To treat or not to treat: Fixing the glitch in glaucoma

Image credit: AdobeStock/rh2010

The formal education of any health care provider in the US comes in, shall we say, 2 flavors. There is the didactic component and there is the clinical component. The didactic component involves facts—many facts. The clinical component involves not just the random collision but also the composition and collation of those facts, which develops a comprehensive understanding of diseases, their relative states, and how to diagnose and manage them properly. Couple this sequence of events with the fact that our understanding of the science of human health is constantly expanding, and you quickly see why we do not “do” health care, but, rather, we “practice” it. We are simply committed to a clinical lifetime of learning.

There have existed several standout instances in my clinical career during which I have found myself acutely aware that I am constantly learning about the human eye, adnexa, and visual system. One such instance was born out of a glaucoma course I was attending maybe a year or two after the completion of my residency. Ah, those were the days: still bright-eyed and bushy-tailed.

The instructor made a comment in passing that really stuck with me. He said, “…and there’s going to be glaucoma that you don’t treat, I promise you.” I recall thinking, “How does one not treat an optic neuropathy that is progressive by nature and by definition?” Of course, there is the adage of the 120-year-old patient who has barely detectable and preperimetric glaucoma, but what of patients who seemingly have years of life left whom we may not treat? Some of my patients have what appears to be evidence of glaucoma, low interocular pressure (IOP), and no signs of progression as evidenced by optic nerve appearance and sequential spectral-domain optical coherence tomography and visual field studies. These patients deserve to be asked a few very specific questions. I ask them about prior steroid use (oral, topical, and injectable). I also ask whether they were ever really sick in their lives, with special attention being paid to a possible history of hemodynamic crisis. What I am getting at is the notion of some causative agent of optic nerve disease that was present in the past but which is no longer an issue (or is simply old news). These are patients for whom treatment may not be necessary. In such instances, close monitoring is necessary and appropriate.

About a year ago, an unfortunate case of glaucoma found its way into my examination chair that turned a patient initially needing a “1 and done” treatment into one whom I now monitor a couple of times a year. This man was in his late 60s at the time and had been to see my father a few times over the past decade or so. He was moderately hyperopic with a spherical equivalent refractive error of around +3.50 for each eye. He presented with a painful red left eye with a history of several weeks of a headache around that eye. His primary care physician had been treating his symptoms with oral pain relievers for several weeks, with limited relief. He denied a recent history of corticosteroid use. His entering corrected visual acuities were 20/20 for the right eye and 20/50 for the left eye. His left pupil was fixed in a middilated state, and his IOPs were 14 mmHg for the right eye and 51 mmHg for the left eye. His left eye’s angle was closed as seen by means of gonioscopy. His right optic nerve was overtly healthy as examined with a precorneal lens through an undilated pupil. His left optic nerve had significant cupping, especially inferiorly, where the neuroretinal rim was essentially cupped out.

I explained to the patient that he was suffering from an acute-angle closure attack, put every drop in his eye that I had that did not have a red cap, and arranged for him to be seen on an emergent basis by an ophthalmic surgeon in town. He underwent a laser peripheral iridotomy a couple of hours later and eventually had a lensectomy performed on each eye. He now is enjoying open angles and no pain. Unfortunately, he does have decreased best corrected visual acuity of 20/40 in the affected eye and a dense superior scotoma.

Semantics aside, this was one of those glaucoma cases that Idid not treat. I simply ensured that the glitch got fixed. Now the only treatment he needs is a spectacle prescription for impact-resistant lenses for full-time wear. As for our dedication to a lifetime of learning with respect to this case, painful red eyes always deserve to have their IOP checked.