Making Decisions
Chat Highlights
April 21, 2010

On Wednesday, April 21, 2010, Dr. Michael Pro, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Making Decisions".

Moderator: Hello, this is your Moderator. Tonight's topic is “Making Decisions” with Dr. Michael Pro.

P: How does a physician make the decision when to begin treatment for glaucoma?

Dr. Pro: First, there are guidelines that we have learned from our training. We are taught to look for certain exam findings and weigh certain risk factors. This goes into making a decision to treat or not to treat. So with this in mind you have to consider that every patient may fit into a generalized pattern, but is still an individual with individual treatment needs. In the U.S. there is no strict treatment guideline. For instance, nowhere does it say that we should treat every patient who comes in the door with an IOP over 21. Other countries or regions do have more specific guidelines regarding treatment of glaucoma.

P: What observations or tests need to be performed prior to writing the first prescription?

Dr. Pro: First you need to take a good history: what is the past ocular history, medical history, and family history? You then need to perform a good examination including vision, and slit lamp exam. Sometimes specific tests are performed which are helpful, like a visual field, corneal thickness, and nerve imaging.

P: Is it ever best to begin treatment for glaucoma with lasers or surgery?

Dr. Pro: This has been studied in several trials. The Glaucoma Laser Trial looked at treating patients with either an ALT (a type of laser procedure that can lower the IOP) or with drops. The laser patients did as well as the drop patients. A similar trial looked at initial surgical therapy (a trabeculectomy) versus medical therapy. Here, too, the two groups were equal.
So, why do we usually start with drops first? Here's how I look at it. You can consider therapy on a safety scale. Generally all drops can have side effects, but they are usually mild and reverse once the drop is stopped. Meanwhile lasers are also safe, but in rare patients you can see persistent or serious problems. Finally eye surgery of any sort, like a trabeculectomy, can lead to rare but serious complications.

P: Should every patient obtain a second opinion about their care, and if so, when? If not, why not?

Dr. Pro: I would not seek a second opinion for every routine decision, especially if you have a trusting relationship with you doctor, but certainly get one if you are presented with a serious decision, like surgery, and you feel you have not had the situation or alternatives explained.

P: I went for second opinions when I was scared, hoping for a magic bullet. Unfortunately, they all agreed with course of treatment at that time.

P: Should a patient tell they doctor they would like a second opinion? Is it offensive to you to have a patient say they would like another opinion?

Dr. Pro: Well, for the doctor it may be natural to feel put off, but you really have to try to see the situation from the patient perspective. When a patient wonders if they could get a second opinion, I welcome it. The only time I am concerned is when I feel the patient needs urgent surgery and I worry that the patient is taking a risk by delaying care.

P: Do doctors usually agree on the need for surgery?

Dr. Pro: Yes, I think most glaucoma specialists are usually on the same page. I think this is because we only see patients with glaucoma, so most of out patients fit into recognizable patterns, and we recognize when a patient is in danger of having their glaucoma worsen.

Moderator: This ends our moderated chat with Dr. Pro. Good night doctor. Thank you!

Dr. Pro: Thank you. Goodnight!

On May 5 Dr. Moster discussed "Neurology and Glaucoma" in the Chat room. Highlights for this chat coming soon. Click here for highlights of that meeting.

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