Gradle lecture: Glaucoma specialists must be ‘soothsayers’

SAO PAULO, Brazil — Glaucoma specialists must act as “soothsayers” for their patients, accurately assessing their needs with evidenced-based medicine, according to a physician honored at a meeting here.

“Soothsayers predict the future, usually based on specific knowledge. That’s what we need to be as we manage glaucoma,” said H. Dunbar Hoskins Jr., MD, delivering the Pan-American Association of Ophthalmology Gradle Medal lecture here at the World Ophthalmology Congress.

“We need to be able to give answers to four questions. Does the patient have glaucoma? Does the patient need treatment? Does the patient need more treatment? Does the patient need surgery?” Dr. Hoskins told the audience.

“If we can answer those questions, if we can predict the future for that patient, then we know exactly what we need to do for that patient,” he said.

H. Dunbar Hoskins Jr., MD, said glaucoma specialists should act as soothsayers for their patients.

A definition of glaucoma is paramount for predicting the progression of the disease, Dr. Hoskins said. He quoted the definition from the online encyclopedia Wikipedia.

“Glaucoma is a group of diseases of the optic nerve involving loss of retinal ganglion cells in a characteristic pattern of optic neuropathy. … Raised IOP is a significant risk factor for developing glaucoma,” Dr. Hoskins quoted from the dictionary.

“Not only is IOP a significant risk factor for developing glaucoma,” he commented, “it’s the only risk factor we know how to treat.”

The challenge of combating glaucoma on a global scale cannot be ignored, Dr. Hoskins said. The World Health Organization has said that of 37 million blind people in the world, 12% are blind because of glaucoma – “a disease that, when managed properly, will not result in blindness,” Dr. Hoskins said.

In developing countries, management of glaucoma presents great challenges, he said; “The cost of treatment often exceeds the annual wages of the patients’ families.”

Dr. Hoskins discussed the role of evidence-based medicine in managing glaucoma. Historically, he said, treatment decisions were based on a physician’s experience, which forms the physician’s opinion of what an individual patient needs at a given time. In the future, he predicted, treatment decisions will increasingly be based on evidence-based medicine.

“As we listen to the experts to make our opinions about how to manage care, we must examine their sources of data, their information, and understand that it is trustworthy and credible,” Dr. Hoskins said. But expert opinion is the lowest level of evidence-based medicine, he said.

Dr. Hoskins said the American Academy of Ophthalmology’s Preferred Practice Patterns series is an attempt to help physicians evaluate existing evidence. But recommendations in that series for management of glaucoma are not “supported very strongly by anything much more than a consensus of experts,” he said.

In short, the clinician still needs to be a soothsayer to determine treatment options for each patient the physician sees, Dr. Hoskins said.

“What we really want are devices that will consistently give us reproducible measurements and predict the future of treatment,” he said.