Common Mistakes Patients Make
Chat Highlights
March 8, 2006

On Wednesday, March 8, 2006, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Common Mistakes Patients Make."

Moderator:  Tonight the topic is “Common Mistakes Patients Make.”  What is the most common mistake patients make?

Dr. Rick Wilson:    The most common mistake patients make is probably not taking their drops consistently and persistently over the years.  Several studies have pointed out that the fluctuation in IOP (intraocular pressure) that occurs naturally in everybody, but to a greater extent in glaucoma patients, is a risk factor for progression.  Patients who do not take their medications spread out evenly over the day, day to day, just make that fluctuation worse.

P:  Is anything being done to help patients improve compliance with taking eyedrops?

Dr. Rick Wilson:   Yes.  Alcon Inc, which supports the Glaucoma Service Foundation Website with an educational grant, just came out with a compliance monitor.  The dropper bottle is placed in the monitor and gives a warning when the next drop should be taken. It also records whenever the lever to release a drop is squeezed.  When the patient returns to the doctor, he or she brings the monitor along.  The doctor puts the monitor in a holder and downloads data to a computer about each time the patient took the medication.  That provides a complete record of the patient's compliance with instructions.

What do you patients think about that?  Would you consider the monitor a help?  An invasion of privacy?  Would you bring the monitor back to the doctor?

Moderator: I would, if I am ever on drops again.

P:   I would.  Maybe it would convince him that I AM taking my drops.

P:   I would use it.

P:   I would use it, too.

P:   I think it would be a waste of time, except for those not willing to take responsibility for their own health.  Wouldn't the patients who need it the most be the least likely to use it?

P:   It does seem like an invasion of privacy, but not so bad if it's optional.

P:   I would think it would only be used for patients that the doctor suspects are not compliant.

Dr. Rick Wilson:   Yes, but doctors are no better than chance at telling who of their patients is taking their medication correctly.  A monitor like this is a good start to helping with the problem.

P: Such a monitor would be good for forgetful elderly patients.

P:   Those things that all of you are mentioning are just so discouraging for me as a glaucoma suspect.  Why would I need to follow up with a doctor and to have millions of drops that you ultimately forget about even if you want to lead a normal life?

Dr. Rick Wilson:   Most glaucoma suspects, when they are put on medication, are only on one medication at bedtime for years. If that keeps the patient from becoming symptomatic from poor vision, it seems a small price to pay.

P:   What is another common mistake patients make?

Dr. Rick Wilson:   Many people make the mistake of choosing a doctor on the recommendation of friends or neighbors, who usually base their judgment on the personality of the doctor they chose.  Personality is important, but competence is paramount.  A better way to pick a doctor is to consult the specialties' Websites, like the American Glaucoma Society's www.americanglaucomasociety.net.

Then see who your internist recommends and hope the two coincide.  The best way is to have a doctor in the family who will do some sleuthing for you.

P:   How important is it to get a second opinion for treatment options?

Dr. Rick Wilson:   It is very important, if you are concerned about the way things are going or have any doubt about the suggested treatment.

P:   Is not seeing a glaucoma specialist a mistake?

Dr. Rick Wilson:   Not if your glaucoma is in the early stages or is not complicated.  On the other hand, a glaucoma specialist costs no more than a general ophthalmologist and should be more knowledgeable, if there are any concerns about treatment options.

P:   One of the biggest mistakes I've made over the years is not asking my doctors more questions.

P:   I asked my doctor (a Wills Fellow) a lot of questions and told him I participated in this chat room.  He freaked out and said I talked too much and had too many ideas.  Imagine that!

Dr. Rick Wilson:   One way that I think helps to get your questions answered is to think of them all and write them down in order of importance.  Then make a copy for the doctor.  He can read quickly through them and answer them, one after another, without being exasperated by the amount of time you are taking.  Remember, managed care and Medicare have cut back severely on the amount they pay doctors for each visit, so the doctor has to see more people than he used to in order to keep his office afloat.  That results in a time stress with each patient.

P:   I, too, told my doctor about this chat room and he didn't seem impressed.  I would think that most doctors would be happy that any patient was getting support of some kind.

P: I worry about the people like me, who stay with incompetent doctors simply because they don't know about glaucoma specialists.  Thank goodness for this Website.

P: An eye doctor told me he feels that some, many, of his colleagues are using highly aggressive treatment for glaucoma and glaucoma-suspect patients when it probably isn't warranted.  The doctor thinks they are concerned about malpractice suits. Comment, please.

Dr. Rick Wilson:   For some, the use of the selective laser trabeculoplasty (SLT) as a first-line treatment is, unfortunately, influenced by the financial return.  The most common mistake I see referring doctors making is treating patients with the laser who have no chance of any enduring improvement.  That is not to gloss over the huge increase in defensive medicine, with more tests and treatment than would otherwise be prescribed.

P:   Can you please be more specific about what you mean by "enduring improvement"?

Dr. Rick Wilson:   Young patients, say under 60 years of age, and those with little pigment in their trabecular meshwork, are unlikely to get a year or more of IOP lowering with an SLT or ALT (argon laser trabeculoplasty).  For me, it is more prudent to move on to either maximal medical therapy, if it has not yet been reached, or on to more effective surgery, like trabeculectomy.

P:   Is it common for patients to mistakenly rush into surgery when alternatives are available?  Or the reverse, to avoid it when needed?

Dr. Rick Wilson:   That is a mistake.  Putting off surgery for too long adds to the extent of optic nerve damage accrued before definitive treatment is given.  Most glaucoma specialists are conservative about cutting surgery, and more aggressive with laser surgery and its fewer complications.

P:   When my Mom was living, she always told me to be aware that I might develop glaucoma, because she was diagnosed with it.  A doctor told me that she may not have had glaucoma. She could have been a glaucoma suspect, and therefore I may be a glaucoma suspect.  Any advice for glaucoma suspects?

Dr. Rick Wilson:   My advice for suspects is to be seeing an ophthalmologist who uses a short-wavelength automated perimeter, the blue-on-yellow perimeter, that will pick up an abnormal visual field several years before the white-on-white perimeter.  Also, don't drop out of follow-up.  Just because you have been told you don't have definite disease yet, glaucoma could be caught at any time and the disease deserves good follow-up.

P:   My Mom's doctor retired around the time of her death in 2001.  I am trying to get her records.  Maybe they are archived somewhere.

Dr. Rick Wilson:   Good night and good luck!

Moderator:  Thanks, Dr. Wilson.

Dr. Rick Wilson:   Have a wonderful week.

On March 15, Dr. Wilson discussed "Lowering Intraocular Pressure" in the Chat room. Click here for highlights of that meeting.

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