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MS. SARAH DISANDRO: Hello, and welcome to today’s Glaucoma Chat, “Gathering Support for Your Glaucoma Diagnosis.” My name is Sarah DiSandro, and on behalf of BrightFocus Foundation, I’m pleased to be here with you today as we talk about how to navigate a glaucoma diagnosis with confidence.
Our Glaucoma Chats are a monthly program in partnership with the American Glaucoma Society, designed to provide people living with glaucoma and the family and friends who support them with information straight from the experts. All Glaucoma Chats presented by BrightFocus Foundation are also available to listen to as podcasts on YouTube, Spotify, iHeartRadio, Amazon Music, Apple Podcasts, and Pandora.
BrightFocus Foundation’s National Glaucoma Research Program is one of the world’s leading nonprofit funders of glaucoma research and has supported nearly $51 million in scientific grants exploring the root causes, prevention strategies, and treatments to end this sight-stealing disease.
Now, I would like to introduce today’s guest speaker. Dr. Lawrence Geyman is a fellowship-trained glaucoma specialist with expertise in glaucoma management and surgery. He has a particular interest in addressing the needs of diverse patient populations and in optimizing clinical workflows. Aside from his clinical work, he serves on the American Glaucoma Society Patient Care Committee and on the Advisory Board of OphthoQuestions, an online study platform dedicated to educating ophthalmologists in training. Dr. Geyman prioritizes patient education and satisfaction and strives to build a warm, meaningful patient–physician relationship. He strongly believes in empowering patients to make health care decisions that align with their goals. Welcome, Dr. Geyman.
DR. LAWRENCE GEYMAN: Thank you. It’s a pleasure to be here.
MS. SARAH DISANDRO: Great. Okay. So, we know that when it comes to glaucoma, early detection and adhering to a treatment plan are key to slowing its progression and vision loss. Where does a person start if they are concerned about glaucoma? What type of provider should they seek out?
DR. LAWRENCE GEYMAN: Thank you. That’s a wonderful question to start with. I think that many adults, maybe younger adults, they see an optometrist for vision exams, which is a provider who is typically charged with prescribing glasses, contact lenses, and has some experience with medical care. I would say that if one is already seeing an optometrist as part of annual screening, if they are younger than 50 and there is no concern about glaucoma, neither from the patient nor the optometrist, there is no family history, then it would be reasonable to stay with that provider, especially if this provider has some more experience with the medical aspects of vision care. But if one is above or around the age of 50, or if there is any concern either from the provider that you are seeing or from the patients, especially if there is any family history—and this is a strong focus now, actually, from the American Glaucoma Society—certainly seek care with an ophthalmologist. And if there is any doubt, seek care with an ophthalmologist. These providers, I myself being one, have experience in the medical and surgical aspects of eye care. In terms of seeing a glaucoma specialist, I would say this would be recommended if one is at least a moderate-risk suspect for glaucoma or certainly if one has been diagnosed with glaucoma. And just a small point: Although unrelated, an optician is frequently confused with these, and that is simply somebody who dispenses spectacles, glasses, not a physician.
MS. SARAH DISANDRO: Right, okay. So, that’s a great information. So, an optician, you know, that’s somebody you would see maybe … I am thinking of like Target or Walmart. You might see an optician, and that person prescribes glasses. Okay, but then they could refer you.
DR. LAWRENCE GEYMAN: And this is, sort of, a point of confusion among many, many people, that an optician being somebody who just dispenses spectacles and optometrist being a provider who specializes more in the measuring of vision but also has some experience with the medical aspects of vision care. And then we have an ophthalmologist who is the medical doctor, the surgeon, and then within that, a glaucoma specialist for those who have glaucoma—or I would say are at least a moderate-risk suspect for glaucoma.
MS. SARAH DISANDRO: Okay, great. Thanks. Can you walk us through what should happen during that first appointment, including testing and all of that? What should occur at that first appointment?
DR. LAWRENCE GEYMAN: The first appointment is a busy one. There are certain examinations and techniques that are used that may only be done at that visit, and that visit is a longer visit, certainly, by quite a long stretch of time. Most likely, you will first be seen by an ophthalmic technician. This is akin to somebody at a regular doctor’s office checking blood pressure, but instead of that, we have our own “eye vital signs,” the vital signs for the eye. This being the eye pressure, this being the visual acuity, how well we can read those letters or numbers on the screen. Then, the patient will often be seen by a photographer, somebody who will take pictures of the eye and somebody who will administer a visual field test, which we will address in a few seconds. And then, typically, the third medical person that the patient will see will be a doctor, either a comprehensive ophthalmologist or a glaucoma specialist. The glaucoma specialist may repeat the pressure of the eye, and this is actually a frequent point of confusion, both for patients and for providers and just for staff in general. Sometimes the eye pressure is measured several times on different modalities.
One thing to note, especially for patients, is the gold standard, the most accurate way to measure eye pressure is the way that is measured during the physician’s portion of the exam with a little blue light that gently pushes on the eye, but there are other estimations that we use that suffice in most clinical cases. Most patients will undergo a visual field test, which is a test that measures the peripheral vision. Since glaucoma affects the peripheral vision before the central, we want to check the peripheral vision, and patients will often look at a light and then be asked to click a button if they see flashing lights around them. And then, finally, there is the actual examination by the doctor, which is a microscope exam, and sometimes they put a little contact lens on the eye, typically in that first or second visit. It’s a little uncomfortable, but it’s an important exam. And that’s the first visit.
MS. SARAH DISANDRO: Okay, great. Thanks for walking us through that. So, how can people who have glaucoma best prepare for their appointments to get the most value from their time with their doctor?
DR. LAWRENCE GEYMAN: Certainly. The time is a little limited, and appointment slots have gotten shorter and shorter and shorter over the years. I would say certainly getting a good night of sleep. Lack of sleep can make one more light sensitive. And a certain amount of light sensitivity is natural, especially with the bright lights that we use, but it will make it easier for the physician to examine the eyes if one is well rested. For those who wear makeup, this is something that’s not talked about quite a lot, but it does make a difference. The surface of the eye can actually not be as clean if there’s a lot of makeup being worn, so just a note to minimize that if possible for that appointment. And then, coming prepared with outside notes if this is a referral, if this is a second opinion. Either faxing or emailing those notes in advance or perhaps just bringing them for the doctor to review on the day of the appointment is key, and certainly coming with any questions prepared, although most offices now have some sort of patient portal where questions can be posed after hours.
MS. SARAH DISANDRO: Okay, that’s very helpful. Now, once you receive a glaucoma diagnosis, how often should you return for follow-up appointments?
DR. LAWRENCE GEYMAN: This is very case-dependent, and it’s provider-dependent. I would say if a patient has diagnosed glaucoma—it’s not a suspicion anymore, it is a true diagnosis—typically, the visits are anywhere from every 3 to 6 months. Over 6 months would be a bit unusual. We strike a fine balance between seeing the patient soon enough to notice any changes in the examination or testing; however, also long enough for any changes to manifest, for them to not be ambiguous or uncertain. Shorter than 3 months, very reasonable. That would be if the condition is active, something is getting worse, unfortunately, or maybe the eye pressure is too high—even visits every 2 to 3 weeks in those cases. It is not unreasonable for after certain glaucoma surgeries to see a patient multiple times a week, where we’re really trying to set the patient up for success. But for a general appointment, it would be 3 to 6 months on average.
MS. SARAH DISANDRO: Okay, great. Now, what are the warning signs that should prompt somebody to seek immediate care between scheduled appointments?
DR. LAWRENCE GEYMAN: It’s a great question. I would divide these into medical reasons and then patient-related reasons. Medical, it depends on the type of glaucoma. There is a less common type of glaucoma called angle-closure glaucoma, where the natural drain in the eye is at risk of closing. And it can close at any time, unfortunately. We try to lessen that risk with procedures, but it can still happen. As I often tell my patients, there is nothing subtle about the natural drain closing suddenly. The eye will be incredibly painful, red, and there will be severely blurry vision. If a patient is deciding whether or not this is something urgent, it’s probably not this. This is very, very obvious.
Aside from that, which is fairly rare, there are signs that the vision is worsening. One is bumping into objects, tripping while walking. They can no longer navigate even in their home well. Since glaucoma affects the peripheral vision before the central vision—there’s a slight asterisk there because I say in most cases—the navigation and movement are typically affected before the reading vision, and so it’s important to see how one is moving about and making sure that one can still see their feet while walking or the sides when they are moving.
The last is those patient-related reasons, and that’s probably the most common: medication causing irritation, having itching around the eyes. Sometimes medications or treatments can even cause the skin around the eye to become dry and scaly. Certainly, we don’t want our patients being uncomfortable, and so these are all reasons to come in sooner or, at least, to notify your physician that this medication may not be the one for me.
MS. SARAH DISANDRO: Right. Earlier, when you were talking about when people start to notice differences in the way they’re navigating and things like that, if somebody notices something like that, that they’re bumping into walls like you mentioned, what should they do? Should that be an immediate call to their eye doctor, or how quickly should they seek care if that were happening?
DR. LAWRENCE GEYMAN: Certainly, we would not consider this an emergency. But certainly, I would move the appointment up to within a week or two. I wouldn’t say very rare, but it is not uncommon for glaucoma to progress rapidly. In our field, we call these “rapid progressor patients,” patients whose glaucoma for whatever reason, and it could be very high eye pressure, there could be a genetic predisposition. This is ongoing, active research that is very frequently being published now about genetic predispositions. Their glaucoma, even after some stability, can progress more rapidly. Again, rapidly in the context of glaucoma—we are still talking in the order of months—but certainly, want to stop that declining vision, and so we would ask the patient to certainly make an appointment within a week or two, repeat the visual field test that I was mentioning so we can see: Is this glaucoma, or maybe not? Maybe if there is a cataract in the eye clouding up the lens, it could be that. Perhaps the eyes are dry. These are two other often confounding factors that doctors have to piece apart to see if it is the glaucoma or not.
MS. SARAH DISANDRO: I see. That’s very helpful. Thank you. In general, how is glaucoma treated, and is treatment done in the office, or can it be done at home?
DR. LAWRENCE GEYMAN: That’s a great question. I divide it for my patients into offense and defense. Offense is the eye pressure. That is what is trying to damage the optic nerve—which is the recipient of the damage—and the optic nerve is damaged, and then the patient loses vision. The optic nerve connects the eye to the brain, and so if the optic nerve is damaged, the brain will never get the information from the eye, and there we have the vision loss. The defense is how strong is the optic nerve. Unfortunately, we do not have any proven therapies on how to improve the health of the optic nerve. So that is, again, an area of active research. We call this neuroprotective, neurological protective, where we are trying to strengthen the optic nerve. In that realm, a healthy diet and exercise has been shown to help, and certainly steering clear of chronic diseases and maintaining normal blood sugars and blood pressure and working with your primary care doctor to overall lead a healthy life. This is important for that defense.
For the offense, that’s how we treat it. We treat the eye pressure. We lower the eye pressure to stop that damage onto the optic nerve. There are three ways to do it. We can either use eye drops, which work in various ways, and they’re typically used one to three times a day. We have some laser procedures that we have had for about 2–3 decades, but there has been some recent studies in the past, 5–7 years that have given a lot more support to using these laser procedures sooner, even sometimes as the first-line therapy. And although this is a U.S.-based practice, in the U.K., actually, they have as their first-line, the laser treatment. That is their recommended first line, and it’s an in-office procedure. Lastly, we have real surgeries, and we would only do that, of course, if there is truly a need for it, if the eye pressure is not responding to something more conservative.
MS. SARAH DISANDRO: Thank you. That’s very interesting and such great advice. So, what information should someone who is newly diagnosed with glaucoma know that they don’t often ask about?
DR. LAWRENCE GEYMAN: I think it’s important to ask what one’s personalized risk is for worsening. Although the holy grail would be genetic predisposition and, sort of, a genetic score—again, this is an active area of research—we don’t have that, and so we look at the maximum eye pressure, family history, very important. That is, in a way, the genetic risk factor score without all the research. And then one’s overall level of health, I think, are all factors that we take into account. I would secondly ask the doctor, “If I have vision loss”—if the patient has vision loss—“how will this impact my function?” There has been a lot of research, a lot of work that came out of Baltimore that really informed our understanding of how glaucoma affects patient’s vision, and that’s an important conversation to have, if it has gotten to that point, with one’s doctor. As they mentioned, glaucoma typically affects the peripheral, the side vision first. So, it will not be so much central. So, if it’s peripheral, well where is the peripheral loss? Is it on the bottom? So, if it’s on the bottom in both eyes, we need to be very careful about walking and making sure that the patient can see the bottom of their feet, the floor when they are looking straight. If it is on the sides, then we move into driving. Can we see the cars next to us? Are we bumping into objects? And then if it’s central, this is typically more commonly seen in women in their 50s and 60s. There is a sub-form of glaucoma where the central vision can be seen, and it is also seen in certain ethnic groups, as well, and your doctor can speak to that a little more, the central vision can actually be affected early, and then we are talking about reading.
MS. SARAH DISANDRO: All right. As with any new diagnosis, there are costs associated. What can you tell us along the lines of payment and insurance information?
DR. LAWRENCE GEYMAN: It’s a very common question. Thank you for asking that. This is a question that I and many physicians receive. There’s a little bit of lack of transparency sometimes with insurance carriers, and patients always want to know, is this covered? First and foremost, glaucoma is a medical diagnosis, and the coverage should be through medical, not vision insurance. The vision insurance is really for glasses. It doesn’t fall under the medical diagnosis category. Then, are the medications or surgeries covered? Medications are typically covered, and the question is always generic versus brand name. The efficacy on the whole is pretty equal. There are some studies that will suggest that certain brand medications may be better, but I would ask your doctor if they feel that that difference is clinically meaningful. Where brand versus generic really comes into play—and again, brand is going to be a more of a challenge with the insurance coverage—is in comfort. There are really no medications that are preservative-free. There is a preservative in all bottled medication that for some patients is very irritating and for others is just at least annoying enough to be a problem. So, all generic medications typically will come with this preservative, and some patients are just not tolerant. Then, that’s a conversation about getting medications that do not have this preservative, and those are almost all brand name, or finding medications that have a preservative but it’s gentler, and there are two medications like that. For patients who tolerate standard, normal eye drops with the standard preservative, usually there is no reason to go down the route of the no-preservative medications, but again, that’s a conversation with one’s doctor.
With surgery, again, these are medically necessary procedures. The in-office laser procedure is medically indicated. It’s typically covered by insurance, but, again, every plan is different in regard to deductibles, copay, and coinsurance. For true surgery, sometimes you do cataract surgery with some additional procedures. This is a highly evolving field, and if your doctor is recommending one of these, maybe stents or drainage system procedures, I would certainly ask them, “Do you think that this will be covered? Is there a chance it will not be?” Certainly, nobody wants surprise bills.
MS. SARAH DISANDRO: Right, exactly. That’s very helpful information. We actually receive questions about this, as well, and it’s such a nuanced area. So, let’s move into resources and support for glaucoma, starting with low-vision therapy. How beneficial is low-vision therapy, and how would our listeners be able to get started if they were interested in that?
DR. LAWRENCE GEYMAN: It is very beneficial, and it’s something that I recommend to my patients who have vision loss where I feel they may benefit from the assistive devices or other technologies that low-vision specialists can provide to them. I will typically ask patients who may be at this point with their vision if they are able to carry out complex tasks, like shopping, paying bills, or cooking, and then even simpler tasks, such as bathing or brushing teeth, things along that nature. And if we see that there is some difficulty, I will offer it to my patients.
Low vision is a subspecialty of optometry, that field I mentioned before that is more related to dispensing of glasses and contact lenses, but low vision is one of their subspecialties, and certain optometrists are specialized in this, and others also do it maybe without the formal specialty. And most communities will have a few low-vision specialists. Some states also have commissions for the blind and visually impaired. They also have vocational rehabilitation, maintaining employment skills, skills for independent living, and other educational services. So, you can always ask your doctor or call the number for the commission to see what resources they have.
MS. SARAH DISANDRO: Okay, that’s great. Building a support system of family, friends, and those in your community can be beneficial, as well. What advice do you have for our audience on places to seek support?
DR. LAWRENCE GEYMAN: Seeking support can be tricky, but there are support groups, both in person and online, that are available. There are university-sponsored peer support groups. I’m based in New Jersey, and there’s one that is offered over the phone at Rutgers University. There is a support education group in New York, for example. I would start by asking your physician if they know of a local group. Certainly, in person is better than virtual, if one can do that, just to connect with other people. As I mentioned before, there is commission for the blind in my home state of New Jersey, but most states also will have a commission for the blind or a similar organization. If your vision loss is advanced where you may benefit from their services, as I mentioned a few minutes ago, they may also have support groups where you can learn from other individuals how they are going about and treating their glaucoma and how they are treating their low vision if it has gotten to that point.
MS. SARAH DISANDRO: Right, great. That’s very helpful. Also, BrightFocus Foundation’s National Glaucoma Research Program also has a Facebook support group. We’ve noticed some people communicating there and sharing advice, and it’s moderated. So, I think that’s important with a group to make sure that it is moderated, that the information is legitimate, as well. That’s great. Thank you so much.
DR. LAWRENCE GEYMAN: Very good. Yeah.
MS. SARAH DISANDRO: Yeah. So, how important is psychological support for glaucoma patients, and how do we address that aspect of care?
DR. LAWRENCE GEYMAN: Addressing this is very important, and there’s been very little written about this specifically when it comes to glaucoma patients. There have been articles written about vision loss in general. We see the world through our eyes, and we’re always acutely aware of the presence of our eyes and of our vision, probably more than any other organ. And so, I always feel that it is particularly unsettling to know that one has a condition affecting their eyes because they are so ingrained in our psyche and, really, in ourselves. Every individual approaches news differently—positive and negative—and everybody has different risk tolerances for procedures and has a different goal in mind. Some approach news with anxiety; others are fairly relaxed. And I am sure everyone in our lives has seen this—not just in vision loss, but across all spaces. There is no right approach. It depends on the personality. I would say working with your physician, who should be guiding you through difficult periods. If there is a time of vision loss, perhaps the glaucoma progressed very rapidly before things were able to be stabilized for various other reasons, certainly, you should work with your doctor to make sure that you are feeling cared for and that there is no undue stress and that all of your needs are being taken care of, you are still able to do all of those activities that I mentioned before, certainly.
MS. SARAH DISANDRO: Absolutely. Okay. So, that ends our questions, but we do have some time to move into some listener questions that we’ve received. The first question that came in says, “I’m getting proper medical care and following medical advice, but that may not stop my glaucoma. Are there things I should be learning or doing now while I can see to prepare for the possibility of losing my sight?”
DR. LAWRENCE GEYMAN: Certainly, I wouldn’t say there’s a way to “prepare” for the possibility of losing sight, and I don’t address this with my patients. Most patients do well and do not suffer a rapid or cataclysmic decline, but if one does feel like their condition is headed in that direction, there are measures to take to alleviate that loss of function. With glaucoma and all eye conditions, there’s a loss of contrast. We know this from many studies. We know this from speaking to patients. So, making sure that one’s household is well lit, every room is well lit, to make sure that really a tremendous amount of light is coming into the eyes because there’s just fewer nerve cells that are available to transmit lights, so we really want to make sure that every single nerve cell in a way is getting the most amount of light. Other interventions: no-slip floors; fall-proof bathrooms, such as showering with a chair; making sure the floor is decluttered; securing rugs to the floor. This gets to seeing one’s feet when they’re walking. If that becomes an issue, we want to make sure that nothing is mobile, the floor is decluttered, clear walkways. People can mark doors, use tactile markers to locate items. And when it comes to driving a motor vehicle, that’s an honest conversation that one needs to have. Lastly, to go back to the low-vision specialist, I think that’s a very valid path to take if the vision has really gotten to that point regarding assistive devices and having family and friends help with more complex tasks, such as shopping and cooking, if needed.
MS. SARAH DISANDRO: That’s great advice. All right, so next is another listener question that we received. “What tips do you recommend for those who have trouble remembering to take their eye drops each day? Also, if someone is on multiple drops, how far apart should they be taken?”
DR. LAWRENCE GEYMAN: That’s a great question, and this is a question that I receive all the time. Some people will set an alarm, and I think that’s a very valid approach. Most eye drops are taken one to two times a day. That third afternoon dose, if your doctor recommends it, of course, do it. That’s typically the one that is forgotten, and there are very few medications—I mean, really just one, maybe two—that need that or could possibly benefit. So, setting an alarm is reasonable, putting the medications by your nightstand. There are at least two classes of medications that are only taken at night, and then all the others are at least twice a day, meaning one of them will be at night. So, putting the medications by one’s nightstand.
Lastly, and this is an answer that this is not something that’s covered by insurance, and I wish it were. And I hope that in the future we have more options. There are pharmacies that can create custom medications. So, this answers the first question and gets to the second. Patients who are on multiple medications, there are actually some pharmacies that will combine them together and create essentially a new medication, and that does make it easier for certain patients to take their medications. And they will do this even though this medication does not exist commercially. Interestingly, in other countries, they actually do have combinations that we don’t have here, but there are these avenues, these specialty pharmacies that can make these eye drops for patients and make it easier to remember if now it’s not many eye drops—one, two, three times a day—maybe it’s just one or two. Lastly, the question about how long to wait. We typically recommend waiting about 3 to 5 minutes between eye drops to make sure that the second one does not kick out the first.
MS. SARAH DISANDRO: Okay, that’s great. Thank you, Dr. Geyman, for the invaluable insights you shared with us today. Dr. Geyman, before we close, do you have any final words of advice for our audience?
DR. LAWRENCE GEYMAN: Thank you. I would say that the majority of patients do well, though it is important to continue to follow the instructions of your doctor throughout this long-term diagnosis, especially when it comes to medication use and the appointment frequency. If you feel that your vision loss has affected your daily life, it’s important to discuss that with your doctor. This is a chronic condition, and its treatment stretches for years. Having a strong patient–physician relationship, I believe, is of utmost importance, possibly the most important. We, as glaucoma specialists, we’re striving to stave off vision loss, and it’s a combined effort between the patient and physician that brings about positive outcomes in our experience. I appreciate everyone for listening. Thank you. Thank you for your time, and I wish all of our listeners the best of luck in their health.
MS. SARAH DISANDRO: Thank you so much, Dr. Geyman. Our next Glaucoma Chat, “Can Non-Drug Interventions Reduce Glaucoma?” will be on Wednesday, April 9. Thanks again to everyone for joining today, and this concludes today’s Glaucoma Chat.
Useful Resources and Key Terms
BrightFocus Foundation: (800) 437-2423 or visit us at BrightFocus.org.
Available resources include—
Helpful treatment options or resources mentioned during the Chat include—
- Low-vision therapy
- Home interventions (such as no-slip floors, shower chairs, rugs secured to the floor, decluttered floors, and clear walkways, as well as marking doors and using tactile markers to locate items)
- State commissions for the blind and visually impaired
- Rutger’s University Eye2Eye Peer Support Program for Vision Loss
- Specialty pharmacies that can combine medications (also known as compounding pharmacies); note that this may not be covered by insurance.
