55 EyeWorld Asia-Pacific | March 2025 GLAUCOMA 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 treatment options for glaucoma now—from drops (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 at a high risk for needing glaucoma surgery, especially a trabeculectomy or a tube, Dr. Rosdahl often tries to bring it up as early as possible so it is not a surprise 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 consenting 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 measurements. About half of the patients who have glaucoma have lower pressures, below 21. “You have visual fields to assess the amount of damage to the optic nerve, and the visual fields now are much better than they were when I was a resident,” Dr. Robin said. “They’re black and white, and you can point out black is bad; white is good. It’s always good to repeat visual fields because often on the first time, patients have trouble with it, and you can get a better idea of the amount of damage.” He added that OCTs and slit lamp examinations are crucial to determine the type of glaucoma and any potential adverse effects of medications used to treat the glaucoma. Treatments And Education If a patient is young and understands what’s going on, Dr. Robin often starts with either eye drops or laser treatment. He will give patients a bottle of artificial tears and see if they can get a drop in their eye. Using drops is extremely difficult, and some people just can’t do it. Additionally, many don’t have a partner or significant person in their lives who can help them. The second thing that you have to consider, if you decide to go with drops, is what kind of systemic diseases or illnesses the patient has. All topical IOP-lowering medications have different side effects. Some of the prostaglandins can cause eye redness, change the color of the iris, etc., so you have to make sure that a patient understands this. Additionally, Dr. Robin said that beta blockers, like timolol, can cause asthma and exacerbate congestive heart failure. They can also cause a slowing of the heart rate, and a slowing of the heart rate in someone who’s a 25- or 30-year-old track runner whose baseline heart rate is 55 or 60 could cause significant medical issues. You want to make sure you have a full understanding of their systemic health, he said. “If they can’t put in a drop, my first choice would be a laser trabeculoplasty. You have to explain to patients that this is not a cure; patients always think that there’s a cure,” he said. The other thing to consider, Dr. Robin said, is how low you want the patient’s pressure to be. You want to make sure that you explain that to the patient. What’s the goal? How do you assess if there’s a change? How do you know you should be more aggressive? You want to ensure that you’re lowering the pressure in a way that prevents visual field loss, so you have to explain the purpose of the visual field to the patient. “I have never met a patient who loved taking visual field examinations,” he said.
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