Observer & Eccentric

Dr. Mark Rubinstein sees the future of glaucoma treatment moving more and more toward the use of laser but there's still no substitute for early detection and compliance by patients who are prescribed eye drops or medication.

When Rubinstein started treating glaucoma patients more than 20 years ago, the only options were drops and surgery. Today, 15 new drugs and the latest laser technology control the disease better.

While advances are being made, a cure is elusive. The sad fact is that three million Americans have glaucoma. Half of those remain undiagnosed and may lose sight before seeking treatment. Damage to the optic nerve from glaucoma is irreversible. Worldwide glaucoma is the leading cause of preventable blindness.

Eye drops, oral medication, laser and surgery treat the disease by lowering pressure in the eyes. Early treatment may eliminate the need for surgery Ð and prevent irreversible loss of vision.

Compliance factor

"The biggest problem is poor compliance," said Rubinstein of the Michigan Eyecare Institute in Southfield, Livonia and Dearborn. In 1982, Rubinstein participated in a pioneering study of lasers as a treatment for glaucoma at Sinai Hospital.

"Laser is relatively safe. When it comes to drops or laser, there's a great number of patients who don't use their drops. Laser has a huge advantage because compliance is not a factor. Laser is 95 percent successful with few complications. Drops are not free of side effects and can cause dryness, decrease in vision." The cost can also deter a patient. Eye drops can run more than $100 a month. For the uninsured and seniors on Medicare that's an out-of-pocket expense.

The latest laser treatment, SLT (Selective Laser Trabeculoplasty), leaves no damage to tissue but may need to be repeated over time. Even with well-controlled glaucoma, a patient needs to be seen every three months.

Rubinstein doesn't expect that to change anytime soon. Genetic studies probably won't help to eradicate glaucoma but the picture isn't all gloomy. Recent studies have yielded findings of one more possible risk factor to add to those of family history, diabetes, high blood pressure, and African descent. African Americans are especially at high risk, four to eight times that of Caucasians. These are the knowns.

Dr. Nauman Imami, an ophthalmologist and director of glaucoma services at Henry Ford Hospital, is investigating the unknown as part of the Ocular Hypertension Treatment Study, which has been ongoing for the last 10 years.

"We've learned that treating high eye pressure can reduce the risk, and measuring corneal thickness is important," said Imami, a glaucoma specialist who primarily sees patients with advanced disease at the Henry Ford Medical Center in Livonia and West Bloomfield in addition to Henry Ford Hospital. "Corneas thicker than normal read pressure higher than what they are. People with thin corneas we thought they were normal but their eye pressures are really greater than that. We think thin corneas are a risk factor but is it just a measurement difference?"

Future studies will reveal possibly more tools for predicting and treating glaucoma. Henry Ford Hospital is in the research stage of finding a medication to strengthen the optic nerve so it can fight the pressure that causes glaucoma.

See the doctor

"The most important thing is glaucoma is a painless, gradual disease that gradually takes their vision," said Imami. If they don't come in, they can lose a lot of their vision.

"I tell my patients to have their family examined, especially children around 40 or 50. Catch it at that point and you can prevent most of the problems. They're looking at a lifelong process that can't be cured, only controlled. With treatment pressure is down but you're never rid of glaucoma. You need to follow up. In my experience, if detected early enough they can control it enough so they don't lose their vision. The problem with glaucoma is it's an irreversible loss of vision, not like cataracts. With cataracts they can't see but if removed can start seeing 20_20 again. With glaucoma what you lose is forever lost."

Rubinstein recommends anyone over age 40 have their eyes checked for glaucoma every two years, over 50 or at high risk every year. Glaucoma can affect anyone at any age but especially individuals over age 60.

"The goal is to diagnose it earlier. Untreated glaucoma gets worse, and don't be afraid to ask for a second opinion," said Rubinstein.

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