Sick or Not Sick?
Subjective factors are often more important than objective measures.
By Dan Liu, MD
Mr. Smith came to our clinic as a last resort. He arrived with the weariness of someone who has exhausted all of his options but the optimism of someone seeking just one more. He was 84 years old and remarkably healthy for his age, having been a marathon runner his entire life. His wife, too, was an accomplished runner, and the couple had only recently decided to cut down their mileage to half-marathons.
Mr. Smith had a history of primary open-angle glaucoma, and he had already been seen by several glaucoma specialists in the area, all of whom recommended surgery for his progressing disease. He came to us hopeful that we could tell him otherwise, as he could not tolerate the idea of any interruptions to his daily running schedule.
In medical school, my understanding of glaucoma was limited to its association with IOP. In residency, I began to appreciate that glaucoma can be quite challenging and involves more than just IOP measurements; rather, it is a nuanced disease process monitored over time by OCT and clinical examination of the optic nerve for structural changes and by visual field testing for functional vision loss, all tailored to each patient based on the physician’s experience.
We use these parameters to guide our clinical decisions on a daily basis. My glaucoma attending, however, likes to ask for an additional evaluation. “Sick or not sick?” he’ll ask us. This parameter, of course, is a broad categorization of the patient’s overall health status, including medical comorbidities, functional status, and quality of life. In other words, what are the patient’s overall life expectancy and quality of remaining life, weighed against the progression of his or her glaucoma?
Mr. Smith was, by all measures, “not sick,” likely due in part to his lifelong dedication to running. However, it was clear that his glaucoma was progressing despite his having had multiple previous laser trabeculoplasty treatments in both eyes and being on maximum medical therapy. His visual fields showed an increasingly large nasal step with an arcuate scotoma in one eye and a dense paracentral scotoma in the other.
Like the other ophthalmologists he had seen, we recommended surgery. As with his previous ophthalmologists, the patient deferred. He refused to accept any option that could even temporarily affect his running. Thus, his many subsequent follow-up visits circled around the same dilemma: The very activity that likely kept him healthy and would extend his life expectancy seemed to be an insurmountable barrier to treating his glaucoma and preserving his vision. Preserving his vision, in turn, seemed to be necessary to maintaining his passion and quality of life.
My understanding of glaucoma and its management is ever evolving. Much of glaucoma management is based on objective measures, laid out in visual fields of black and white (or OCT graphs of red, yellow, and green); these are often the easiest to assess. The gray areas lie in the subtle subjective judgments we make based on our clinical experience.
But how do we predict which will outlast the other, vision or life? How do we assess whether the patient is able to self-administer drops? And how do we reconcile our idea of what is best for the patient with his or her own wishes? The difficult cases in glaucoma, I’m learning, are complicated by more than just borderline OCT scans and visual fields. They are influenced by other individualized, subjective parameters for which there are no concrete data, such as general health, life expectancy, functional status, compliance with prescribed medical therapy, patient preferences and autonomy, and even access to transportation.
STILL RUNNING STRONG
Our team had extensive discussions about surgery with Mr. Smith because we expected that he would have a long life expectancy. However, subjective factors, especially patient autonomy, are often more important than our objective measures. Mr. Smith never underwent surgery, but he is still happily running half-marathons.
Albert S. Khouri, MD | Section Editor
• Associate Professor, Program Director of Ophthalmology Residency, and Director of the Glaucoma Division at Rutgers New Jersey Medical School in Newark
• Member, Glaucoma Today Editorial Advisory Board
• Financial disclosure: None
Dan Liu, MD
• Second-Year Resident, Albany Medical Center
• Financial disclosure: None