Ask Dr. Pat · Health

Glaucoma: The Eye Disease You Don’t Know You Have Until You Have Loss of Vision

Dr. Pat likes to work as a collaborative physician. Her patients, she believes, will be her best partners in providing diagnostic information—as long as they are asked the right questions. She also believes in consulting with the best medical minds on issues that require specialization or unique clinical experience.

This week, during Glaucoma Awareness Month, she calls upon the expertise of ophthalmologist Leila Rafla-Demetrious, M.D., who specializes in glaucoma, to interpret the current recommendations on screening for this vision-stealing condition.

Dear Dr. Pat:

I am a 50-year-old African-American woman with hypertension that is well controlled, plus some slight enlargement of the heart that causes no symptoms. I am a master teacher in a highly regarded magnet school in New York. I asked my primary care doctor for a referral for an eye exam, since my sister recently developed older-age glaucoma (she is 70) and may become blind from a late diagnosis. The primary care doctor did a basic exam (finger wiggling to check if I could see from the sides of my vision and looking into my eyes with a simple hand held instrument). She told me that since I had no symptoms and had no change in my vision (I wear drugstore readers in restaurants with dim light), I did not need a referral for a visit to an ophthalmologist. She told me that the U.S. Preventive Services Task Force had found no reason to support screening for glaucoma in adults who had no symptoms. She said that the screening tests were inconclusive and that I would be given eye drops that might cause cataracts.

I had read about glaucoma and found that it is increased in African-Americans and that I was at greater risk because I had a sister with glaucoma. She still refused to give me a referral.  So I went to a major teaching hospital here in New York City, where I was examined by a resident, then by the senior doctor in charge of the clinic. I still had to pay for my visit, but certainly less than I would have paid to see a private ophthalmologist.

The resident doctor dilated the pupils of my eyes and examined them thoroughly. He measured the pressure inside my eye and looked at my eye nerve disc with a more sophisticated instrument than the hand-held device used by the primary care doctor. He then asked the senior doctor in the clinic to evaluate his findings. I do have glaucoma after all, even though my vision has not changed. I have wide-angle glaucoma, and the pressure inside the eye is still normal. The doctors told me to use two eye drops daily in each eye and to come back to the clinic in three months. There has been change already in the nerve disc, but they are hopeful that they can arrest the progression of damage. I always thought that glaucoma was caused by high pressure in the eye, but apparently not.

I am relieved that I have this diagnosis before I have lots of damage, and that I have a place to go where I can get good care. But how many other primary care doctors are there who do simple visual field testing by wiggling their fingers and looking into the eyes of patients that have not been dilated, and then refuse to allow patients access for screening? My sister may become blind because her glaucoma was found very late. Who makes these recommendations?  Should my brothers and sisters be screened?  What causes this kind of glaucoma, anyway? Can these drops keep me from losing my sight?



Dear Shirley,

I have asked our WVFC Medical Advisory Board member Leila Rafla Demetrious, M.D., a board-certified ophthalmologist, to answer this question. She is fellowship-trained in the medical and surgical treatment of glaucoma. Glaucoma is the No. 1 cause of blindness in African-Americans, and the risk of developing this kind of glaucoma is increased when a brother or sister develops it. You should tell your family members about this.

Primary care doctors are all aware of the recommendations from the U.S. Preventive Services Task Force (USPSTF) these days. Insurance companies plan to hold down costs by refusing to pay for a great many previously available preventive care evaluations—such as a visit to an ophthalmologist for glaucoma testing—to improve their bottom line, while pointing to the increasing health care costs as the reason.

Most patients do not have your determination to do the research that you did, then choose to pay for your evaluation because you made a decision that the “recommendations” did not make sense. Do share this information and the medical evaluations from the ophthalmology clinic with your current primary care doctor. All health care providers need to know their diagnostic limitations, and doctors need to really listen to the patient. You were at greater risk for glaucoma, and you did need an evaluation.

Thank you for sharing your experience and sending in your questions.

Dr. Pat

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