more likely to have the disease and six times more likely to be blind from it.  They are half as likely to be treated for it.  African Americans are usually diagnosed 10 years earlier than whites and are 14 to 17 times more likely to go blind between the ages of 45 and 65 than Caucasians.

Five to seven million people worldwide are blind from all types of glaucoma. Glaucoma is responsible for 15% of world blindness, after cataract and trachoma.  For example, in Nigeria, 10% of  the population has glaucoma.  Of that 10%, 91% are unilaterally blind; 34% are bilaterally blind.  High intraocular pressure/glaucoma is a marker for decreased life expectancy.  (Glaucoma survey of general population by age:  40-49, 50-59, 60-69.)

End of highlights for January 9, 2002.

On January 16, Dr. Wilson discussed "Insurance and Glaucoma" in the Chat room. Click here for highlights of that meeting.

Click here for the most recent glaucoma chat highlights and links to the chat archives.

Click here for upcoming glaucoma chat events.