Here at Dartmouth, the coming of autumn marks the start of a myriad of seasonal activities. Students can drink in the fall colors on hiking trips and turn out on weekends to support fellow student-athletes on game days. How different these memorable events would be if we were unable to observe the splendor that blankets hillsides in early October or to identify a familiar face in the mass of players on a field. These, however, are realities for people in the advanced stages of glaucoma, the second most common cause of blindness worldwide (Quigley 1996).
Dr. David Campbell, an ophthalmologist at the Dartmouth-Hitchcock Medical Center specializing in the treatment of glaucoma and cataracts, addresses the challenges of treating glaucoma in the article “Initial treatment of pigmentary glaucoma” (1993). Glaucoma, a condition involving damage to the ocular nerve, is typically the result of fluid pressure build-up in the eye resulting from blockage of aqueous humour flow between the cornea, the iris and the lens. The progression and causes of glaucoma vary between patients, as glaucoma is a term encompassing many diseases (Morrison & Pollack 2003). In the article, Campbell offers his take on treatment options for a hypothetical patient experiencing glaucoma as a result of pigmentary dispersion syndrome, in which fluid circulation is inhibited by eye pigment flaking off the iris.
According to Campbell, reducing intraocular pressure must be a priority in treating the glaucoma, to reduce the possibility of further damage to the patient’s field of vision. To bring about such a reduction, Campbell recommends initially prescribing a β-blocker, a class of drugs that reduces intraocular pressure by diminishing production of aqueous humor. Should symptoms persist after the β-blocker treatment regimen, the patient would be placed on a miotic, which contracts the pupil, restores the flow of aqueous humor and prevents further flaking of pigment by flattening the iris. Finally, Campbell suggests that surgical treatment options, such as laser iridectomy, should be given consideration as an alternative to the use of medication.
A contrasting opinion on the case is presented by a co-author of the same article, the late Dr. Paul Camras of the University of Nebraska Medical Center. Camras advises against the use of β-blockers, except as a fallback treatment, stating that the use of β-blockers is likely to be counterproductive. In this case, according to Camras, the reduction in aqueous humor production brought on by β-blockers could prevent pigments from being dislodged from positions obstructing the flow of aqueous humor, which would only serve to worsen the glaucoma. Despite this difference between the opinions of Camras and Campbell, Camras concurs that miotics would be effective in this patient’s case and that the potential of laser iridectomy should not be discounted.
Campbell’s publication is directed towards practicing ophthalmologists who deal with difficult-to-treat cases of glaucoma routinely. To the lay reader, the article should serve as a reminder that independent specialists, when presented with the same signs and symptoms, will often choose different ways of administering treatment. In drawing up a treatment plan for a fictitious patient, Campbell offers the reader a window into his 24-year experience as a consultant at the Dartmouth Hitchcock Medical Center.
Works Cited:
Morrison, J. C., & Pollack, I. P. (2003). Glaucoma: Science and practice. New York,
NY: Thieme.
Ritch, R., Campbell, D. G., & Camras C. (1993). Initial treatment of pigmentary
glaucoma. Journal of Glaucoma. 2(1), 44-49.
Quigley, H. A. (1993). Number of people with glaucoma worldwide. British Journal
of Ophthalmology. 80(5), 389-393.
(Original article co-authored by Dr. David G. Campbell, Dartmouth-Hitchcock Medical Center)
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