Page 5 - 21st Century Perspective - Glaucoma Supplement

Diagnostic Considerations

Introduction

The title of this activity is clear: Optometrists treat patients with glaucoma — not just glaucomatous
optic neuropathy. Treating fellow human beings makes the disease entity that much more important,

and more challenging. Most people think that as long as they see well, their eyes are fine. Few truly
understand the importance of regular eye care and screenings for asymptomatic diseases, such as
glaucoma.

Human beings are not utopic patients, and many seem oblivious to the need for consistent
adherence to and compliant use of their medications. To further complicate matters, pharmacies and
insurance companies make their own bureaucratic intrusions into our best efforts to prescribe
attentively for our patients. These companies may have legitimate concerns, but they pale in

comparison to the higher calling of preserving sight and enhancing quality of life. One final sobering
perspective is that lawsuits regarding “missed glaucoma” are commonly successful. Indeed, the
most common reason (by far), “failure to diagnose,” represents the pinnacle of litigation. Before
delving into therapeutic intervention, particularly regarding topical medications, let’s take a brief look
at diagnostic considerations. After all, proper therapy is predicated upon a solid diagnosis.

Lest one think either diagnosis or medical management is always crystal clear, we want to assure

the reader that many cases are diagnostically nebulous; fortunately, therapy is relatively less
challenging.

Diagnostic considerations

Optometrists should first consider patient history to screen for a positive family history of glaucoma,
particularly among siblings. A positive parental history is less important than a positive contemporary
sibling history. Most patients are in their 50s or 60s when they receive a diagnosis of glaucoma; this
means that your glaucoma suspect patient could have parents who were most likely diagnosed in
the latter part of the 20th century. At that time, intraocular pressure (IOP) of more than 21 mm Hg

was generally treated as glaucoma, irrespective of optic nerve head health, and pachymetry was not
yet known to be of importance. Therefore, we place more diagnostic consideration on the ocular
health status of the siblings, who are more likely to have been diagnosed using more recent
diagnostic guidelines.

Beyond a solid family history of disease, we next carefully evaluate the character of optic nerve head

anatomy. This is the most critical diagnostic maneuver, especially noting the neuroretinal rim tissue

5