I have to take exception to “Speak No Evil” (October 2010).

Dr. Fanelli presents a case of advanced glaucoma that was ostensibly missed by another provider and gives advice on how to avoid impugning the reputation of the doctor who missed the original diagnosis. I have no argument with this approach, but in the case presentation, he states that the patient had IOP of 40mm Hg O.D. and 36mm Hg O.S., as well as advanced nerve damage, which he documented at 0.75 x 0.85 O.D., and 0.80 x 0.90 O.S. He scheduled the patient for follow-up two weeks later without beginning treatment.

We all understand that glaucoma is a chronic disease that damages the optic nerve over many months and years, but to let a patient leave the office with IOP at this level and severe optic nerve damage is unconscionable in my opinion. There is no rational explanation that justifies allowing the patient to leave the office untreated with such significantly elevated pressures. It clearly sends the wrong message to your readers (and implies to me that Dr. Fanelli is somewhat complacent in his approach to the disease).

A patient with advanced glaucomatous cupping and IOP in that range should not be left untreated for any additional time.

––Rob Pinkert, O.D.
Phoenix

Dr. Fanelli Responds:

I appreciate the time Dr. Pinkert took to respond to the October Glaucoma Grand Rounds column.

He believes there is no rational explanation for deferring therapy in a glaucoma patient, and that I was complacent in my care. It is important when beginning therapy that all diagnostic data is obtained before initiating therapy. Without this, it is difficult to quantify what therapeutic effect is obtained.

On the initial visit, a structural evaluation of the optic nerve was undertaken. Significantly absent from the initial work-up, due to time constraints, was any functional assessment of the patient’s disease state. This was scheduled to be done within a few days. In our office, when a patient is scheduled for a “two-week follow-up” for a glaucoma work-up completion, the visit must be completed no later than two weeks from the initial visit; it is the longest that the visit would be scheduled. In other words, I am telling the patient to come back within a two-week window. It just so happened that this patient did come back in two weeks after initial presentation and not sooner. At that time, a functional analysis of the patient’s visual field was obtained, along with separate IOP readings.

Yes, IOP was elevated at the initial visit, and there was a significant amount of optic nerve damage present. But, CCT readings were relatively thick O.U., indicating a true intraocular pressure less than the mid-30s. Given those IOPs, moderate optic nerve damage, the lack of evidence of a fragile neuroretinal rim and the complete lack of functional analysis, I deemed it acceptable to defer therapy for a few days until all the information was at hand.

But, Dr. Pinkert seems pretty clear that he would have initiated therapy at the first visit, and feels it was unconscionable that I did not.

This patient had glaucoma, and treatment was initiated. But, only after I had a complete data set, including a functional assessment of the situation. There are times when therapy must be initiated instantly, and there are times when you can wait for a short time period. Complacent? No. Methodical? Yes! 

Interestingly, the entire point of this column was to give the reader suggestions on how to deal with situations when you find patient management (from other providers) not up to your own satisfaction. As I pointed out in the column, it’s often best not to jump to conclusions and impugn someone else’s reputation. Apparently, I did not succeed in getting that particular message across.