Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. Okay, right now millions of people are slowly losing their vision, and they have absolutely no idea. They won't experience pain, blurry vision, or warning signs.

What is this invisible thief stealing their sight a little bit at a time? It's called glaucoma, and it's one of the leading causes of irreversible blindness in the world. The most alarming part: by the time most people notice something is wrong, the damage is already done, and it can't be reversed. Today, we're taking a step-by-step approach to everything you need to know about glaucoma.

We'll discuss what it actually is and how it's detected, the treatment advancements that are changing what it means to live with the diagnosis, and why it's so important to get screened early on. We'll also get into something that doesn't come up enough in the eye doctor's office: the emotional weight of a glaucoma diagnosis and the tools that can help you cope, stay engaged in your care, and protect your vision for the long haul.

Whether you have glaucoma, know someone who does, or simply want to take better care of your eyes, this episode was made for you. First, let me introduce my guest, Dr Sandra Sieminski. Dr Sieminski is a cataract and glaucoma specialist and is the interim chair and the director of Glaucoma Services in the Department of Ophthalmology at the University of Buffalo. She also supports the Glaucoma Research Foundation as a GRF Ambassador.

Welcome to the WebMD Health Discovered Podcast, Dr Sieminski.

Sandra F. Sieminski, MD: Thank you so much. Thank you so much for having me. I'm very excited to talk about glaucoma and mental health. This is a topic I feel very passionate about, and I'm really excited to share this conversation with you today.

Pathak: Full disclosure: I just had my annual eye exam and had the glaucoma test done, so I am very excited to dig into this topic. Before we jump in, I'd love to ask about your own health discovery. In the work that you do, working with patients, the research you do, what questions or issues are they bringing up in private discussions with you about glaucoma and their mental health?

Sieminski: Well, specifically about glaucoma treatment, I would say I work in a university setting. I'm at the University of Buffalo, and a lot of patients come to me asking about the latest treatment. What are the latest drops? What are the latest surgeries and laser therapies? So I focus a lot of my research on surgical and laser therapy, and it has really evolved quite a bit in the past 10, 15 years.

When I was doing my residency, there were only a couple of different options for surgeries, and that has really exploded. There's a term called MIGS, which is minimally invasive glaucoma surgery. I'll be saying MIGS a lot in this podcast, but MIGS is an area of surgical therapy that has really developed a lot and continues to evolve.

I'm involved in the development of new devices, but also testing the devices that are already FDA-approved. It's a very exciting space, and it's really exciting to be able to offer that to patients who may think that glaucoma surgery is very risky and very painful, and might have some misconceptions about what there is to offer for laser and surgical therapy.

Pathak: That's great. That's really helpful and really exciting to hear about the advances. So let's take a step back and just help people understand what glaucoma is. What is this condition?

Sieminski: Sure. I love to talk about this, even with my residents, medical students, and patients alike. I think we all seem to think that glaucoma equals high eye pressure. So I'd like to first start off by saying glaucoma is treated by lowering the eye pressure, but it's not synonymous with high eye pressure.

Glaucoma is actually a progressive disease of the optic nerve. So in most types of glaucoma, it's a very slow and painless process, and often very asymptomatic in the beginning. But high eye pressure does kind of perpetuate that damage.

So slowly, the optic nerve becomes damaged, and with that damage comes loss of peripheral vision, loss of contrast sensitivity, and difficulty adjusting from dark to light and light to dark. So those are the symptoms. But it's not usually—except for things like acute angle closure—a painful process, a very noticeable process, or a very rapid process. So the definition is really progressive optic nerve disease.

With that being said, there is a whole type of glaucoma that is open angle. I'll touch upon angle closure and open angle, but there's a type of open-angle glaucoma that is called normal-pressure glaucoma.

Pathak: So talk to us a little bit about those different types of glaucoma. Can you help us understand open-angle glaucoma and the other types that we should understand the differences between?

Sieminski: So, starting off, the eye is a closed system, and there's a gland called the ciliary body that makes fluid constantly throughout the day, and then it's drained constantly throughout the day. And there are two types of drainage: conventional and unconventional pathways, or what we call trabecular and uveoscleral outflow.

So the trabecular outflow, which is the main outflow pathway, is what is involved with the drainage angle. That drainage angle can either be poorly functioning but open, causing high eye pressure, or it can be somewhat closed by structures in the eye or material in the eye, and so forth.

So, open angle—the angle is actually located… if you look at your eye, everybody has an eye color—brown, blue, whatever—at the very edge of the iris is where the angle is located within the inside of the eye. The middle hole in the iris is the pupil, so we're talking about the other side. That's kind of the cranny of the eye—the angle—and that's where the fluid is drained.

People who have angle closure tend to be people who have a smaller eye, or maybe are farsighted, or maybe have a big cataract. And so their high eye pressure, or their glaucoma, is occurring because their angle is closed. A majority of glaucoma in this country is open angle, though, and there are different types of open-angle glaucoma as well.

Pathak: So let's go back to something you said earlier, which is that in general, in early glaucoma, you are not really going to notice signs or symptoms—that really comes kind of later in the disease process. So tell us: what signs or symptoms might someone experience as their glaucoma worsens?

Sieminski: So again, in early glaucoma, there aren't—especially open angle—so I am making some generalizations here. But in early glaucoma, patients usually don't have symptoms.

Now, a lot of patients will come to me and say, “Well, oh, my peripheral vision is fine because I take a finger, put it out to the side, wiggle it, and I see it.” And that's really a more general and gross way of looking at your peripheral vision, but it's not really a good measure.

When we have you come in and do a peripheral vision test, we're not just testing to see if you can see something moving—we're really testing the contrast and the sensitivity that you have in the very far peripheral vision. And that's what gets affected first, and that is something that's not noticeable in everyday life for most patients.

So that's why the peripheral vision test—doing that from the beginning and following it—is not only very important, but those tests really help tailor the way we treat glaucoma and whether we want to ramp up therapy or go to surgery or so forth.

So if patients go into later glaucoma, I mentioned before, you may have problems with seeing in the peripheral vision. Sometimes you can have central vision loss—that's not as common as peripheral vision loss.

If the peripheral vision loss involves the inferior, or bottom part of your visual field, it can be very debilitating because a lot of our lives—walking around, going upstairs, stepping off a curb—involve that lower field of vision.

And then, in some of my later-stage glaucoma patients, they really have a tough time with adjustment from light to dark and dark to light. So going into a movie theater, leaving a movie theater—everyone else is just getting in their car, but a glaucoma patient with advanced glaucoma may take a few minutes to adjust.

So in terms of early detection, using your wiggle-finger test is not going to be the best way. A peripheral vision test will detect some early vision loss related to glaucoma. But even better than that, we have imaging of the optic nerve that can analyze the optic nerve and the tissue surrounding it and let us know—even before peripheral vision loss starts—that there is degeneration going on.

And we can really get a leg up on treating patients before vision loss happens, because when the vision loss happens, you can't really reverse that and get it back.

So what I'm referring to is OCT—optical coherence tomography. That is basically a scan of your optic nerve and the tissue surrounding it, and it's analyzed based upon a normative database—a group of patients who don't have glaucoma. Then it gives us an idea: is this abnormal thinning, or is this normal?

And then we can compare a patient's scan to themselves over time to see if that is progressing or not. 

Pathak: So can you talk a little bit about what testing, screening for glaucoma looks like when you go in for an eye appointment?

Sieminski: So I mean, certainly. Some patients may confuse the glaucoma test, quote-unquote, as getting the eye pressure checked, and a lot of times in some offices they'll use the air puff. So the air puff tonometer is a way to check the eye pressure for sure. When we are checking the eye pressure in a glaucoma clinic, we are using something called Goldman Applanation tonometry, where we're actually checking it—sort of, a plan or pressing on the cornea and checking a pressure. I like to tell patients that it's like measuring your weight on a scale at the doctor's office with the weights where they're sliding the weights over, compared to getting on a digital scale at Target. And there's like five different digital scales.

So the gold standard is Goldman tonometry. We'll check pressure. But again, having a high eye pressure doesn't mean you have glaucoma, and having a normal pressure doesn't mean that you don't have glaucoma. But I think it's very important to have a practitioner look at your optic nerve, 'cause that's where the disease is. You can get a look at the optic nerve undilated, but the best way is to look through dilation and have that physical exam. And then the scan, the OCT, can be done undilated. It does give us great information. It does give us objective numbers that we can follow over time. And so if you are dilated sometimes, but not all the time, and you're getting this OCT, that is still, you know, a very good way to screen for glaucoma.

And then the visual field is kind of the last piece of that puzzle in terms of really screening a patient. Of course, family history, getting a patient's history, drops, trauma, all of those things are important. Family history is very important because having a first-degree family member with glaucoma really does increase your risk.

And then, of course, vision, checking the eye pressure, doing the exam in the front part of the eye, back part of the eye, OCT, visual field, and also I'll get at some point a disc photograph, which is basically a color photograph of your optic nerve. That's the whole shebang to really getting a good baseline kind of data to follow over time.

Pathak: So we know that a lot of people will avoid eye appointments because they feel fine. There's nothing going on. I catch myself doing that very often too, or I'm like, "Oh, my glasses are working totally fine. I don't need an eye appointment this year." So tell us a little bit about why that is a tricky way of thinking when it comes to glaucoma. And if you could give us the standard of care for how often the general population should get their eyes examined thoroughly, as you just talked through.

Sieminski: So, glaucoma does have a nickname: the silent thief of sight. Because it does, as we've touched upon many times already, it's largely asymptomatic in the beginning. And again, if you're losing a little contrast, losing a little peripheral vision way out in the periphery, you're not gonna notice it.

I think definitely seeing somebody once a year for a dilated exam is standard. If you're a glaucoma suspect, at least once a year is standard. And "suspect" means your optic nerve looks suspicious for glaucoma, but you don't have the progressive optic neuropathy yet, or you have a strong family history, or you have a high eye pressure. One of those three things kind of buys you a yearly examination.

Sieminski: But if you're a healthy person, you know, under sixty years old, I think seeing a practitioner once every two years should be fine. But again, I really do want to hit home on the fact that having the dilated exam, at least once every two years, is gonna really allow us to effectively see the inside of your eye, your retina.

Can you talk a little bit about a step-by-step approach to management once someone's diagnosed? I imagine it depends on severity, depends on the type.

Pathak: So talk to us a little bit about how you approach thinking through your treatment options.

Sieminski: Sure. So, you know, I think many of your listeners will already know that we treat glaucoma with drops, and that is pretty much the mainstay of therapy. And that first-line drop is usually a prostaglandin analog. So we talked about the two types of outflow, the trabecular and uveoscleral. The prostaglandin analogs, or PGAs, are drops that are gonna enhance uveoscleral outflow.

And they're nice because they really don't have systemic side effects. There's kind of like a plus or minus if you're pregnant, 'cause prostaglandin kind of has something to do with pregnancy as well. But just if you have high blood pressure, diabetes, or any chronic diseases, this should not affect you systemically.

And it is easy because it's once-a-day dosing. And that's usually, if I see a patient and I say, "Okay, I think you have glaucoma," I'm looking at your tests, that's what I usually do—put them on that. So there are lots of generic options, preservative-free options, and they're very well covered by insurance.

But what's very different from the time that I did my residency almost 20 years ago was we used to bring up laser as an option kind of later on in the treatment paradigm. So laser is basically lasering the trabecular meshwork to get it to work better. And that's called selective laser trabeculoplasty, or SLT. SLT is very safe. It takes about two minutes to do per eye. It's an office procedure. It's very low risk, and because it works so well and it is repeatable, we really pushed that SLT option up to now when someone's diagnosed.

I bring that up—SLT or drops. And the SLT is gonna lower eye pressure pretty effectively, just as effectively as drops in most patients, and keep it low for three to five years, and then it can be repeated. So I like to bring up SLT, particularly with young patients. I guess I don't consider myself that young anymore, but I try to think of myself and how well am I gonna remember to take a medication every day with my busy schedule and my kids and all these things. I think I would be better off just doing like a "set it and forget it" kind of thing where I get the laser and then I'm good to go for several years. I think that works better for my lifestyle, and I think that works best for young people.

But then, of course, there are patients that are like, "Ooh, that's a procedure, that sounds risky. I'd rather just do drops. It's less invasive." And so, that's the choice that the patient makes. But I do love that we offer SLT. We can offer SLT first-line because I think there are plenty of patients that say, "Okay, I guess I'll take drops," and then they leave, and then they just don't take them because they don't understand how risky it is not to treat glaucoma.

So that, I think, is the real difference from when I was doing residency—SLT, we bring it up first-line.

Pathak: So what are some of the fears that come up most often as you start counseling your patients around their new diagnosis and helping to guide them through sort of shared decision-making around the best next steps?

Sieminski: Yeah, I mean, I think the word "glaucoma" and that kind of stigma of "silent thief of sight" is certainly, if you get the diagnosis, there's gonna be a fear of going blind, of course. And if you're coming to us early and we're starting your treatment early, I could definitely say that your chances of really going blind and having profound vision loss, if you're really treating early, following, and compliant with the treatment plan and coming for your appointments, is very low to really profoundly lose vision.

But of course, there are patients that are in a different boat. They might be coming from somewhere else where they didn't notice it or something, and it's something that they are dealing with. This is their life now—they can't. And with those patients, there are a couple of fears that come up a lot. One, of course, is the loss of independence. If you really have profound vision loss, you may not be able to drive, pay your bills, get to your appointments, and you might be socially isolated.

And then that has a trickle-down effect on patients' mental health. That's a big fear—just losing independence. And kind of hand-in-hand with this too, we talked about inferior visual field loss, and when you have a lot of peripheral vision loss, you might be afraid as a patient to go places because you are fearful of tripping in places where you are unfamiliar. And again, that kind of socially isolates as well, just because you don't want to go places and not be able to navigate and potentially fall.

The last thing that is a very tough decision, but it happens more than you would think, is, "Can I drive?" And so that can sometimes be really pushed back by the patient, but the family wants me to say something and take away their license kind of thing. And it is a tough conversation to have for sure. Every state is different too in terms of the cutoff for visual acuity and peripheral vision. Every state is different.

Pathak: I'm curious around how you counsel people when you're noticing that maybe stress, anxiety, some of these fears, potentially other mental health conditions like depression. When you're helping people move forward with their diagnosis of glaucoma, what are you seeing as some of the challenges that come up with these types of mental health concerns?

Sieminski: Sure. I mean, I think one of a very common ways that I see anxiety or depression manifest in a glaucoma patient is poor compliance. So, that might be because the drops—every time they put a drop in—it reminds them that they have a blinding disease, and so they kind of don't do it. And they want to avoid the whole issue altogether.

Some patients are maybe noncompliant because some of the drops affect the appearance of their eyes. Some of their eye drops make their eyes red, and then people ask them what's going on, and then they're anxious about people knowing that they have glaucoma, and then they stop taking the drops.

Some patients just don't even come to their appointments afterwards because they're like, "Oh gosh, this is… this is really serious and depressing, and I'd rather just kind of forget about it for a while." So people will—I’ll lose them for five years—and then they come back, and then we've really lost a lot of vision again.

It's tough because it's not like a cataract. Cataracts are—you put on glasses: "Wow, I can see better." You take the cataract out: "Wow, I can see so much better." But you can't bring that back with glaucoma. And that's really a point that I hope that the listeners take away from this—not to be scary, but just that you can't put it off. You can't put off the treatment because if you lose the vision, you can't get it back.

Pathak: What are some of the concrete coping tools that you recommend for your patients when they're feeling anxious or overwhelmed after a glaucoma diagnosis?

Sieminski: Sure. There's certainly patient education. It is something that I feel very strongly about. I think empowering patients to understand what's going on with their eyes—and the more educated a patient is, the more well-versed they are in their options—the more fruitful a discussion I can have with them.

So I have patient handouts in the room. I'm very involved with the Glaucoma Research Foundation, and they have a wonderful newsletter called Gleams, which talks about the disease and also some of the new things that are coming out—the research that's going on with glaucoma. So I have those newsletters in the room. I often refer patients to different websites: Glaucoma Research Foundation, which is glaucoma.org, the Glaucoma Foundation, the American Glaucoma Society, and the American Academy of Ophthalmology. They all have excellent patient education, and I think that it is helpful for someone who is overwhelmed or anxious with the diagnosis to get some more education themselves about it. And I really refer to those websites—not just Googling and that canned thing that comes up with AI now. That's not going to be helpful. It's more helpful to go to these websites that are very much—well, a lot of the content on Glaucoma Research Foundation, outpatient education content, are things that we clinicians help write and help edit, so we know that they're accurate.

So I think that's really important. And mental health therapy is another very useful tool for patients. And unfortunately, in our clinics, most of the time we don't have a psychologist sitting right there, somebody embedded waiting for us to refer patients to them. But still, there are some ways that you can kind of bring up mental health therapy for patients.

There is a website called Psychology Today, which is a resource for patients or their eye doctors to help find a psychologist who is nearby, who takes their insurance, and so forth.

Lastly—again, not everyone with glaucoma is going to have profound vision loss, but those who do have vision loss that is profound—there are low vision services as well. And a low vision clinic can really provide a lot of different resources, such as home visits to kind of optimize how the home is configured so falling is less likely, employment opportunities, free low vision aids, hooking up with the state blind association, access to support groups. And again, not everybody needs that, but that does help a lot to know that there are opportunities for employment and support, and a lot of aids to help a patient with low vision really maintain his or her independence.

Pathak: I'm so thankful for this conversation. As we come to the end of our time together, I'd love to know if there's something you wish every person who is diagnosed with glaucoma knew early on. What would that be?

Sieminski: I wish that everybody who is diagnosed with glaucoma early on—I hope that they understand that this is a disease that is not going to end your life. This is not a disease that's going to affect your life in a profound way. If we catch it early, treat it early, and have good follow-up, this is something that you can really manage. I really think that glaucoma is an exciting part of ophthalmology because there is so much development on the surgical side, on the treatment side. Things are constantly being developed and improved upon so that as you move through the disease, there is going to be more and more available to you for treatment.

Pathak: And I'd love to close the episode by asking you to speak directly to our audience and maybe give some examples of how someone can take the next best step to protect their eyes when they go to their next visit with their health professional.

Sieminski: I'll give all your listeners a little bit of homework in that. It's a good idea to be familiar with your family history before you go to your eye doctor. And that's because there are eye conditions that are hereditary, and not all glaucoma is directly hereditary. But as I mentioned before, having a first-degree relative with glaucoma, particularly if that person went blind, is a very large risk factor for you.

And so when you go into the appointment with that knowledge, your practitioner is going to pay very close attention to what your optic nerve looks like, and also may get an OCT just for a baseline because glaucoma is progressive, and it's always good to have baselines to follow you in the future.

So knowing your family history is a great idea. And just everybody should understand too that when you go to your eye doctor, especially if you've never been dilated before, you should have a full dilated exam so that your practitioner can really look at your optic nerve critically, and the rest of your retina.

So going to the eye doctor may mean different things for different people. Some may say, "Oh, I went to X place and got glasses." But getting the glasses is just one part of the piece.

Pathak: That's really helpful information. Thank you so much, Dr Sieminski, for being with us today.

Sieminski: Thank you very much. This was a very enjoyable conversation, and if anyone would like to reach out for any further questions, my email is [email protected].

Pathak: Thank you so much for being with us today. We've talked with Dr Sandra about all things glaucoma—from diagnosis to symptoms and signs—with a segment highlighting the impact on mental health and how vision loss impacts mental health. I'd like to share my three key takeaways from this discussion.

First, regular eye appointments can detect glaucoma early. Today we heard that one of the most important things you can do for your eye health is simple: show up for your eye appointments. Glaucoma can be detected through a combination of eye pressure checks, optic nerve imaging, and visual field testing. Knowing your family history before you walk in the door is a great place to start. If a first-degree relative has had glaucoma, tell your eye doctor, as that alone can help your eye doctor determine what screening options are best for you.

Second, there are many treatment options for glaucoma that are continually being discovered and improved. Glaucoma is one of the most exciting areas of ophthalmology right now because so much is being developed to help patients at every stage of the disease. Treatment has changed dramatically beyond the traditional eye drops. The pipeline of new surgical tools, devices, and protective therapies is actively growing. It's important to consult with your doctor to see what options are right for you.

Finally, glaucoma is typically asymptomatic until its later stages, so it's important to have regular eye exams to prevent irreversible vision loss. The most critical message from today's episode: glaucoma is called the silent thief of sight for a reason. By the time you notice something is off with your vision, damage to your optic nerve has already occurred, and that damage is irreversible.

The subtle early changes, like a slight loss of contrast or peripheral vision at the very edges of your sight, are not things you will notice in your daily life. That's why waiting until something feels wrong is simply too late. Regular eye exams, even when you feel completely fine, are the only way to catch this disease early enough to protect your vision.

You have to find out more information about glaucoma and Dr Sandra Sieminski's work. Make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send a note to [email protected]. This is Dr Neha Pathak for the WebMD Health Discovered Podcast.