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Glaucoma - Not all doom and gloom
- Wendy A Franks, City Road, London EC1V2PD UK (8 October 2006)
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Wendy A Franks, Consultant ophthalmologist Moorfields Eye Hospital, City Road, London EC1V2PD UK
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Christine Hartmann and her ophthalmologist Douglas Rhee report a gloomy story for ‘the patient’s journey’ in this week’s BMJ but glaucoma is a preventable cause of blindness and we have good evidence that treatment is effective. Sadly not all treatments work for everyone but Christine can still see and I hope she and Doug can take heart from the evidence that the future is not necessarily an inexorable progress to blindness. The Early Manifest Glaucoma Treatment Trial (1) was a population based study of treatment versus no treatment for people with glaucoma, including those with intraocular pressure (IOP) within the ‘normal’ range. It showed that a modest reduction in IOP was effective in slowing visual loss. The Collaborative Normal Tension Glaucoma Trial showed the same result. (2) Christine needs to have her eye pressure lowered by whatever means works for her, eye drops, laser or surgery, to preserve her sight. Glaucoma specialists are well aware that lowering eye pressure is not the only answer but clinical trials of other interventions do not have the same level of evidence. We know that there is a group of young women with normal pressure glaucoma who have vasospasm with Raynaud’s symptoms and migraine and who, like Christine, commonly have optic disc haemorrhages. Treating vasospasm may be helpful and small studies to improve ocular blood flow have shown promising results.(3,4) Untreated high tension glaucoma can progress rapidly but low tension glaucoma, even when untreated, usually has a very slow rate of progression, decade on decade. When it develops late on in life there is a case for not treating it at all if it is discovered at an early stage. A more aggressive approach is normally justified when life expectancy is long. Stopping smoking, regular exercise and all those boring thing doctors tell you may also help optic nerve perfusion and may reduce the rate of glaucoma progression. Do not give up Christine – we are on the road to understanding the genetics of low tension glaucoma (5,6) and in the long life I hope you have ahead of you even more effective treatments will come along. Another website that anyone interested in glaucoma might find useful is that of the International Glaucoma Association www.iga.org.uk References 1) Leske MC, Heijl A, Hussein M, Bengtsson B, Hyman L, Komaroff E. Early Manifest Glaucoma Treatment Trial Group. Reduction of intraocular pressure and glaucoma progression:results from the Early Manifest Glaucoma Treatment Trial Arch Ophthalmol 2002 Oct;120(10): 1268-9 2) Collaborative Normal Tension Glaucoma Study Group. Comparison of glaucomatous progression between untreated patients with normal tension glaucoma and patients with therapeutically reduced intraocular pressures. Am J Ophthalmol 1998 Oct; 126(4):487-97 3) Quaranta L, Bettelli S, Uva MG, Semeraro F, Turano R, Gandolfo E. Effect of Gingko biloba extract on pre-existing visual field damage in normal tension glaucoma. Ophthalmology 2003 Feb; 110(2):359-62 4) Gaspar AZ, Flammer J, Hendrickson P. Influence of nifedipine on the visual fields of patients with optic nerve head diseases. Eur J Ophtalmol 1994 Jan- Mar;4(1):24-8 5) Aung T, Okada K, Poinoosawmy D, Membrey L, Brice G, Child AH, Bhattycharya SS, Lehmann OJ, Garway Heath DF, Hitchings RA. The phenotype of normal tension glaucoma patients with and without OPA1 polymorphisms. Br J Ophthalmol 2003 Feb;87(2):149-52 6) Aung T, Rezaie R. Okada K, Viswanathan AC, Child AH, Brice G, Bhattycharya SS, Lehmann OJ, Sarfarazi M, Hitchings RA. Clinical features and course of patients with glaucoma with the E50K mutation in the optineuron gene. Competing interests: None declared |
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