Eyeworld

EW GLAUCOMA 50 by Faith A. Hayden EyeWorld Staff Writer Constructive conversations with glaucoma patients How to focus on the positive and ignite hope, not fear T here's a lot of negativity swirling around glaucoma patients. Known as the "silent thief of sight," many internet resources for the public are quick to point out all of the scary elements of the disease. It's incurable. It can go undiagnosed for years. It's the second leading cause of blindness worldwide. Although all of this is true, so are the happier facts. Most patients do not go blind. Treatment usually works. Damage develops at a glacier's pace. So why the Debbie Downer attitude, Doc? "What we say to the patient reflects our own views about glaucoma," said Reay Brown, M.D., clinical pro- fessor, Emory University, Atlanta, and EyeWorld glaucoma editor. "Un- fortunately, ophthalmologists gener- ally do not have an optimistic atti- tude about glaucoma or its therapy. The main problem of glaucoma pa- tients is their fear of blindness, which is far beyond the actual risk. We have treatments for pressure and symptoms, but I don't think we pay as much attention as we should to their fears." Some glaucoma doctors believe that the patients should be a little fearful. After all, compliance is a huge issue in the glaucoma world, and if patients don't take the disease seriously, why would they take the treatment seriously? "The biggest problem in glau- coma is patients don't take their drops," said Brooks Poley, M.D., Bluffton, S.C. "The only reason they know they have a disease is because their doctor told them. They forget about it. I think you've got to scare them a little because there's no re- covery. Whatever vision is lost is gone, and there's nothing you can do to get it back." Although Dr. Poley believes some element of fear is beneficial, Dr. Brown thinks most patients are scared enough as it is. "I don't ever talk about blind- ness," he said. "I think most of the time that's overkill. Patients already know that. I think it would be the rare person who is already well on the way to blindness who doesn't know what's at risk." That said, if Dr. Brown sees a pa- tient in complete denial about the seriousness of the disease or some- one who isn't taking the drops, then he'll work the dreaded "B" word into the conversation. However, if some- one is obviously distraught over the diagnosis, then there's no reason to lay into that patient further. "There are things we can't do anything about and things we can do something about," he said. "How we talk to the patient is something that is completely under our control. My concern is that we are too nega- tive with glaucoma patients when we can be more positive in a com- pletely reasonable way." One example of reasonable opti- mism can be shown through pres- sure goals. Some doctors, after examining the optic nerve, looking at the visual field results, and assess- ing the overall situation, will set a specific number that they'd like to see a patient reach. The problem is these numbers aren't always realis- tic, and the patient may not reach them even with perfect compliance. "It's easy to say a particular pres- sure is what you'd like, but it may be hard to get there," said Dr. Brown. "Then the doctor gets frustrated and passes that frustration on to the pa- tient. The patient feels like he or she is getting worse, even though there's no change in the status. A pressure of 15, for example, is good enough for almost everyone, but sometimes we are more aggressive in our goals than is possible. It sets us up for fail- ure." One thing doctors can stress is stability of the visual field. If the vi- sual field is not getting worse, that's a positive point to be emphasized. Another encouraging fact to focus on is pressure stability. If the treat- ment is working, say so. Finally, steer the patient away from anec- dotal websites if possible. "The internet gives patients the opportunity to read about what they are most afraid of. Their fears are re- inforced in ways that are not always appropriate for them personally," said Dr. Brown. "They can become much more terrified of blindness through the internet if they choose to read things that may not apply to them." In the end, it's all about effec- tive communication. There will al- ways be a group of glaucoma patients who don't do well, will never do well, and are at a real risk of blindness. For them, it's impor- tant to have an honest but tactful conversation about what the future could hold. "But there is a much larger group that is doing very well," said Dr. Brown. "I think in those patients we need to emphasis that fact. Many of those patients are very worried about becoming blind, and for them the risk is minimal, if present at all." EW Editors' note: Drs. Brown and Poley have no financial interests related to this article. Contact information Brown: reaymary@comcast.net Poley: bjpoley@q.com February 2011 November 2011

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