Stress and Glaucoma
Chat Highlights
July 20, 2005

On Wednesday, July 20, 2005, Dr. Elliot Werner a glaucoma specialist, and the glaucoma chat group discussed "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.

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?

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.

On July 27, Dr. Wilson discussed "The Glaucoma Suspect" in the Chat room. Click here for highlights of that meeting.

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