Conveying the risks to a patient who rejects glaucoma treatment
Mr Smith puts his eye-drops on your desk. 'I don't like these and the hospital says my eyes aren't damaged, so why do I need them?' Dr Melanie Wynne-Jones advises
How do you respond?
Cutting to the patient's ICE (ideas, concerns and expectations) can save a lot of time. The ophthalmologist should have explained the dangers of glaucoma and need for treatment, but what matters is what Mr Smith heard, understands or has been told by family or friends.
Acknowledge his concern, then ask what he knows about his condition, and why he doesn't like the drops.
Should we persuade patients to take preventive medication?
GPs cannot, and should not, insist patients take medication, but we have a duty to present the pros and cons.
Things patients need to consider include:
· What are we trying to prevent (how big is the risk of developing complication X)? People vary in their perception of risk one in 100 may seem like a lot to one person, but good odds to another and many are fatalistic.
· How catastrophic would complication X be? Beliefs about the seriousness of different conditions vary widely. This may be due to ignorance or simply a matter of opinion although most people would rate going blind as a catastrophe. But some may fear the treatment, such as a colostomy, more than the disease itself.
· How likely is the treatment to prevent complication X? Patients will see it in these terms rather than numbers needed to treat (NNT), and sources like clinical evidence1 can provide answers. But in many cases, the exact information is not available, or patients differ yet again on whether a 20 per cent reduction is a significant gain.
· What are the side-effects of the treatment and how likely are they?
What might Mr Smith need to know?
· It is unlikely that his eyes are undamaged; 20 per cent of patients with primary open-angle glaucoma have advanced visual field loss at diagnosis. His field loss may not yet be significant, but any false impression should be corrected.
· Lost sight cannot be restored. Untreated, glaucoma progresses rapidly to end stage with higher intraocular pressures (2.9 years for pressures over 30mmHg, 6.5 years for pressures of 25-30mmHg, and 14.4 years for pressures of 21-25mmHg)2.
· Progressive tunnel vision could affect day-to-day activities, make driving illegal and result in blindness. He may develop other eye problems.
· Surgery rates for primary chronic open-angle glaucoma have almost halved in the last 10 years, thanks to new treatments3.
· If one type of eye drop doesn't suit, it's worth trying others.
· His relatives are six times more at risk of developing glaucoma and should have free eye tests from 40 years onwards.
What other treatment could Mr Smith try?
Suggest asking his ophthalmologist, who may prescribe:
l?-adrenergic antagonists (timolol)
lcholinergic agonists (pilocarpine)
ltopical carbonic anhydrase inhibitors (acetazolamide)
ladrenergic agonists (brimonidine)
lprostaglandin analogues such as latanoprost (which produces additional reduction of intraocular pressure in combination with one of the above).
He should be counselled about the side-effects of each, and interactions with other medication. His real worry may be difficulty in using the drops; advice leaflets4 and compliance aids5 may help.
What if he still says no?
lhe cannot reliably monitor his own visual fields. Even if he refuses treatment now, he should still attend for regular six-monthly checks on his eye pressure, optic disc appearance and visual fields
lto report red flag symptoms such as redness, blurring of vision or eyeball discomfort immediately
lto come to you if he changes his mind.
· Glaucoma is a serious but insidious threat to sight
· Compliance is usually about patients' ideas, concerns and expectations, but occasionally due to practical problems
· Patients' views on preventive medication may be different from that on acute treatment
· Give as much information as patients need; check understanding
· Negotiate damage-limitation strategies where possible