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Optimizing care of patients with ocular hypertension and glaucoma requires understanding that glaucoma is a chronic, progressive disease existing along a continuum both in terms of clinical severity and its impact on quality of life.
Orlando, FL-Optimizing care of patients with ocular hypertension and glaucoma requires understanding that glaucoma is a chronic, progressive disease existing along a continuum both in terms of its clinical severity and its impact on quality of life (QOL), said John Spalding, OD, at the annual meeting of the American Academy of Optometry. Dr. Spalding led a session on QOL in the glaucoma continuum, together with Anthony B. Litwak, OD, Baltimore Veterans Administration Medical Center (VAMC).
"Conventionally, optometric training for glaucoma care and the clinical approach to management taken by practitioners focuses on monitoring IOP, visual acuity, visual fields, and structural changes. Certainly, attention to those endpoints is important for guiding clinical decisions and providing good patient care. However, from the perspective of affected patients, what matters most is how well they function and how well they feel," said Dr. Spalding, optometry resident and student program supervisor at the Orlando VAMC, Orlando, FL.
"Recently, we have seen a paradigm shift with an increased interest in [QOL] issues," he continued. "Investigating [QOL] in patients on the glaucoma continuum gives the eye-care provider (ECP) a sense of how to intervene to improve our patients' life experience, and by letting them know you care, it can also can help to build a better patient relationship."
There is good evidence that glaucoma has a substantial impact on QOL. Even though patients are not symptomatic based on traditional measurements until later in the disease continuum, their QOL can be affected at the very beginning.
Multiple factors contribute to the QOL effect of glaucoma-the diagnosis itself has potential psychological ramifications, the disease can lead to functional loss that interferes with lifestyle, and treatments can create a burden because of direct and indirect costs, side effects, and convenience issues. The importance of these various factors differs depending on where patients are on the glaucoma continuum, Dr. Spalding explained.
Disease-related QOL issues for ocular hypertensives relate in part to the diagnosis itself because patients who are told they have glaucoma can develop fear and anxiety about their risks of vision loss and blindness. With these psychological ramifications in mind, clinicians should think carefully about placing the burden of a glaucoma diagnosis on a patient without structural damage or functional vision loss, Dr. Spalding suggested.
For patients who are very early on the glaucoma continuum, the potential impact of treatment on QOL should also be considered along with traditional risk-factor assessment when deciding about initiating treatment. When treatment is definitively indicated because of existing structural or functional loss, the management decision should also weigh the effects of different therapeutic options on QOL.
"Although the role of selective laser trabeculoplasty as the first-line of treatment for patients with glaucoma is somewhat controversial, from a [QOL] perspective it can have several advantages compared with medical management. However, laser treatment also has downsides as it is not without side effects, may not eliminate the need for medication, and its IOP-lowering effect may wear off," Dr. Spalding noted.
Taking away the keys
An impact on QOL associated with functional vision loss emerges when visual field loss has progressed so that the mean deviation is worse than –12 dB. At this point, patients are more symptomatic and the greatest impact of their vision loss is likely to be on their ability to drive.
"It's been well established through a number of studies that [QOL] diminishes when driving is compromised due to loss of independence and self-esteem. For example, results of the Salisbury Eye Evaluation Project showed that once patients stop driving, they are more likely to enter a long-term care facility and have higher rates of depression," Dr. Spalding said.
Therefore, as patients progress along the glaucoma continuum toward this point, it becomes important to discuss with them and their families how their disease may eventually prevent their ability to drive.
"Patients and their families must be educated that there are vision-related requirements for driving, and doctors must also understand and fulfill their responsibility to report patients who should no longer be driving," Dr. Spalding said.
Once patients develop severe visual impairment from glaucoma, that is, visual acuity of worse than 20/70 or severe visual field constriction, general mobility becomes impacted. For example, these individuals will find the need to walk slowly and experience trouble navigating stairs and crossing the street. Optometrists can help to improve QOL for these end-stage glaucoma patients by making sure they receive proper referral to a good vision rehabilitation specialist, Dr. Spalding said.
"Vision rehabilitation service is one of the most underused areas in eye care because, unfortunately, patients are often unaware of its availability, do not receive an appropriate referral from their [ECP], or are in denial and fail to follow up on a referral," noted Dr. Spalding.
Although some generalizations can be made about QOL at different stages along the glaucoma continuum, patients have different perceptions on what defines QOL and are therefore impacted differently by the disease. Therefore, individual investigation is important and, for this purpose, the 15-item glaucoma QOL questionnaire (GQL-15) is considered by some researchers as the most clinically useful tool for ECPs to use in routine patient care.
The GQL-15 focuses on the physical impact of the disease and asks patients to rate their difficulty in performing 15 activities of daily living using a scale of 1 (no difficulty) to 5 (severe difficulty). The 15 items represent four broad categories of visual disability-central and near vision, peripheral vision, dark adaptation, and outdoor mobility, and the impact of the patient's glaucoma is determined by computing the total numeric score.
"Optometrists should consider the inclusion of a basic [QOL] assessment at the diagnosis of glaucoma and again at periodic intervals. These results along with traditional measures of the patient's status (VA, IOP, VF, ONH/NFL analysis) may lead to a better understanding by the doctor of what patients are going through along the glaucoma continuum," Dr. Spalding said.
"Improved understanding of ocular disease and its impact on patients is what we are all trying to attain. [QOL] assessment is just one more weapon in the battle," he concluded.