Eyeworld

76 | EYEWORLD | WINTER 2024 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Alan L. Robin, MD Emeritus Associate Professor of Ophthalmology and International Health Johns Hopkins University Baltimore, Maryland Jullia Rosdahl, MD, PhD Associate Professor of Ophthalmology Duke Eye Center Duke University Durham, North Carolina (new classes, preserved and non-preserved) to injectable meds to lasers to MIGS to traditional glaucoma surgeries, plus vision rehabilitation— and the treatments vary so much on how they might affect a patient's life in the near and long term, what is a good match for the type and stage of glaucoma, the patient's other ocular and health conditions, and their expectations." When a patient seems to be a high risk for needing glaucoma surgery, especially a trabe- culectomy or a tube, Dr. Rosdahl often tries to bring it up as early as possible so it is not a sur- prise for the patient. "We might say something like, "We will start with these eye drops, but we might need to consider incisional surgery to control your glaucoma." We provide handouts about glaucoma surgery early on, so the patient is learning about it well before they are consent- ing for surgery and meeting with the surgical scheduler." She also mentioned handouts from the American Glaucoma Society (AGS) about treatments. The important thing is understanding and communicating with the patient, Dr. Robin said. If a patient doesn't understand what's going on, there's no way that he or she will cooperate and could be lost to follow-up and potentially go blind. "I think developing trust with the patient is crucial, and I think the first thing that has to be done is to find out more about the patient," he said. "What you want to do is get a basic understanding of what they think glaucoma is. It's a difficult disease to treat because most people feel like they're doing great. People have no idea they have visual field loss or peripheral vision loss, and you basically have to convince someone who's totally asymptomatic that there is a problem, and the treatment you're going to be giving them may cause symptoms itself." You have to gain the patient's confidence, discuss the disease, answer any questions, Dr. Robin said. Patients want to know things like what glaucoma is, if they'll go blind, if they have to take drops, etc. Dr. Robin said the tests that are needed include gonioscopy, perimetry, and IOP mea- surements. About half of the patients who have glaucoma have lower pressures, below 21. W hen it comes to treating glau- coma, educating the patient about their disease is a crucial step. In addition to finding an appropriate treatment plan, it's important for the patient to understand the nature of their disease, which can often be hard because physicians are helping them control their disease, rather than cure it. Alan L. Robin, MD, and Jullia Rosdahl, MD, PhD, discussed how they help patients understand glaucoma and how testing and treatments options play into the discussion. Dr. Rosdahl said that because she is a glau- coma specialist, most patients that come to her have an idea that they either have glaucoma or are at risk for it. "It surprises me, though, how even some long-standing patients don't realize that they have a glaucoma diagnosis, even my own patients," she said. "Glaucoma is tough to understand." First, Dr. Rosdahl said you need to find out where the patient is, what they already under- stand about glaucoma and their condition, and what their concerns and fears are. Testing is very helpful, she said. "Patients for the most part do understand eye pressure and the need to lower eye pressure," she said. "The visual field testing and optic nerve imaging (OCT) are helpful, too, especially when there has been a change over time. When patients see those changes on the testing, they understand that their glaucoma is getting worse even if they don't notice the change symptomatically." Dr. Rosdahl said the hardest thing is to explain that vision won't be getting better with the treatments, and they are only working to preserve the sight they have. "Often, even when patients understand this before surgery, they are hoping/expecting to have improved vision afterward," she said. "It is a conversation to have multiple times and as gently as possible, especially if someone has advanced glaucoma and a lot of vision loss already." While Dr. Rosdahl doesn't use a formal questionnaire, she does find the discussion with the patient essential for identifying the best treatment program. "We have so many treat- ment options for glaucoma now—from drops Helping glaucoma patients understand their disease and treatment options

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