End-stage glaucoma requires outside-of-the-box management

Although the aim of glaucoma management is to maintain visual function, the role of the ophthalmologist does not end once a patient has lost useful vision.

Speaking at the Glaucoma Symposium during the 2017 Glaucoma 360 meeting, Robert L. Stamper, MD, discussed care for patients with end-stage glaucoma, including provision of palliative measures, counseling on resources that will enable a reasonable lifestyle, compassion, and hope.

“It is important for us not to abandon end-stage glaucoma patients because we feel failure or frustration or because they are blind,” said Dr. Stamper, professor of clinical ophthalmology, director emeritus of the Glaucoma Service, University of California, San Francisco. “The fact is there is still a lot we can do for them.”

Other assistance

Dr. Stamper pointed out that when physicians cannot slow the process towards blindness, they need to be knowledgeable about other assistance they can provide. “We need to communicate to patients the services that are available,” he added. “We should always offer comfort and sympathy.”

In the contemporary era and despite the best of care, up to 11% of glaucoma patients become blind or visually disabled. Dr. Stamper suggested that once a patient has lost a considerable amount of vision, it is time to talk about the possibility that significant visual disability may be forthcoming.

“It is important to acknowledge the patient’s feelings of helplessness, isolation, and loss of independence,” Dr. Stamper said. “It is not a bad idea to acknowledge your own feelings of frustration at not having been able to stop the inextricable downhill course.”

Having the patient’s family or friend present for the discussion can help the individual recall and process the information later. The conversation might include a suggestion that the patient seek a second opinion.

“Keep in mind that no physician can think of every option for every situation, so offer the patient the idea of seeing another glaucoma specialist or consider discussing the case with a respected colleague,” Dr. Stamper said.

When conversing with these patients, physicians should choose their words carefully, remaining sensitive to cultural differences and the perceptions that blindness may have for a particular individual. They also should be alert for signs that the patient is depressed.

“Help the patient understand that visual disability is not the end of things, but rather the beginning of a different type of life,” Dr. Stamper said.

“If the patient seems depressed, however, discuss psychotherapy, and be proactive about finding out whether the patient has thought about hurting himself or herself and thus requires urgent psychiatric referral,” he added.

Host of resources

Host of resources

Dr. Stamper reviewed tools and services for the visually impaired that are available from federal, state, and private organizations. They include groups for emotional support and vocational counseling services for those who are in the workforce.

“It is important to realize that 30% of people who are blind are still employed,” Dr. Stamper said. “People who are blind can still enjoy life and many recreational activities that sighted people do.”

There are aids for assisting patients with activities of daily living, including handicapped parking stickers for transportation, products that enable reading if the patient is partially sighted, and products and services for maintaining function and safety at home.

“In California, the Department of Rehabilitation operates a residential center, where patients can live for six to nine months to learn skills to function as a partially sighted or blind person,” Dr. Stamper said.

There are also programs that provide training in financial management and financial assistance for the visually impaired. Individuals may be eligible to receive disability or supplemental income payments from Social Security, income tax credits, reduced public transit fares, free prescriptions, free postage for books or other items related to their disability, and coverage by Medicare or Medicaid.

Ophthalmic care

Ophthalmic care

For glaucoma patients who have lost useful vision, the focus of medical care shifts to palliation. Intraocular pressure still needs to be controlled at a level that is low enough to prevent pain.

It is also important to manage corneal edema to prevent the development of painful bullae. That may include the use of hypertonic salt solution, bandage soft contact lens wear, keratoplasty, or corneal cautery.

Interventions that can be used for pain control include atropine, topical corticosteroids, topical NSAIDs, retrobulbar chlorpromazine, or alcohol–even evisceration or enucleation.

“Some of my happiest patients are the ones who finally agree to evisceration or enucleation after enduring pain for some time in a blind eye,” Dr. Stamper said.

Robert Stamper, MD

E: stamperr@vision.ucsf.edu

Dr. Stamper has no relevant financial interests to disclose.