Glaucoma Diagnosis: Key Questions and Insights

Q: Glaucoma Diagnosis: Key Questions and Insights

Hello： 1. <br>Physicians may not actively schedule ophthalmic examinations because they assess that the patient's current condition does not require frequent checks. <br>2. <br>Physicians may have conducted updated evaluations based on the patient's condition, leading to a decisi

How is glaucoma diagnosed?

I have severe myopia of over 700 degrees and was informed that my intraocular pressure (IOP) is high, ranging between 20 and 22 mmHg, when I got my glasses.
Therefore, I started monitoring my condition in December 2016.
During my initial visit, in addition to measuring IOP and visual acuity, an OCT was performed.
The doctor used a slit lamp and informed me that due to my thicker cornea, my IOP was within a safe range, and that I should continue to monitor it.
The diagnosis noted was "grossly normal," and I have floaters, but I was not actively scheduled for a follow-up appointment, so I made subsequent appointments myself, returning every six months to a year.

Until November 2022, during my follow-up, my IOP remained around 20 to 21 mmHg.
I casually asked how often I should repeat the initial tests, and the doctor replied that I could schedule it whenever I wanted.
In February 2023, I underwent another OCT, and the doctor glanced at the report and said, "Your optic nerve is thinning; I will prescribe you eye drops." I was unfamiliar with the term "optic nerve thinning," so I asked the doctor what it meant.
The doctor replied, "It indicates glaucoma." I was prescribed Timolol to use once a day and was scheduled for a visual field test a week later, with a follow-up appointment to review the results in a month.
I have several questions:
1.
Why did the doctor not actively schedule appointments over the years, leaving it to the patient to remind them about the need for an OCT? (In other words, if I hadn't prompted, I might never have had another OCT.)
2.
If the doctor believed my eyes did not have significant issues, why was I able to receive a diagnosis in such a short time? (The entire visit lasted only two to three minutes.)
3.
Why was I diagnosed before undergoing the visual field test? (The health insurance classification changed from bilateral ocular hypertension to glaucoma.)
4.
Are glaucoma eye drops covered by health insurance? However, I was charged a 40 NTD copayment for the medication.
Therefore, I am unclear whether I have been officially diagnosed.
5.
Based on my current experience and concerns about my eye condition, should I seek a second opinion from another doctor? Once medication is started, it is typically lifelong, and I want to be cautious.

Additionally, I noticed that the cup-to-disc ratio (CDR) recorded by the physician has always been 0.3, while this year's OCT showed a CDR of (horizontal) R: 0.47 L: 0.38 and (vertical) R: 0.55 L: 0.31.
Is the cup-to-disc ratio an important criterion for diagnosis? Thank you, Dr.
Gao, for taking the time to respond.

Lisa, 50~59 year old female. Ask Date: 2023/02/11

Dr. Gao Pilin reply Ophthalmology

Hello: 1.
Physicians may not actively schedule ophthalmic examinations because they assess that the patient's current condition does not require frequent checks.
2.
Physicians may have conducted updated evaluations based on the patient's condition, leading to a decision to assist in confirming the diagnosis.
Additionally, the time spent during the consultation may not be a critical factor, as physicians can quickly examine and determine a diagnosis, especially if they possess sufficient experience and skills.
3.
Diagnosing glaucoma without a visual field test is possible because physicians can confirm the diagnosis through other methods, such as tonometry and pachymetry.
However, visual field testing can ensure the accuracy of the diagnosis.
4.
There should be a partial burden of medication costs.
5.
If patients have concerns about their condition, it is indeed advisable to seek a second opinion from another physician.
Some diagnoses require the use of multiple testing methods and techniques, so consulting multiple physicians can ensure that patients receive the best diagnosis and treatment.
The cup-to-disc ratio is an important indicator of ocular disease, but it is not the sole basis for diagnosis.
Optical Coherence Tomography (OCT) is a commonly used imaging test for assessing the condition of the retina and can also evaluate retinal structure and intraocular pressure.
Before reaching a definitive diagnosis, physicians typically need to assess the retinal condition, including measuring intraocular pressure, conducting a fundus examination, and performing visual field tests to arrive at a conclusive diagnosis.

Reply Date: 2023/02/11

More Info

Understanding glaucoma diagnosis can be a complex and sometimes overwhelming process, especially when it involves multiple tests and varying interpretations of results. Your concerns are valid, and it’s important to address them thoroughly.

1. Follow-Up and Proactive Care: It’s concerning that your previous doctors did not schedule regular follow-ups for OCT (Optical Coherence Tomography) tests. Regular monitoring is crucial for patients with a history of elevated intraocular pressure (IOP) and other risk factors for glaucoma, such as high myopia. Ideally, healthcare providers should take a proactive approach in scheduling follow-ups, especially when a patient has risk factors for glaucoma. If you feel that your care has not been as proactive as it should be, it’s worth discussing this with your healthcare provider or seeking a second opinion.

2. Diagnosis Timing: The rapid diagnosis of glaucoma after your recent OCT test raises questions about the thoroughness of your previous evaluations. If your doctor identified thinning of the optic nerve, it indicates a potential progression of the disease. The fact that your doctor was able to make a diagnosis quickly could suggest that the changes in your optic nerve were significant enough to warrant immediate attention. However, it’s also important to consider that a comprehensive assessment typically includes a combination of IOP measurements, visual field tests, and OCT results.

3. Diagnosis Without Visual Field Testing: It is somewhat unusual to diagnose glaucoma without conducting a visual field test, as this is a critical component in assessing the functional impact of the disease. While OCT can provide valuable information about the structure of the optic nerve, visual field testing assesses how glaucoma affects your peripheral vision. If your doctor diagnosed you based solely on the OCT results, it would be prudent to ensure that a visual field test is performed to confirm the diagnosis and assess the extent of any vision loss.

4. Medication Coverage: Regarding the cost of glaucoma medications, it’s important to clarify with your healthcare provider or pharmacist about insurance coverage. In many cases, medications for glaucoma are covered by health insurance, but there can be exceptions based on specific plans or the type of medication prescribed. If you were charged for the medication, it may be due to a co-pay or a specific policy regarding the drug prescribed.

5. Seeking a Second Opinion: Given your concerns about the diagnosis and the implications of lifelong medication, seeking a second opinion is a reasonable and often advisable step. A second opinion can provide you with additional insights and reassurance about your diagnosis and treatment plan. It’s essential to feel confident in your healthcare decisions, especially when it involves long-term management of a condition like glaucoma.

6. Cup-to-Disk Ratio: The cup-to-disk ratio is indeed an important factor in diagnosing glaucoma. A higher ratio can indicate damage to the optic nerve, which is characteristic of glaucoma. Your reported ratios (0.47 and 0.38 for the right and left eyes, respectively) suggest some degree of optic nerve involvement, but these should be interpreted in conjunction with other findings, including IOP, visual field tests, and OCT results.

In conclusion, navigating a glaucoma diagnosis requires clear communication with your healthcare provider and a thorough understanding of your condition. If you have lingering doubts or concerns, don’t hesitate to seek further evaluations or opinions. Your vision is invaluable, and ensuring you have the best possible care is paramount.

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