Meghal Gagrani, MD, Glaucoma Fellow at the University of Nebraska Medical Center, talks about an app that shows glaucoma patients and family what they see with their impaired vision.
Talk to me about this glaucoma app. How does it work?
GAGRANI: The idea behind it was being able to see what our patients see through their peripheral vision. Now, what happens with glaucoma is patients tend to lose their peripheral vision while their central vision is intact. Meaning that they would see 20/20 when we test their vision on the chart. Since the peripheral vision is what gets affected first. When we were trying to design the app, the idea was to see exactly what they see. We asked around to a lot of our physicians as to what they thought our patients saw, and we received a lot of different answers. Some would say they saw darkness – a black spot in the eye. If you look at pictures on the internet, it would just be shown as visual field effects, which are all blacked out. So, we were curious as to what do our patients really see? So that was the idea behind it. And how that would help is just educating us, the patient and their family. How it works is that we had the patient see a large poster and then sit about three feet from the poster. Then, on the iPad app, they have a similar picture. Now, what they do is, by forced comparison – we tell them to look at the poster and then at our app and mark areas where they see blurry or there is a decrease in contrast or color. And they have sliders in there so they can actually grade it on a scale of one to 10 and make it look exactly like they see it on the poster. Now, because their central vision is good, when they are looking at the iPad app, everything looks clear to them so they can make a good comparison when they are comparing it to the poster.
So, some doctors – I guess since they don’t really know what a glaucoma patient sees – think, ‘oh, they see blackness on the side of their eyes’ – how does that affect treatment?
GAGRANI: Where it would help is in rehabilitation more than just treating glaucoma. So, let’s say in everyday life, when they’re driving, if somebody has a superior visual field which is affected and they see blurry, they will have problems seeing the traffic signal. Let’s say if they have inferior problems in their inferior field of vision, they will have problems seeing a dog crossing the road or a child crossing the road. So, these things can have serious implications. Therefore, it is important to educate our patients to be able to recognize them so we can direct rehabilitation. Other than that, just making them aware of the degree of damage that they have in actual, real world cases like these rather than just giving them some random numbers which we find on our test – like, you know, you have this percent of visual field loss, or this is what your intraocular pressure is, which we treat in glaucoma – this gives a real picture of what they actually see. I think it helps in compliance to treatment and follow-ups, which is really very important in glaucoma. It is a lifelong disease, and they have to follow up throughout their life, just like any other chronic disease such as hypertension or diabetes mellitus.
So, there is not necessarily, a cure for it?
GAGRANI: Not yet. Our science is limited at this point of time.
Are there any particular treatments that could reduce the symptoms, maybe eliminate them?
GAGRANI: Once the damage happens, glaucoma is irreversible. All we can do is prevention. We’ve got to prevent further visual field impediments. The irony here is that, in the United States, by the time a glaucoma patient sees a physician, almost 50 to 75% of them have moderate to severe visual field loss which they are not aware of. So that is the problem there. So not being aware of their visual field loss, they do not really seek treatment, and then that goes in a vicious cycle because we can only prevent it. Once the damage happens, there is no cure as of now with us.
What kind of treatments do you guys use for prevention?
GAGRANI: The most commonly identified risk factor is the raised intraocular pressure, which is pressure inside your eye. We try to decrease that. The most commonly used modality is drops that can help reduce pressure. Then we have some laser treatments available. And then if that doesn’t work, we go ahead with surgery. But it’s a lifelong process. We have to keep following up and they have to keep doing their drops. I think compliance is a very big issue here. Most of our patients are elderly patients, so doing drops for the rest of their life is a big challenge too. So, it’s important not only for the patient to realize, but also for the family to see how it impacts their life. Just think of it like, if you’re seeing everything blurry, like we saw in our patient, imagine trying to find something on a kitchen shelf. It’s difficult if you don’t really see very well.
I know you said the pressure is a risk factor, but what causes that pressure? Are there certain other risk factors that could cause that?
GAGRANI: A lot of it is genetic. Other than that, just old age. With aging, what happens is the function of the drainage system in the eye decreases, so that’s what causes the pressure to go up. There can be other reasons too; hypertension, diabetes, all these systemic risk factors – they kind of add on to what damage can happen because of the raised interocular pressure.
Would current vision problems also cause risk factors? Like, for example, I need glasses, but for somebody who currently has 20/20 now, am I more likely compared to them to have glaucoma?
GAGRANI: Not with glasses, no. But I think anybody with a family history of glaucoma should definitely get an annual exam and get worked up for glaucoma. Also, anybody over the age of 40 years old should get an annual eye exam done by an ophthalmologist.
Talk to me about the study that you guys did with the app.
GAGRANI: Like I said, most of the doctors stated that it looks like a black spot or a faded area or things like that. All of our patients recorded what they see as blurry in that visual field. We first did one eye at a time, then we compared both the eyes. Obviously, the blurriness was more prominent when we did one eye. When we did both the eyes, it was a bit better because the other eye compensates for it. Even then, they had a significant amount of blurriness in their vision, which was more than they would know. And some of our patients were really disturbed by seeing what they actually see through the help of the app. It’s like, they never knew they saw this bad. Only when they could now see that this is actually what they’re supposed to see but what they see is really blurry. We had one patient who was literally in tears learning that. And I think it’s really important for them to realize this because it helps them in rehabilitation and, like I said, again, compliance with treatment.
The patients that took part in the study, it was about 12 patients, correct?
GAGRANI: Right.
Did they already have eye problems or were these just random?
GAGRANI: All of these were patients with glaucoma who had some amount of visual field loss, and they were able to do their visual fields consistently, so we knew that they had a definite visual field loss, and they were on treatment for glaucoma. All of them had good central vision, so that was our patient population. But with this app, seeing its utility forward, I think we can potentially translate it to almost any disease which affects the peripheral vision.
Could you give me some examples of those?
GAGRANI: Diabetes mellitus, retinitis pigmentosa, almost anything – optic neuropathies. Some of the optic neuropathies also affect peripheral vision initially.
What are the next steps with this?
GAGRANI: We would want to expand it to other diseases, and we are also trying to get the app for use in other clinics so that doctors can use it to help educate their patients. I think, in a controlled setting, it can be used to educate patients and their family, and it will have a great impact.
I know you touched on this before, especially when you mentioned the woman who was basically in tears when she realized, you know, this is what I really see. What impact do you think that would have for someone not knowing that they had these issues before and actually visually being able to see that?
GAGRANI: I think that would make them be more cautious of their surroundings. Another patient told us that she knows now that she’s not able to see very well in the night, so she avoids driving at night rather than putting herself at risk. The other day we had a patient that said he was just walking in his living room, and he stumbled across a little bag, fell and had bruising all over his eye. Now, he thought he just stumbled, but we know he had some inferior visual field loss and probably didn’t really see the bag lying there and stumbled across it. I think making them aware of the fact so that they’re more careful. Eventually the aim would be to develop rehabilitative measures for patients directed to their particular region of visual field loss. Let’s say a patient has superior visual loss and they’re planning to drive, and they cannot see the traffic signal – so specifically educating them on, where the visual field loss is, so they know to try to look up and around, go slow, don’t go on highways, things like that. And these are some things which we can educate the patient on. Eventually we can develop mechanisms or alert mechanisms in the car directed to a particular patient, and I think that would be great.
For the patient that we just talked about, she says she can’t drive at night. Does nighttime affect the vision?
GAGRANI: Yes, it does. In glaucoma, because you’ve lost your peripheral vision, there’s only so much you can see. It does affect your driving at night. Even during the day if they have severe vision loss. We call it tunnel vision, they see everything centrally very well, but everything around is blurry. So, you can imagine how difficult it would be to drive on the interstate or anything like that.
Anything I didn’t ask you that you feel that people should know?
GAGRANI: No, I think my only message here would be to go get an annual eye exam with your ophthalmologist if you are over the age of 40 and if you have a family history of glaucoma.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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