Glaucoma, The Big Picture
Chat Highlights
September 11, 2002

Norma Devine, Editor

On Wednesday, September 11, 2002, Dr. Courtland Schmidt, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma, The Big Picture."

Moderator:  The topic tonight is "Glaucoma, The Big Picture."

Dr. Courtland Schmidt:  I thought we could have a wide-ranging chat about glaucoma treatment of all kinds.

Moderator:  Do you have any opening comments, Dr. Schmidt?

Dr. Courtland Schmidt:  I don't think it's always clear to patients what a given doctor's philosophy about treatment is.  I can lay mine out, or respond to questions.

P:  Please tell us about your philosophy first.

Dr. Courtland Schmidt:  I feel my job is to give patients the pros and cons of various treatments, so they can make the decision that is best for them.  There is often no one best way, and different patients have preferences about medications, surgery, etc.
Some patients want to have a great deal more proof than others about progression before changing therapy.  Others are so afraid of any small change they will accept treatment risks sooner.

Moderator:  Does age play a role in what course of treatment you would suggest? 

Dr. Courtland Schmidt:  The time frame to preserve vision is very important.  If a patient needs to preserve vision for 80 years, as with an infant, treatment must be more aggressive.  Conversely, I have 85-year-old patients who have elected minimal, if any, treatment, because if you have to live to be 110 years old to be blind, who cares?  And why expose such elderly patients to the risks of overly aggressive treatment?

P:  Please explain what you mean by aggressive treatment versus minimal treatment.  Do you mean surgery sooner for younger people?

Dr. Courtland Schmidt:  I don't necessarily do surgery sooner for younger people.  It sounds trite, but you want to individualize the treatment to the patient.  In general, if glaucoma can be controlled medically, that is preferable to surgery, in my view.  Laser is often less helpful, though, in younger people.

P:  Sorry, I still don't understand what you mean by aggressive treatment versus minimal treatment.  Could you please give an example?

Dr. Courtland Schmidt:  I have an 80-year-old patient with a pressure of 35 mm Hg, who is slowly getting worse in one eye.  He can't tolerate drops, and laser didn't work.  He has had four heart attacks, and can barely walk up ten steps.  Why should I expose him to the risks of surgery if he will not lose enough vision in ten years to notice the loss?  I might even kill him if he had another heart attack on the operating table.  Minimal treatment is more likely to preserve his OVERALL quality of life, rather than aggressive treatment.  

P:  Do you consult a patient's family doctor or specialist?

Dr. Courtland Schmidt:  I ask patients how old their parents were when they died, and try to assess the patients' overall health with risk factors, such as diabetes, hypertension, smoking, obesity, etc.

P:  What are the negative long-term effects of mitomycin C (MMC) in children? My son has not had any problems in over 2 1/2 years, but I keep hearing people say there are problems with it.

Dr. Courtland Schmidt:  The negative effects for the eye possibly include IOP (intraocular pressure) that is too low and risk of infection.  We carefully weigh the risks and benefits of MMC in kids because of such problems.  On the other hand, if blindness might result from not using MMC, you have to take the risk.

P:  Why don't doctors usually tell patients when they will probably go blind if the disease continues to progress? 

Dr. Courtland Schmidt:  Because we don't know.

P:  How often does glaucomatous damage occur in one eye, but not the other, and does this differ for NTG (normal-tension glaucoma) patients?

Dr. Courtland Schmidt:  Glaucoma damage is more often present in both eyes than in just one, although it can be very asymmetrical.  The degree of asymmetry in NTG can be quite marked, possibly due to differing blood flow between the two eyes.  However, no one is sure.  It's relatively rare to have one eye with no glaucoma at all; it's more common to just have much less in one eye.   

P:  I am 20 years old and have had glaucoma for five years, with pain and headaches.  I can barely read print, and use a seeing-eye dog to get around.  My glaucoma is stable now, but if it gets worse, my doctor says surgery would not help me, because of my other eye conditions.  If I have to contend with glaucoma the rest of my life and I am in pain all the time, is it feasible for me to continue treatment?  

Dr. Courtland Schmidt:  I firmly believe that each patient gets to decide whether the side effects of a given treatment are acceptable to him or her.  It's the doctor's job to list the pros and cons of the various options, and it's the patient's job to let the doctor know what is tolerable and what isn't.

P:  If a patient doesn't know when he or she will probably become blind, how can he or she choose the best treatment? 

Dr. Courtland Schmidt:  Just out of curiosity,  do many of you feel that the risks of treatment are adequately addressed by doctors?

Moderator:  No.  Not my local doctor, anyway.

P:  I do, but I've only been diagnosed with glaucoma for a year. 

P:  No! 

P:  No, I do not.

P:  Absolutely not.

P:  My doctor wanted to put me preventively on drops without a real cause.  

P:  No.

P:  Yes, but only by some of them!

P:  Yes.

P:  No.

P:  I think my child's pediatric ophthalmologist has been straightforward about the risks.  

P:  I think glaucoma specialists are more likely than ophthalmologists to describe the risks.

P:  No.

P:  Absolutely not.  I have never once been told what the side effects are of the drops I am taking. When I do tell my doctor  about the side effects, he never says anything. The only thing he did discuss was the risk of surgery for a patient who has had so much damage.

Dr. Courtland Schmidt:  I think that neither doctors nor patients like it, but risks are a fact.  We ignore that fact at our peril, because doctors can't make the risks go away; they can just keep you aware of the possibility.

P:  I have learned much more here than from my glaucoma doctor.

P:  You are right!  Guess that's why we tune in.

P:  Doctor Schmidt, your philosophy is wonderful.  I wish more doctors shared it. 

P:  Do you need to see a certain amount of visual loss before you decide on surgery?

Dr. Courtland Schmidt:  No, as always it is just using the best judgment about risks and benefits for that particular patient.

P:  The scleral expansion band procedure (originally developed to treat presbyopia) has had equivocal results.  Is there any new information about its use to reduce intraocular pressure? 

Dr. Courtland Schmidt:  I have not seen anything convincing in this regard, but have to admit that I have not been following it carefully.

P:  If a patient has glaucoma and uveitis, should both conditions be treated by a glaucoma doctor, or by a uveitis specialist and a glaucoma specialist? 

Dr. Courtland Schmidt:  That depends on each doctor's comfort level with the other disease.  For example, I would treat simple uveitis myself, but would quickly involve a specialist if the response were poor.  It is probably a rare glaucoma specialist who knows as much about uveitis as a uveitis specialist, and vice versa.

P:  What sort of discomfort and pain is associated with glaucoma?  I have been using drops for years, but only recently have I started losing vision in one eye. That eye tires easily and is uncomfortable all the time.  I am just beginning to explore the risks.  I think my doctor is open with me.  

Dr. Courtland Schmidt:  Glaucoma itself usually involves no discomfort or pain, except in rare, acute cases.  Treatment with drops or surgery can make the eye uncomfortable.  Tiring easily is usually not glaucoma related, unless only a tiny bit of vision remains. 

P:  I just saw my glaucoma specialist on Monday.  I told him of the horrible migraines I have almost continually now.  He never said one word to me, but went outside the room to discuss why I was having migraines with the young intern he had with him.  He must have forgotten I wasn't also deaf.

Dr. Courtland Schmidt:  You should ask your doctor to repeat his comments to you.  That may or may not clue him in to his bad habit.

P:  I'm curious.  How much time do you spend with a patient?

Dr. Courtland Schmidt:  Between one minute (for a post-laser pressure check) and 45 minutes (for a complicated problem).  I have been known to say to a patient, "I can give you all the time you need, but not all the time you want."

P:  I have learned a lot from this web site. When I went to my new doctor, he was impressed with the questions I asked.  Since I asked about the memantine study, he asked if I would like to participate in the study.  I am waiting for final approval.  It will be a five-year study and 75% of the participants will get the medicine and 25% will get a placebo.  Can you tell me more about the research being done?

Dr. Courtland Schmidt:  Memantine is an attempt to protect the optic nerve.  The groups will be compared to see if it is neuroprotective.  We eagerly await the results of this and other studies about neuroprotection.  

P:  If you are taking memantine (let's say that it does work), would it still be necessary to lower the IOPs?

Dr. Courtland Schmidt:  Probably a combination of protecting the nerve and lowering IOP would be best, but we'll find out over the next 5 to 20 years!

P:  Is there a way doctors note how an optic nerve looks during each visit?  My doctor says he sees no change to the optic nerve in the damaged eye, but how can he remember four months later what it looked like?  

Dr. Courtland Schmidt:  He is either drawing the nerve, writing notes about it, taking a picture of it, using a scanning laser to map the contour, or some combination of those.  In my opinion, a drawing is not sufficient.  Optic nerve photographs as a baseline are a must.

P:  Would you prescribe Xalatan for closed-angle glaucoma?

Dr. Courtland Schmidt:  Has an iridectomy been done?

P:  Yes, along with a trabeculectomy.

Dr. Courtland Schmidt:  Then Xalatan is probably a good choice, if the trabeculectomy function isn't all that could be desired.

P:  What does seeing a ring around lights indicate?  

Dr. Courtland Schmidt:  Rings around lights can indicate high eye pressure with corneal edema, but can also be a refractive error or even early cataract.

P:  I have been a normal-tension glaucoma suspect for two years now, and only today began compiling copies of my visual field tests for myself.  I have one traditional test and three blue on yellow tests taken over two years.  I was shocked to see that I have increasingly gray areas in the central part of my tests, where the crosshairs are.  While the blue on yellow report still says "within normal limits," I see expanding and darkening squares along the horizontal line and under it.  I think my doctor is perhaps not comparing all of these tests, or is just looking at the GHT (Glaucoma Hemifield Test) report that says "within normal limits." Could it still say this, yet be worsening?  Remember, it's the blue on yellow test I'm taking, since no one knows if I actually have glaucoma or not.  My optic nerve looks healthy.

Dr. Courtland Schmidt:  Visual fields are a land mine.  The best advice I can give you is to take all of the tests to your doctor and ask if he or she thinks you are missing any visual field and whether it's changing.  The paracentral area is often where NTG patients lose field, but this could just as well be fluctuation. 

P:  Would HRTs (Heidelberg Retinal Tomograph) be sufficient if photos and laser mapping are not being used?  I feel under- photographed after what you said! 

Dr. Courtland Schmidt:  I still feel good photos are the gold standard.  I get a baseline HRT and photos for everyone, then HRT at yearly intervals and photos at four to five-year intervals.  (We hope the HRT will pick up changes sooner than photos can.)  For baseline, though, if I could have only one, I would take photos.

P:  The photos taken of my optic nerves are very fuzzy.  Is it important to have sharp images, and how can one ensure that?

Dr. Courtland Schmidt:  You need to have the best quality image you can get.  Assuming no cataract or corneal damage, most people can get good photos.  

P:  Are there many (or enough) surgeons who perform trabeculotomies?  Is it a more difficult surgery to perform than a trabeculectomy?

Dr. Courtland Schmidt:  As with most surgical procedures, doing more of them makes you better. Even most glaucoma specialists don't do many trabeculotomies.  Technically, it's not much more difficult than a trabeculectomy, if you know what you are doing.

P:  I'm a 37-year-old white female.  I found out I had glaucoma a year ago.  My IOP is 27 mm Hg and I was  put on Lumigan.  My doctor said I have just a little damage in my right eye and no damage in the left.  I will be taking my yearly HRT test on Friday.  I have noticed a gray area in the right corner of my eye, which I think is getting worse.  If that's so, do you think I should have a change of eye drops or surgery?  

Dr. Courtland Schmidt:  If you think you are getting worse, make sure you tell your doctor and make him or her prove to you through visual field tests, etc., that you are not.  If you are getting worse, more drops would probably be the next step, if you can tolerate them.

P:  What color should the optic nerve be?  My doctor said mine is white.  

Dr. Courtland Schmidt:  The usual optic nerve color is a pinkish orange, and white often indicates damage, as a general rule.  That being said, optic nerves have as much variability in appearance as people do, and the most important thing is that the appearance doesn't change, since this almost always indicates a lack of continuing damage.

P:  My doctor says my optic nerves are small.  What does that mean?  

Dr. Courtland Schmidt:  Small optic nerves mean just that.  One consequence of small nerves is that glaucoma damage is harder to see if it occurs.

P:  I have small eyes and small nerves and have had closed angles, aqueous misdirection, and multiple operations.  My local doctor says I now have ocular hypertension. 

Dr. Courtland Schmidt:  Often, small nerves have little if any cup, so there's likely to be more damage before it's noticed, if not watched carefully.  

Moderator:  Thank you so much for all your many answers, Doctor Schmidt.  

Dr. Courtland Schmidt:  You're welcome.  Thank you all for participating.  Good night.

End of highlights for September 11, 2002.

On September 18, Dr. Henderer discussed "The Optic Nerve" in the Chat room. Click here for highlights of that meeting.

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