Afew weeks ago, I walked into the examining room to see a new patient, a 52-year-old woman referred for a second opinion on whether or not she had glaucoma. Her examination confirmed excellent central acuity in both eyes, an elevated pressure of 26 mm Hg OU, thin corneas, open angles, early visual field loss, and abnormal disc imaging studies— all consistent with the diagnosis of primary open-angle glaucoma. When I confirmed the diagnosis suggested by the referring doctor, I noticed tears in the patient's eyes. I handed her a Kleenex and stated that she had essentially every sign associated with the early diagnosis of glaucoma. She asked if I were certain. I answered affirmatively and then mentioned that she needed to start treatment and, likely, a lifetime of observation and care. She sobbed and asked if I could “throw her a bone.” I impulsively responded, “Unfortunately, there are no bones in glaucoma.” Then, I began to wonder if there are.
It is not easy to be upbeat in this specialty. Glaucoma is a silent, insidious disease that is often diagnosed and/or discovered incidentally. As in this case, the patient is often surprised and then upset, particularly by the prognosis. Ironically, the happiest visitors to my practice were the families of infants born with congenital glaucoma that was successfully managed surgically. Today, most, if not all, of my patients deny the presence of their disease and are therefore only marginally compliant with therapy. Perhaps glaucoma's slow progress acts to their benefit. Unlike patients with macular degeneration, glaucoma patients continue for some time to be unaware that their nerve fiber layer is eroding. Fortunately, their central vision usually remains intact, and the onset of disease is often later in life.
Besides its slow course, glaucoma may offer a few other “bones.” For one, its treatment can only improve. We have made so little progress in this regard since the introduction of the prostaglandin analogues more than 10 years ago, yet surgical options have broadened significantly as of late. Moreover, basic research is finding similarities between glaucoma and other chronic neurologic disease such as Alzheimer's.1 Additionally, work in the areas of genetics, stem cells, and optic nerve regeneration are all positive signs of future progress.
Sometimes in our day-to-day interactions, we must act like the glass is half full. We must behave like the physicians of old who provided emotional support because they lacked therapeutic options. As caretakers in this period of transition, we must continue to offer patients the hope of a bone while silently realizing that a cure remains years away.
