Glaucoma and the Elderly
Chat Highlights
August 15, 2007

On Wednesday, August 15, 2007, Dr. Michael James Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and the Elderly."

Moderator:  Welcome back to chat Dr. Pro.  Tonight the topic is “Glaucoma and the Elderly.”  At what age do you consider a patient elderly?

Dr. Pro:  In terms of epidemiology, many studies have grouped people over age 70 as being at higher risk for glaucoma.  Indeed, the prevalence of glaucoma increases with increasing age.  Certainly I don't consider my 70-year-old patients elderly.  In fact, I really think the term is not accurate, because many of my patients are active and robustly healthy.

P:  Can some medications, such as beta blockers, be too potent for elderly patients?

Dr. Pro:  Yes, and I try to elicit an accurate medication list from my patients.  For instance, many are not aware that they are taking a systemic beta blocker.  Adding a topical beta blocker can sometimes cause adverse effects.  Smokers and those with lung problems are at increased risk for increased shortness of breath.  But other problems are subtle, such as sexual dysfunction in men or fatigue and depression.

Moderator:  That’s a good point.  Patients should give their eye doctors a list of all their medications and the dosage.

P:  What changes in the eye should the elderly expect?

Dr. Pro:  The biggest change is cataracts.  All people can expect some degree of cataract by the time they are 65 years old.  Not all lenticular changes, though, are visually significant.  Presbyopia (the loss of accommodation) is common, and leads to a need for reading glasses, except in patients who are mildly nearsighted.  They can remove their eyeglasses to read.

As to glaucoma, studies have shown increasing intraocular pressure (IOP) with age. Increased IOP is a risk factor for developing ocular hypertension and glaucoma.

P:  Can a trabeculectomy be too difficult for an elderly patient to endure?

Dr. Pro:  By “elderly”, do you mean fragile?

Moderator:  Yes.

Dr. Pro:  In that case, any intraocular surgery may be a bit more difficult.  The healing is slower, and the ability to administer the post-op drops may be difficult for an elderly patient.  Serious health conditions, such as cardiac disease or lung disease, can preclude surgery except in an emergency.

A significant problem for elderly and dependent patients, I think, is transportation.  In many parts of this country, public transit is inadequate and patients must depend upon relatives.  Those patients are more hesitant to proceed with surgery if they feel that they will be a burden to others.  I try to make sure that relatives are present for the pre-op discussion, and that everyone is aware of the need for more frequent post-op visits.

We have all been a bit spoiled by the tremendous success of cataract surgery and its relatively uneventful post-op recovery.  Although glaucoma surgery is much better than it was 30 years ago, the frequency of post-op visits can be greater.

P:  Why and how would cardiac or lung disease preclude surgery?

Dr. Pro:  For instance, a patient with a newly diagnosed cardiac arrhythmia first needs to be stabilized by a cardiologist.  Patients on 24-hour oxygen generally need to have their surgery performed in a hospital setting.  That’s because most ambulatory surgery centers are not comfortable handling patients at greater risk for complications.

Complications can happen, because there is a slight strain on the patient’s cardiac and pulmonary system.  The patient may be anxious, and the intravenous sedation may slightly depress the central nervous system.  Fragile patients are at a higher risk for heart attacks or other complications.

Moderator:  Do some communities and hospital organizations provide transportation for patients?  Is it difficult to qualify for such outreach programs?

Dr. Pro:  Of course, and patients in assisted living or nursing homes almost always have some type of transportation available.  There are also regional transport agencies for which patients may qualify.  Some patients receive this benefit if they qualify financially.

P:  How many post-op visits are usually required after a trabeculectomy?

Dr. Pro:  My general rule of thumb for post-op visits is as follows:  one day, one week, two to three weeks, one month, then about two months.  The number of post-op visits can vary, depending on whether I need to cut more sutures with a laser or at the slit lamp, and whether I think the patient should get an injection of anti-scarring medicine.  Of course, the post-op visits are more frequent if I need to monitor more closely, such as if the intraocular pressure (IOP) is too low.

P:  This isn't a complaint, but when the visits are frequent, waiting two or more hours to see the doctor can be hard on the family member with a job who drives the patient to the doctor’s office. Isn’t there some way the visits of post-op patients could be streamlined?

Dr. Pro:  Well, every office has different protocols.  I think we all try our best to see our post-ops as quickly as we can.

P:  Are glaucoma surgeries performed under general anesthesia?

Dr. Pro:  No, they are usually local and with mild IV (intravenous) sedation.  As I said, even mild stress to the system can be too much for a sick, fragile patient.

P:  How do you handle a confused, elderly patient?

Dr. Pro:  For surgery, a very demented patient usually gets general anesthesia.  The draping of a patient and even light IV sedation can send a mildly confused elderly patient into a more confused state.  The patient can get restless and combative and sometimes needs to be switched to general anesthesia.  That is why a medical clearance is necessary before surgery.  The OR (operating room) staff needs to know if a patient can handle anesthesia safely.

P:  Do you find elderly patients tend to be more or less compliant than younger patients?

Dr. Pro:  Elderly patients are more compliant about trying to use eyedrops.  Their problem is getting the drops into the eye.  Younger patients tend to be less compliant about using the drops.

P:  Can communication between the doctor and elderly patients be a problem?

Dr. Pro:  Of course, so I really make sure other members of the family are present when I discuss surgery (providing the patient wants them to be there).  I want everyone to know what the goals of the surgery are. I also want them to hear about options and potential risks.

P:  Are programs available for the elderly to help pay the costs of medications, office visits, etc.?

Dr. Pro:  Such programs are sort of piece-meal.  Each of the pharmaceutical companies sponsors some sort of program that can help eligible patients.  Of course, Medicare Part D is now helping many patients with the medications, except those in the "Donut".

Moderator:  What is that?

Dr. Pro:  The Donut is a level of spending on drugs.  Up to a certain amount is covered for the patient.  Then, if the cost of the medication rises above a certain amount (sorry, I don't know the exact amount), the drugs are not covered.  If the cost of the drugs rises above a second amount, the expense is covered again.

P:  Why do elderly people often have a pouchy area in the upper eyelid, right beside the nose?

Dr. Pro:  That area has loose connections between the skin and the underlying tissue.  Therefore, fluid can accumulate when the elderly person is lying down.  Some of that fluid is re-absorbed when the person is upright during the day, but the skin begins to look baggy due to stretching.

P:  Do elderly people lose pigment in the iris?  Some of them have very pale blue eyes, much paler than I see in younger people.

Dr. Pro:  Yes, they do. It is not a known risk factor for glaucoma, like pigment dispersion syndrome.  Some people believe that the loss of pigment in the iris is caused by decreased sympathetic (a branch of the central nervous system) tone to the eye.

P:  Do you think ophthalmologists will be prepared to cope with an increase in the number of glaucoma patients among baby boomers now reaching their sixties?

Dr. Pro:  We better be!  Seriously, we will be under more stress to see more patients and will be seeing more cataracts and glaucoma.  The American Academy of Ophthalmology is aware of the problem and addresses it periodically in our meetings.

Moderator:  That’s all for tonight.  Thank you Dr. Pro.  See you in September.

On September 5, Dr. Wilson discussed "Dry-eye Syndrome" 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.