glaucoma: why you should be getting regular screenings...

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Glaucoma: Why You Should Be Getting Regular Screenings Webcast March 28, 2011 Raghu Mudumbai, M.D. Mark Slabaugh, M.D. Carl Beebe Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you. Carl’s Story Andrew Schorr: Glaucoma affects more than four million people in the United States, and half the people don't even know they have the disease. As a leading cause of blindness, early detection is the key to prevent loss of vision. Coming up, ophthalmologists from UW Medicine Eye Institute in Seattle will discuss diagnosis and treatment of glaucoma, and you'll also hear from someone who has benefitted from treatment. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by UW Medicine Health System. I'm Andrew Schorr. Well, I take daily eyedrops in one eye to lower the pressure. How come? Because I am a suspect, if you will, the doctors call it, for glaucoma, and glaucoma of course can narrow your peripheral vision, create sort of a tunnel effect in some people, and if it persists can lead to blindness. And that was a concern for my dad, Max, who eventually had surgery, where they created a little flap in his eye to relieve the pressure, but many people can have medication. There are other procedures as well. We're going to learn all about that today because it's so critical. You do not want to limit, certainly, or lose your vision to glaucoma. Now, it can be very subtle. Imagine, all of us of course need our vision, but if you think about the fields where somebody is depending upon it every second of their work, can you think of a field where, you know, it would be so critical? One would be being a graphic designer, or being a photographer. Well, 65-year-old Carl Beebe of Seattle is a photographer and he is a graphic designer, and, guess what, he went to the doctor, the optometrist to check his vision and get new glasses, and it came up that his visual field, in other words seeing on the periphery, was not so great. Did I get it Carl? That's where it all started? Carl: Yes, you did, Andrew. Andrew Schorr: And what did they see about the visual field? What was going on?


Carl: They noticed that there were areas within my visual field that I was not getting any vision whatsoever. Andrew Schorr: Hmm. Now, when you thought about it, was there anything that you noticed in your vision that was unusual? Any spots or anything like that? Carl: I had not, no. There was nothing. There was no indication whatsoever. Before I had gone to the optometrist for my every two years, getting my lenses replaced in my glasses. Andrew Schorr: Hmm. And there was no family history of glaucoma? Carl: None whatsoever. Andrew Schorr: Were you even familiar what glaucoma was? Carl: Yes, I was, only because I have a background in medicine from my youth and so I send--tend to stay current with what's happening with the human body. Andrew Schorr: And you knew that dealing with glaucoma and getting ahead of it was important. Carl: Without a doubt. Andrew Schorr: All right. So that took you to the UW Medicine Eye Institute. So what happened there? Was it medications first? Carl: As a matter of fact, it was. It's kind of an interesting story because I--my first appointment was with the head of the department of ophthalmology, and he had recommended that I make an appointment with Dr. Mudumbai, and so I had gone out to the front desk and made the appointment, and about an hour and a half later I received a phone call from him saying that I see that you can't get in to see Dr. Mudumbai for about a month so I want you to start taking these eyedrops immediately. He says which pharmacy would you like me to call it in? So he gave me an early indication that this was serious enough that I need to pay attention to this.


Andrew Schorr: So you took the medication for a while, and was it effective or effective enough? Carl: There's no way that you can really tell as a patient whether or not unless you go into an exam to find out if your IOP, or intraocular pressure, has changed at all. So there's no physical things that I could see that were any different. Andrew Schorr: I know just a few weeks ago it turned out that surgery was appropriate for you, so you had that surgery, that flap I was talking about to relieve the pressure. How are you doing? Carl: I'm doing fine. It all went very, very, very well, and you'll find when you talk to Dr. Mudumbai that I'm healing at the normal rate, and it's looking real good. Andrew Schorr: All right. Well, we hope this takes care of it for you. Let's mention your doctor that you've mentioned, and that's Dr. Raghu Mudumbai, who is associate professor in the department of ophthalmology at the University of Washington, and of course he's at the eye institute. Dr. Mudumbai, tell us, this situation that Carl described, where he didn't really notice it, that's typical, isn't it? Aren't we talking about maybe half the people, half the four million in the US with glaucoma don't know? Dr. Mudumbai: Yes, that's actually a very classic presentation for glaucoma. There are certain patients who will have what we call acute angle-closure glaucoma where the eye pressure dramatically rises and they'll feel pain and can't see and they know it, but in this country at least, Mr. Beebe's presentation, Carl's presentation is a lot more common where patients have a gradual loss of vision, have symptoms that really they can't recognize unless it's been diagnosed by an ophthalmologist. Andrew Schorr: So typically you are trying medications first to lower the pressure because of course you're concerned about damage to the optic nerve, I understand, and then surgery may be an option if the medications are just not getting the job done? Dr. Mudumbai: That's correct. In Carl's case he actually had an issue with one of his medications, timolol, which led to some side effects, which made it difficult for him to breathe properly, and he was fatigued quite a bit by it. So we tried various medications, and we followed


him with his eye pressure checks and the visual field checks, and it looked as if--that it wasn't really doing what we needed to do to lower his eye pressure sufficiently, and that's when we decided to go ahead with surgery. Andrew Schorr: And just to understand this procedure, what do you call it where you make this flap in the white of the eye to let some fluid seep out? Dr. Mudumbai: Yes, so that's a variety of procedures, but we typically start off if possible with a procedure that we make a flap, as you said, called a trabeculectomy. What is Glaucoma? Andrew Schorr: All right. We're going to learn more about that in a minute. I want to put this in perspective and bring in our other expert guest from UW, that's Dr. Mark Slabaugh who is an assistant professor there and an ophthalmologist, a glaucoma specialist at the UW Medicine Eye Institute. Dr. Slabaugh, so help just define for us what is what is glaucoma. Dr. Slabaugh: It's an interesting question because we classically think of glaucoma as a problem with eye pressure, however the vision loss that is caused by glaucoma is really damage to the optic nerve. And so a number of people actually have glaucoma and never have eye pressures that are seriously elevated, and so if I was to define glaucoma I would say a characteristic optic nerve problem that develops in the setting of a number of risk factors, one of which is elevated intraocular pressure, but that's certainly not the only one. Testing and Check-ups Andrew Schorr: Okay. Now, this visual field test, though, seeing whether you're losing peripheral vision, though, that would be across everyone, wouldn't it? Dr. Slabaugh: Yes, that is a constant finding in glaucoma is progressive visual field loss, and again this is a finding that is very difficult to appreciate from a patient's standpoint because a small area of vision loss in one eye can be filled in from the other eye with your brain's ability to process images, so only when testing one eye in a formal way by, you know, flashing lights around in the peripheral vision is one really able to detect early glaucoma. And that's really when we can make our biggest impact is with early treatment of early glaucoma.


Andrew Schorr: I know from my checkups, and, Carl, maybe you've had this too, so the visual field test I have, oh, maybe once I year I think it is, one eye closed, looking into sort of a box with little--looks like little starry night, if you will, and you hit a little button when you see a light flash. And then the other thing that I have had, and I imagine maybe this is standard too, Dr. Slabaugh, is I have had photographs taken of my optic nerve. So what are you looking for there? Dr. Slabaugh: So with photographs what we're trying to document is the exact appearance of the optic nerve. And so as you mentioned we do screen with visual fields. We also screen with the optic nerve appearance. Just by examining patients with our slit lamps, with the microscope that we use, we can make some judgment about damage that might be present, but it's very difficult to recall after a year or two what the exact appearance was, and so we tend to document the appearance of the optic nerve using some type of imaging, whether that's a photograph or some other type of more advanced imaging. But regardless when we take a photograph we can look back after several years and compare those photographs to see if there's been any structural change. It's felt that structural change tends to precede functional change, and functional change would be like a change in your visual field. So optic nerve head imaging is one way of documenting very early glaucomatous change. Andrew Schorr: Dr. Mudumbai, let's talk about checkups. So, first of all, who is at highest risk for glaucoma? Dr. Mudumbai: There's various groups that are at high risk for glaucoma. That includes various ethnic groups. African-Americans tend to have a significantly higher rate of glaucoma than other ethnic groups. People who have a family history of glaucoma should also have heightened concern or suspicion for glaucoma, and people who are older should have concern for glaucoma. It's a little bit unusual to develop glaucoma in early age, although that does happen and we take care of patients in that setting, but more typically we see patients in the 50s, 60s and beyond as a real time frame for developing glaucoma. Andrew Schorr: Dr. Slabaugh, any other risk factors? Dr. Slabaugh: So one other risk factor that we know of is that patients with diabetes, which is obviously very common, are at a higher risk of developing many different eye problems but specifically, per our topic today, they are at high risk for developing glaucoma. So we encourage any patient with diabetes to undergo regular eye screening, and a part of that should be measurement of intraocular pressure and evaluation of the optic nerve.


Andrew Schorr: All right. That's me. I go for checkups. So with these groups how often should you be checked? Dr. Mudumbai: It really depends upon what the initial finding is. As in Carl's case, it was quite clear from the beginning that he had had advanced damage to his optic nerve and loss on his peripheral vision, and for him initiation of treatment immediately was appropriate and following him on a regular basis about every four months or so was appropriate to see if any change was taking place. For other patients where there may be less damage or less of a concern of actual glaucoma being present, once a year may be more appropriate. Andrew Schorr: All right. And then when you come in once a year, pressure check probably, visual field, sometimes photographs? Dr. Mudumbai: That's correct. As Dr. Slabaugh mentioned, we take baseline testing on these various different parameters, intraocular pressure, the way the optic nerve looks, the way the visual tests look, and some of the advanced imaging of the eye, and we're able to use that baseline imaging to then determine if a change is taking place over time, and if so that's a concern for us or a way for us to believe that damage has taken place, and we need to be more aggressive in the treatments. Andrew Schorr: Dr. Mudumbai, are there other tests beyond the visual field or taking pictures of the eye, measuring pressure, that can be helpful now? Dr. Mudumbai: Yes, as you mentioned, those modalities we've used on a regular basis and still use today to evaluate the optic nerve, but over the past 10 to 15 years imaging of the optic nerve, structural imaging, which we look at the nerve fiber layer of the retina, which is the layer that tends to get diminished as glaucoma progression takes place, we can actually do that for the first time. That is a very exciting area because it now allows us to look at glaucoma for more cellular basis, and because of that we can look at changes that take place in patients' eyes prior to the development of changes that take place on a more global basis of their optic nerves or on their visual field test. And thereafter we can hopefully catch them before these changes lead to loss of vision.


Treatment Andrew Schorr: Carl, now, in your case you were not doing as well as one would want with the medicines you were taking, and then it was proposed that you have surgery. And the whole idea of, you know, any eye surgery, our eyes are so precious, one maybe hesitates. You really have to think about it. It was clear to you that there was benefit from the procedure and moving forward? Carl: Without a doubt, because the only other option was to go blind. Andrew Schorr: You said it, okay. We don't want that to happen. So, Dr. Slabaugh, help us understand. Okay. So medications for some people can work, and hopefully mine has been working over many years, and in my case, that's keeping the pressure low and they check the visual field, peripheral vision and every once in a while photographs of the nerve, so I'm just being followed. And many people, that can work, right? Dr. Slabaugh: Yes, that's correct. So there are many risk factors for progression, and it seems that patients who have had prior severe damage, as in Mr. Beebe's case, seem to be more prone to having further progression, and those patients tend to do better with even further decrease of their pressures. If we're not able to achieve that low pressure result with medications or if the disease continues to progress in spite of sort of maximum medical therapy, then we often will recommend surgery as a next option. Andrew Schorr: Okay. We talked a little bit about one version of the surgery, so that's creating the flap. Are there other ways to do it? Like for instance what about, you know, we've heard so much about laser eye surgery, do lasers help at all here? Dr. Slabaugh: There is a specific type of laser that can be done to lower eye pressure. It's called laser trabeculoplasty, and again it's similar word to trabeculectomy, which is the surgery that Mr. Beebe had, but it is a different procedure. The way that works is by using a laser to apply very light energy to the drain meshwork of the eye, and the drain meshwork is in a 360 degree ring right around where the white of the eye starts next to the iris, and we need to use a mirror to view that area, but with a light application of laser to the drain meshwork we can sometimes lower pressure. It works very well on some people. Some people it doesn't work that well. It has a fairly low risk so we often will try that in addition to medications before moving on to surgery.


Andrew Schorr: One more question for you, Dr. Slabaugh. So when somebody has one of these surgical procedures does that alleviate the need for medication, or there may be some medication they need after they recover or ongoing? Dr. Slabaugh: It can be either one of those scenarios. Some patients have a very nice low pressure after a trabeculectomy or one of our other glaucoma surgeries, and then in that case that may obviate the need for further eyedrops. And that's a great result. There are other patients who tend to heal their glaucoma surgery closed so that it's not working quite as well, and in those patients they may end up back on some eyedrops, hopefully with a lower pressure than they had prior to the surgery. Andrew Schorr: Dr. Mudumbai, so if I have a slit in my eye, I wasn't born that way of course, so you worry. What happens to that fluid? What happens inside the eye, and where does the fluid go? Dr. Mudumbai: So the fluid, as you said, there's a natural circulation inside the eyeball which is different from what you'd recognize as tearing taking place. That circulation normally goes in and out of the eye without any issue. When we make the flap or the slit surgery, the fluid goes from inside the eyeball to a space that's right above the white of the eye. That area fortunately is covered by a membrane that we all have on the surface of the eyeball, and then various blood vessels and other tissues absorb that fluid back into the body. Andrew Schorr: Now let's talk about risks and complications. These are outpatient procedures, right? Dr. Mudumbai: That's correct. Andrew Schorr: Okay. With any surgical procedure you always say, well, gee, what are the risks, so tell us about that, sir. Dr. Mudumbai: Well, you know, the risks always that are present with any type of surgical procedure can include infection that can take place, and with this type of surgery there's a potential risk both for infection early on in the course after surgery as well as late term. There's a risk of bleeding that can take place. But probably the biggest risk of the surgery for most people is that it doesn't work, that we have to do another surgical procedure, or that it works too well and that the pressure is too low inside the eye. Fortunately, we're able to titrate that fairly well with various advances that have taken place in the surgical technique so that those have become less and less of an issue.


Prevention Andrew Schorr: When we talk about glaucoma, how important is it for people to, as I said earlier, stay ahead of it, pay attention to it, and really get help, be assessed for it? Dr. Mudumbai: I think it's very, very important, and the main reason for that is that unlike cataracts, where once you have a cataract surgery you get a complete recovery of the vision that you have lost as a result of the disease, unfortunately with glaucoma that's not true. Because it's damage to the nerve and it's a nerve that does not regenerate with our current state of technology, whatever you've lost, you've lost permanently. And so if we can try to minimize the amount of damage that has taken place, that maximizes the quality of life and maximizes the ability to see. Andrew Schorr: Dr. Slabaugh, how do you encourage people to come back for regular checkups? Dr. Slabaugh: I try to emphasize the importance of good, continued care. Glaucoma is a chronic disease, and it requires ongoing surveillance. Unfortunately, many people don't notice that they're developing a problem and so it can be difficult to impart the severity of vision loss that can result from advanced glaucoma. And as Dr. Mudumbai pointed out, when you have lost vision from glaucoma you will not get it back. So I try to impart to patients that it's very important to be on a regular schedule with eyedrops. It's very important to get regular follow-up so that any ongoing damage can be detected early and that can guide changes in therapy as needed. Andrew Schorr: How quickly does glaucoma move? So we've talked about how subtle it is, Dr. Slabaugh. So are we saying that in some people it moves fast, some slow, or what's typical? Dr. Slabaugh: Yes, I would hesitate to call any rate typical just because there's such a wide variation. It seems that some patients progress quite rapidly, and some patients will develop a small visual field defect that stays stable over many, many years, so I think it's really an individualized care agreement that needs to go on with their physician. And again following up every four months or six months is appropriate. And really being religious with those--with those appointments and keeping eyedrops on a regular schedule, all those things can really give us more information about the rate that we're seeing. Part of the problem is if the follow-ups become very irregular or perhaps the application of eyedrops becomes irregular, when we do see a change we don't know how much of that is an ineffectiveness of treatment or an ineffectiveness of sort of a constant therapy that we're shooting for.


Andrew Schorr: Dr. Mudumbai, this is the age of patient empowerment and all of us trying to take more control of our health. So I know I have to take responsibility for using those eyedrops, kind of like when I brush my teeth, and I have to take responsibility whether the clinic calls or not to maintain a schedule of regular checkups, right? I mean, because the downside sounds like it's quite significant. Dr. Mudumbai: Right, you hit it right on the head in a sense that it's a cooperative effort between the physician and the patients. Part of our goal as physicians, and one thing I strive for, is to have an ongoing communication with the patient in terms of showing them the physical parameters of change, showing them the visual field, actually looking at the areas where the vision has been disturbed and reviewing the medications, to ask the patient if they've been compliant with the medications, if they're having difficulties for whatever reason. And as we talked about earlier Carl, had developed an issue with one of the medications, and if we hadn't had the discussion perhaps that wouldn't have come out and I wouldn't have known whether or not his pressure, lack of pressure reduction or his advancement of glaucoma was taking place because he wasn't taking his medications properly. So I completely agree that patients in this day and age have a right and a need to be educated about what is going on with their health problems mainly to help facilitate their own care, their own ability to take care of themselves. The Importance of Check-ups Andrew Schorr: Well said. Now, Dr. Slabaugh, we talked about how you may not notice anything. Carl didn't. But some people do have some indications that something is going on with their vision. What would those be? What should people say, oh, oh, I haven't been checked lately and I'm noticing this. What would be signs if they had any at all? Dr. Slabaugh: Well, with low pressure glaucoma or moderate pressure elevation in glaucoma, unfortunately if patients notice something with their vision it's likely very late. As we, I think we previously mentioned, it does tend to affect your peripheral vision first and so if the visual field defects had encroached into an area where you're actually noticing them it's probably a very late sign of glaucoma. And I think that's really important to understand, that screening is really the way to go in picking up glaucoma early, and so I really encourage people to get regular exams. But with any decrease in peripheral vision we always are wanting to take a look at the reason for that. Certainly if patients present with high pressure glaucoma or acute glaucoma attacks they may notice a red, painful eye, a lot of light sensitivity, and most of those symptoms would prompt people to seek care anyway.


Andrew Schorr: Wow. Now, what about with my illness, Dr. Slabaugh? Is there any condition, chronic condition somebody might have where it could cause increased pressure and a high risk of glaucoma? Dr. Slabaugh: Yes, there are actually a number of conditions that can cause an increased risk of glaucoma. Really, any condition that involves chronic use of corticosteroids, which are immune system modulating therapies, so patients who are under treatment for an autoimmune type condition, those patients probably should be screened a little bit more frequently for glaucoma. Certainly patients who have other eye disease, such as uveitis, which is inflammation inside the eye, those patients would also be at high risk for glaucoma. Thankfully they're probably getting care for those as well, but those are the patients that I would expect to be at higher risk for glaucoma. Andrew Schorr: Dr. Mudumbai, let's ask about urgency. So people listen and say, oh, my. I'm worried about this. I better get checked. I fall into this group, or like me, my dad had this, etc. So when you determine that there needs to be an intervention, and I know this varies because Carl told the story of the doctor he first saw at your clinic saying, well, let's get him on some medication right away. But let's say related to surgery, is it like we got to do it tomorrow, or this is developing over a long period of time, it doesn't move lightning fast, but we do need to be attentive to it. So give me sort of a time line. Dr. Mudumbai: Yeah, well, there certainly are situations where there's a quite significant urgency to operating on the patient, but fortunately with all the advances that have taken place with our medical regimens that we have available, the number of medications that are out there to lower eye pressure plus the other interventions, I think that for the vast majority of patients that's a decision that can be made on a less than emergent or an urgent basis. I think that the key to all this is what we've been discussing all along, which is to get into the system, to get yourself examined by an eye MD, to get your eye pressure measured, to get your visual field checked, to know where you're starting from. Because really where you're starting is really the pinnacle of your vision, and the only place you can go from there is down. And so if you can get yourself screened at an early point you can preserve the high quality of vision that you hopefully have at that time. Andrew Schorr: Dr. Slabaugh, what do you want to say to people listening to kind of encourage them to get checked? Dr. Slabaugh: Yes, I would reiterate the same things. It's very important that patients see their ophthalmologist on a regular basis to be screened for glaucoma as well as other eye condition that is can develop without patients being aware of them. Again, as Dr.


Mudumbai mentioned, this is a chronic disease, requires ongoing care. It is not optimal that patients are taking eyedrops every day and requiring follow-up visits, however, thankfully, with early intervention and aggressive treatment we can often preserve patient's vision for a very long time. I think the other thing to recognize is that we continue to live longer and longer, and it is well known that the rates of glaucoma do increase with age. And so we are seeing more glaucoma, and I really encourage people to just get regular eye care by an ophthalmologist who is certainly qualified to screen for glaucoma and just get into the system that way. Advice for Others Andrew Schorr: All right. Let's talk to someone who has lived it. Carl, what would you say to people who are listening who maybe haven't kept up with checkups, maybe haven't had one in a long time but where this specter of glaucoma could be out there which could really limit their vision? Carl: Well, I'd say there's a great importance in getting checkups done on some kind of regular basis just to give you an initial indication that something is going on, whether it is yes or no. But in my case it was a situation that by the time I had gone in and had my eyes checked by these professionals it had advanced to a state where I was already suffering from loss of vision. And so my advice to anybody obviously is get in to a doctor, get in and get it checked. Andrew Schorr: And how do you feel about the future of your vision now, staying on top of it and having had the surgery? Carl: Oh, I feel very comfortable with what's going on right now. It's an ongoing process. You don't really know what's going to happen next. You just hope for the best, and so far everything seems to be working out. Andrew Schorr: You hope for the best but you're getting those regular checkups too. Carl: Without a doubt. Andrew Schorr: Okay. Carl Beebe, thank you so much for being with us. I'm glad you're doing well after surgery for your glaucoma and hope you get to do I'm sure what you enjoy, the graphic design with significantly good vision for many years to come. All the best, Carl.


Carl: I appreciate that. Thank you, Andrew. Andrew Schorr: And our doctors, Dr. Mark Slabaugh at the UW Medicine Eye Institute. Thank you for what you do and being with us, Dr. Slabaugh. And Dr. Raghu Mudumbai, thank you for being with us too and helping us understand glaucoma. Gentlemen, thanks. Dr. Mudumbai: Thank you. Dr. Slabaugh: Thank you. Andrew Schorr: Important to stay on top of your vision. Just think how precious that is, and I think about my dad working hard and with his ophthalmologist to keep his glaucoma in check. I am doing the same. I'm going to make sure every day I brush my teeth, for me, I'm taking those eyedrops and get the regular checkups, and I urge you to get your vision checked too. Thank you for being with us. I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of UW Medicine, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.

glaucoma: why you should be getting regular screenings...

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