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HMOs and glaucoma, defering Rx, awaiting optic nerve damage?

Question:

i have now been to my local HMO where I have been told that my IOP is elevated. I cant remember the exact number, but it was 2x normal pressure. BUT — "no Optic Nerve Damage, Mr Boatright," they took pictures, and sent me along my way for another check in 6 months…… Is this Ok, I am frankly not very trusting of this HMO, they are reputed to be willing to do alot to save money, and the physicians do definately get a Christmas bonus tied to the amount of non-Rx they can accomplish. what are your thoughts folks is this standard of practice? John Boatright (jnlz0…@aol.com)

Response:

- Hide quoted text — Show quoted text -Mark Friedman wrote: > Jnlz0000 wrote: > > i have now been to my local HMO where I have been told that my IOP is > > elevated. I cant remember the exact number, but it was 2x normal pressure. > > BUT — "no Optic Nerve Damage, Mr Boatright," they took pictures, and sent > > me along my way for another check in 6 months…… > > Is this Ok, I am frankly not very trusting of this HMO, they are reputed > > to be willing to do alot to save money, and the physicians do definately > > get a Christmas bonus tied to the amount of non-Rx they can accomplish. > > what are your thoughts folks is this standard of practice? > > John Boatright (jnlz0…@aol.com) > Just my opinion and I’m not a doctor…but if your pressure is 2x > normal  (which could be 30-40) you might want to be checked in less then > 6 months.  This could be normal for you and there may not be damage to > the nerve at this point…but 6 months seems like a long time to me > between checks with a pressure over 30. > Mark

I would be greatly concerned, having high pressure in one eye ( 24 to 27) for three years now, but no nerve damage. I am on eye drops and just changed to a new medication to see if it will drop the pressure. The problem I have heard from three different medical eye specialist is that you should not, repeat, not wait until there is nerve damage to start treatment. I understand that with HMO’s that is the procedure, until there is nerve damage they will provide no treatment. That is a little like closing the barn door after the cow escapes, or is it the horse. Please see an independent or ask why you have to wait until there is damage, is not preventative a good approach. Fred — Please change my email address to ‘fr…@ionet.net’. Email sent to ‘fr…@paloverde.com’ will be forwarded temporarily, my server has changed. Maximum frustration is encountered immediately before the solution is found.

Response:

Jnlz0000 wrote: > i have now been to my local HMO where I have been told that my IOP is > elevated. I cant remember the exact number, but it was 2x normal pressure. > BUT — "no Optic Nerve Damage, Mr Boatright," they took pictures, and sent > me along my way for another check in 6 months…… > Is this Ok, I am frankly not very trusting of this HMO, they are reputed > to be willing to do alot to save money, and the physicians do definately > get a Christmas bonus tied to the amount of non-Rx they can accomplish. > what are your thoughts folks is this standard of practice? > John Boatright (jnlz0…@aol.com)

Just my opinion and I’m not a doctor…but if your pressure is 2x normal  (which could be 30-40) you might want to be checked in less then 6 months.  This could be normal for you and there may not be damage to the nerve at this point…but 6 months seems like a long time to me between checks with a pressure over 30. Mark

Response:

"Kim M. Clark, O.D." <kimcl…@burgoyne.com> wrote (only in alt.support.glaucoma): – Hide quoted text — Show quoted text -……………… >    Glaucoma is not a disease of elevated pressure.  Glaucoma is an optic >neuropathy.  Elevated pressure is a significant risk factor and should >not be taken lightly.  I would estimate that at least 25% of the >patients I treat for this disease had normal intraocular pressure (IOP) >at the time of the diagnosis.  There are three fundamental factors I >look at in determining whether or not the patient has the disease: >1) IOP, 2) Optic Nerve morphology (appearance and configuration), 3) >Visual Field (VF). >    If the IOP is elevated but there is no "cupping" to the optic nerve, >and the VF is normal, the patient has ocular hypertension and not >glaucoma.  This patient should be followed at least every six months. >If there is cupping (especially if it is assymetrical … ie, there is >more cuping in one eye than in the other), and if the VF evidences >damage to the nerve, the patient has glaucoma and should be treated >accordingly.  It matters not if the pressure was normal–a damaged nerve >is a damaged nerve and requires medical attention.

I like this straightforward view, and it jibes with current apolitical writings.  There’s still a ton of the past OMD garbage all over the Net.  The only thing is, when you come to the bottom line of your post, what do you figure is *effective* "medical attention"?  I’ve certainly seen enough indication of the other kind, the vast majority of it dealing with lowering the IOP, whether high or low and whether there is any indication of its slowing or stopping progression of nerve damage.  Do you see much of this "medical attention" coming from ODs?  (I live in a state where they can legally only diagnose glaucoma.) I would like to also add that *other* assymmetries in the orbital areas should be monitored to see if they indicate possible development of glaucomatous or other nerve damage.  I developed considerable assymmetry in astigmatism prior to manifestation of glaucoma,  the more cylindrical eye becoming the only one to develop glaucomatous damage.  Both IOPs rose, from perhaps too-low values, to only the high teens and low 20s, the higher one being on the damaged side, but I don’t think the pressures rose *prior* to detectable nerve damage, but I don’t know, since nobody runs around detecting such things, and only *I* first detected the VF symptom by looking at the sky.  (But why detect it earlier when, mostly likely, if you’re only going to try to drop the after-the-fact pressure, and not chase after the actual cause (most often some, maybe a bit remote, blood-supply problem), you aren’t going to be able to do anything about stopping or slowing increase in the damage.)  (All you gain (?) is conversation with practitioners you’d just as well never meet.)  There usually isn’t any reason to get your eyes checked by an OD for refraction (what you traditionally think of going to one for) during later midlife.  I think it’s pretty clear that my eyes’ pressures (both) only rose a little as a *result* of either the nerve damage to only one, or of the cause of same. If ODs successfully crash this area of medicine (inter)nationally, let them bring clean, up-to-date views of the subject matter, such as yours — and maybe help in redirecting research money away from pressure-biased work and into areas of neurochemistry and -pharmacology and into small-vessel blood-flow monitoring and angiology. Ray (nonmedical, non-eyecare)

Response:

Thanks Dr. Kim! thats very helpful. I put in a call (before I saw your posting) to my HMOs member reps, they were going to check into it, that was several days ago, i got a call saying that the head OD was going to call me. still waiting for that, but i appreciate your info, its nice to hear from someone who Cabt have a vested interest in undertreatment. thanks again johnb

Response:

- Hide quoted text — Show quoted text -Mark Friedman wrote: > Jnlz0000 wrote: > > i have now been to my local HMO where I have been told that my IOP is > > elevated. I cant remember the exact number, but it was 2x normal pressure. > > BUT — "no Optic Nerve Damage, Mr Boatright," they took pictures, and sent > > me along my way for another check in 6 months…… > > Is this Ok, I am frankly not very trusting of this HMO, they are reputed > > to be willing to do alot to save money, and the physicians do definately > > get a Christmas bonus tied to the amount of non-Rx they can accomplish. > > what are your thoughts folks is this standard of practice? > > John Boatright (jnlz0…@aol.com) > Just my opinion and I’m not a doctor…but if your pressure is 2x > normal  (which could be 30-40) you might want to be checked in less then > 6 months.  This could be normal for you and there may not be damage to > the nerve at this point…but 6 months seems like a long time to me > between checks with a pressure over 30. > Mark

John & Mark,         Glaucoma is not a disease of elevated pressure.  Glaucoma is an optic neuropathy.  Elevated pressure is a significant risk factor and should not be taken lightly.  I would estimate that at least 25% of the patients I treat for this disease had normal intraocular pressure (IOP) at the time of the diagnosis.  There are three fundamental factors I look at in determining whether or not the patient has the disease: 1) IOP, 2) Optic Nerve morphology (appearance and configuration), 3) Visual Field (VF).         If the IOP is elevated but there is no "cupping" to the optic nerve, and the VF is normal, the patient has ocular hypertension and not glaucoma.  This patient should be followed at least every six months. If there is cupping (especially if it is assymetrical … ie, there is more cuping in one eye than in the other), and if the VF evidences damage to the nerve, the patient has glaucoma and should be treated accordingly.  It matters not if the pressure was normal–a damaged nerve is a damaged nerve and requires medical attention.         There is much more that could be said about this insidious disease.  If you have specific questions email me and I’m only too happy to assist you.  Best of luck.         Kim Martin Clark, O.D.

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