Eyeworld

EW GLAUCOMA 68 June 2015 by Lauren Lipuma EyeWorld Staff Writer Pearls to help patients function better with low vision W hen it comes to glaucoma patients, the role of the oph- thalmologist does not end at evaluating vision and giving treatment, said Anjali Bhorade, MD, MSCI, associ- ate professor in the Department of Ophthalmology and Visual Sciences, Washington University School of Medicine, St. Louis, Mo. Physicians should also be sources of informa- tion and provide resources that can help patients function better with low vision, she said. "As clinicians, we often dis- cuss intraocular pressure, the optic nerve, and visual field testing with our patients, but this may confuse them as to the applicability to their daily life," Dr. Bhorade said. "When patients ask us, 'How can I improve my daily life?' we may be stumped for a simple solution." Speaking at Glaucoma Day at the 2014 American Academy of Ophthalmology (AAO) annual meeting, Dr. Bhorade discussed ways to assess how well glaucoma patients function with low vision and the solutions and resources clinicians can offer to improve their patients' quality of life. Evaluate the 5 Ds When treating glaucoma patients with significant vision loss, evaluate the 5 Ds—daily activities, driving, disability from falls, dual sensory loss, and depression. The first step is to assess the 5 Ds during the office visit, Dr. Bhorade said, by evaluating the patient and asking questions. Ask patients if they have problems with performing daily tasks, mobility, and driving. In addition, look for evidence of recent falls and evaluate the patient's hearing and mobility. Assessing whether the patient suffers from depression is more difficult, but clinicians can use the 5-item geriatric depression scale to deter- mine whether further evaluation is needed. The most important thing to do is to listen to your patients, Dr. Bhorade said. "Are they telling you about trouble at home? A recent fall or ac- cident they had? Were they recently diagnosed with cancer or grieving the death of a loved one? Do they have difficulty hearing you? Do they have bruises or other injuries?" After evaluating the 5 Ds, clinicians can address these issues by offering simple solutions and referring the patient to the appropri- ate specialist. Offer simple solutions For patients who have difficulty with daily activities, one of the simplest solutions is to recommend increased home lighting. "In our recent study, 85% of older adults had home lighting levels below the recommended lev- els," Dr. Bhorade said. "Poor light- ing within the home is associated with worse vision, therefore simply increasing lighting in the home may increase their vision." In addition to lighting, making home modifications such as adding contrasting materials and placing color markings on appliances can help patients see better. Adding a contrasting tablecloth or placemats can reduce glare and help the pa- tient see plates, glasses, and flatware better while dining. Simple home modifications can also go a long way in prevent- ing an injurious fall, Dr. Bhorade said. Recommend that the patient increase lighting and place contrast- ing materials in entryways and at the top and bottom of staircases. Many patients fall while walking down stairs because they are looking through their near add, Dr. Bhorade said, so she recommends changing a patient's bifocals to separate distance and near glasses to reduce that risk. Easing the burden of vision loss in glaucoma patients A lthough our treatments for glauco- ma are generally successful in helping to prevent blindness, there will still be some patients who lose functional vision and whose lives are dramatically impacted by their impaired vision. These patients challenge us in a multitude of ways. First, they may remind us of failures in our treatment or surgical complications. This may make us want to avoid seeing them. Second, most of our training focuses on telling patients what to do rather than listening to them. Listening and empathizing may be much harder for us than recommending treatments and evaluating vision. In this month's "Glaucoma editor's corner of the world," Anjali Bhorade, MD, gives us many helpful tips in working with patients with serious visual loss. His suggestions require that we ask questions and then listen for answers. This sounds simple, but it is not. One measure of how well you are listening to your patients is to keep track of how many open-ended questions you ask. It is often easier—and faster—to ask a faux question like, "Mrs. Jones, you're taking all of your glaucoma drops, aren't you?" But you are unlikely to uncover compliance issues this way. It is common for low vision patients to come and see us regularly—and some- times frequently—even when we can offer them very little helpful treatment. We have a responsibility to follow Dr. Bhorade's advice and help our low vision patients get the services they need. They may feel a strong bond to us despite their vision loss. In fact, we may know these patients very well since we may have been seeing them for many years. They want—and deserve—our sup- port and our continuing care and empathy. Reay H. Brown, MD, glaucoma editor The five Ds to evaluate in glaucoma patients with vision loss Glaucoma editor's corner of the world 1. Daily activities 2. Driving 3. Disability from falls 4. Dual sensory loss 5. Depression

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