Overcoming Treatment Challenges in Glaucoma
Chat Highlights
January 25, 2006

On Wednesday, January 25, 2006, Dr. Jeff Henderer, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Overcoming Treatment Challenges in Glaucoma."

Moderator:  Dr. Henderer, tonight we would like to discuss how you overcome the challenges of patients' glaucoma treatment.

Dr. Jeff Henderer:  That's a tough topic.

Moderator:  What are some of the challenges you face?

Dr. Jeff Henderer:  Well, I guess there are challenges that are big and small. Big challenges would be things like 50% of the people with glaucoma don't know they have it. And that's in developed countries. Smaller challenges would be things like many people don't use their eye drops as they should.

Moderator:  Should we start with the big challenge of helping people who do not know they have glaucoma?

Dr. Jeff Henderer:   How do we get people to be interested in their own care to get them to the doctor and then to get them to use the drops?

Moderator:  Yes.

Dr. Jeff Henderer:   Screening for glaucoma is one of my principal interests. We have developed a pretty good screening protocol, but it turns out that only about 20% of those whom we feel need follow up actually get follow up.

Moderator:  I am helping to form a new organization, Association of International Glaucoma Patient Organizations (AIGPO), to help people in other areas of the world start support groups.

Dr. Jeff Henderer:   I think that is great. But we are preaching to the choir here. We need to get the message to all those who aren't participating tonight. Harry Quigley, a famous glaucoma doctor at Johns Hopkins, suggests that the place to start is with the members of each glaucoma patient’s family. That would be great!

Moderator:  Do most of those who attend the screenings see an eye doctor when that is recommended?

Dr. Jeff Henderer:   It seems that the people who attend the screenings are aware of the problem of glaucoma and have access to a doctor, but choose not to go. I'm not sure why.

P:  They need to receive a phone call asking if they have made an appointment with a doctor.

P:  What do you mean by a "screening"?  Is that an eye examination or a series of questions asked to assess risk factors?

Dr. Jeff Henderer:   We go to a location, usually senior centers, where there are likely to be glaucoma patients. We test vision, intraocular pressure, look at the optic nerve, test the visual field, and inquire about a family history of glaucoma. We then make a recommendation.

Moderator:  Do you have a van with equipment in it?

Dr. Jeff Henderer:   Usually, I just drive my car. But others are also interested in screening for glaucoma. For instance, Friends of the Congressional Glaucoma Caucus Foundation has been instrumental in promoting screenings. They have vans equipped for mobile screenings. In fact, we just held a screening last Saturday at a community center in Delaware.

P:  Would screening improve if more optometrists used a tonometer, rather than the puff test, to check the intraocular pressure?

Dr. Jeff Henderer:   It turns out that screening using eye pressure alone is like flipping a coin. It's not very useful to identify glaucoma cases. The best way to screen, in my opinion, is to look at the optic nerve, just as we do in the office. That might be tough to do, because of the inherent difficulty of such an exam, but it is the best way.

P:  Perhaps what is needed is more public awareness through intensive advertising campaigns, such as those used to encourage people over age 50 to have a colonoscopy or women to have annual mammograms.

Dr. Jeff Henderer:   You are right that other diseases get good publicity. Glaucoma really doesn't. We are working on that through the Foundation, which does the public relations' work. Dr. George Spaeth will be on TV next week on local Channel 8.

P:  It's too bad the audience will be so limited for Dr. Spaeth's appearance on TV.

P:  Most glaucoma patients are asymptomatic until a considerable amount of visual field loss occurs. What percentage would be caught faster by screening; that is, between the time optic nerve damage begins and visual field damage shows up?

Dr. Jeff Henderer:   It is probably too much to ask to diagnose the patients with very, very early glaucoma. There is just too much overlap between normal and early disease. We would probably do better by finding those who are further along in the course of the disease. Remember, the more sensitive you make a test, the more likely you are to call normal people diseased. That comes at a big emotional and financial price. We have to balance screening for glaucoma with screening for other diseases, too. That's what the city of Philadelphia said to me. "Fine. We'll screen for glaucoma, but then we can't screen for diabetes." How was I going to argue with that? There is only so much money.

P:  Dr. Henderer, many of the patients here tonight who are in their 50's thought glaucoma was a disease of the elderly.

Dr. Jeff Henderer:   Excellent point. Glaucoma can occur at any age. Most of the time the risk for glaucoma starts to go up as the reading vision begins to wane, around age 40 or so. That means people will be heading to the eye doc anyway, so we can examine them for glaucoma then. Family history plays a big role in identifying those who may develop the disease earlier in life.

P:  Isn't the kind of glaucoma seen in older people (60 and up) likely to progress slower than in people under 60 years of age? If so, why not push to screen the younger group?

Dr. Jeff Henderer:   I agree that it does seem as if glaucoma can be more aggressive in young people. But it is so uncommon in this group that it is like looking for a needle in a haystack. You end up finding a lot more sharp straws than actual needles.

P:  Patient compliance must be a challenge for eye doctors. How, besides checking on patients' prescriptions, can you tell if they are being compliant?

Dr. Jeff Henderer:   Well, most drops cause redness of the eye. When I see a patient whose eyes aren't red, I get suspicious. Other than that, it's tough to know. Remember, the people who go to the doctor are by definition more likely to comply. It's the people who don't come back that concern us more.

P:  Besides early detection and lack of compliance, are there other treatment challenges you encounter?

Dr. Jeff Henderer:   Probably the next most common situation is the patient who does not respond to medication. Sometimes changing drops can help and sometimes you have to consider surgery. I should also mention that we constantly struggle to assess progression of the disease. That is a rather poorly defined term. Sometimes it can be a real challenge to assess progression. Now, if there's a family history, then those people should be screened. That's why I try to mention to my patients that their children and siblings should be examined.

P:  Do patients who have difficulty controlling their glaucoma become stable, or do they always have that problem?

Dr. Jeff Henderer:   I suppose I have selective memory about that. It seems to me that tough glaucoma is tough. Not exactly sure why that is. Some work done in France not too long ago found that people with a certain gene mutation were less likely to respond to medication and usually needed surgery. We're still learning about that.

P:  What do you think of having newborn babies screened for primary congenital glaucoma so that pediatricians can diagnose glaucoma at birth and start treatment?

Dr. Jeff Henderer:   I am in favor of knowledge. There is no question that treating congenital glaucoma early in life is critical to permitting vision to develop. Anything that helps identify those who have disease is useful in my book.

P:  Do you consider allergic reactions to medications and/or the BAK preservative used in many drops a treatment challenge? How often do you encounter that kind of problem and how do you deal with it?

Dr. Jeff Henderer:   I sort of put this in the "not responding to meds" category, although obviously there is a difference between "not able to use" and "does not lower eye pressure." Often that problem cannot be overcome. You might try drops with other preservatives (Alphagan P) or less BAK (Lumigan) or you might try non-preserved drops (timolol or pilocarpine) or you might have to consider surgery.

P:  Have you ever had to deal with a patient who developed Stevens-Johnson syndrome, where reaction and tissue destruction were severe? [Editor's Note: Stevens-Johnson syndrome typically involves the skin and the mucous membranes.]

Dr. Jeff Henderer:   I have not seen Stevens-Johnson syndrome.

P:  The number of treatment challenges facing us glaucoma patients seems to be overwhelming. They include finding which, if any, medications work and coping with their side effects; worrying about surgery and the complications and potential for failure; progression of glaucoma despite the doctor's best efforts. The challenges for us never seem to end.

Dr. Jeff Henderer:   That is true of any chronic disease, from high blood pressure to diabetes. I guess we can all be thankful that we have a wider variety of medications, with generally fewer side effects. Surgical techniques are improving, new things are in the works and, for most people, glaucoma is a slowly progressive disease.

Last weekend I read in the Philadelphia newspaper about a researcher who tried to find out what made highly successful people successful. Is it brains? Money? It turns out that the common denominator is the will to win. It's those who try the hardest that often come out on top, which is why chat rooms like this one are so valuable. This chat room offers support to keep up the fight.

P:  Good analogy. Glaucoma is a life-long battle!

P:  Does the increasing number of glaucoma patients having access to medical information on the Internet make treating them more or less challenging?

Dr. Jeff Henderer:   I welcome informed patients. It means I can communicate better with them. Unfortunately, the Internet does not really permit rational ranking of things. For instance, serious effects are rare, but bad things get a lot of attention. In general, I'm in favor of patients' having knowledge.

P:  Which test is the most accurate for measuring IOP (intraocular pressure)?

Dr. Jeff Henderer:   The most accurate test is still Goldmann applanation tonometry. The new version of that, called DCT (dynamic contour tonometry) might be better, but Goldmann is still the gold standard.

P:  Is trabeculectomy performed any differently today than, say, 30 years ago?

Dr. Jeff Henderer:   Yes! It turns out that we have a better understanding of everything from operative anesthesia to wound construction to the use of anti-scarring agents. It is far from perfect, but it is much better. We always are looking for improvements.

P:  Do you have any information on the new vaccine being developed for glaucoma?

Dr. Jeff Henderer:   I know that there is some work in Israel that suggests glaucoma may be an autoimmune disease. Others have also found evidence of this. The vaccine is an attempt to prevent this autoimmune process. As far as I know, there is evidence in animal models, but no evidence in human beings that the vaccine is helpful.

P:  What questions should a glaucoma suspect ask at the first appointment with a glaucoma specialist?

Dr. Jeff Henderer:   Well, the most fundamental questions are: "Why am I a suspect? Is it my optic nerve, my intraocular pressure, my visual field, or my family history?" Then you will know what to follow more closely.

P:  If SLT (selective laser trabeculoplasty) lives up to the hype, do you think it will be applied as primary treatment for glaucoma?

Dr. Jeff Henderer:   Yes, that will probably become more common. But some people don't have open angles and some just don't respond to laser. Don't forget that there isn't any evidence, that I'm aware of in the peer-reviewed literature, that SLT is a repeatable procedure. We'd sure like it to be, but I'm not aware of any studies indicating that it is.

P:  Do you think that fewer than the usual number of 50 spots (180 degrees) used in SLT may turn out to be more than actually required for many glaucoma patients?

Dr. Jeff Henderer:   I don't know. I think there are too many ways people are doing SLT to get any clear handle on this. I like to treat 270 degrees, but I have no evidence to support my approach. But it saves some space for later.

Moderator:  That hour flew by. Thank you, Dr. Henderer.

Dr. Jeff Henderer:   Thanks, everyone. I hope this has helped. Keep up the hard work!

On February 1, Dr. Wilson discussed "Complications Accompanying Shunts" in the Chat room. Click here for highlights of that meeting.

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