11/13/24, 8\:18 PM Guide | Glaucoma counselling

Glaucoma counselling

Table of contents

Introduction

Being able to share information in a clear and concise way is an essential skill in all
simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis.
Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may
also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to
communicate more e
This guide provides a step-by-step approach to explaining a diagnosis of glaucoma. You should also read our overview of
how to e

Structure

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information
being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.
Explanation structure

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before
explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to
establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better
understanding of their problem. After introducing yourself, it is important to take a brief history (this is the
structure)\:
What has brought the patient in to see you today?
What are their symptoms, if any?
Are there any risk factors that can be identi
sighted)
For example, a patient may have recently had an eye test and were told they have 'high pressures in their eye'
, which is most
often the case.
Tip\: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all
your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction
and brief history between 1-2 minutes maximum.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Some patients may have a family
member with glaucoma and therefore have a good understanding of what the condition entails. Other patients may have heard
of glaucoma but only have a vague understanding of the important details.
Due to these reasons, it is important to start with open questioning. Good examples include\:
“ A r e y o u a w a r e o f t h e r e s u l t s o f y o u r r e c e n t e y e t e s t ?”
“ W h a t d o y o u k n o w a b o u t g l a u c o m a ?”
“ W h a t h a s b e e n e x p l a i n e d t o y o u a b o u t g l a u c o m a s o f a r ?”
Open questioning should help you to determine what the patient currently understands, allowing you to tailor your
explanation at an appropriate level.
At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks
(i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal
communication such as nodding).
Checking the patient’s understanding should not be solely con
throughout by repeatedly ‘chunking and checking’
.
Tip\: Try using phrases such as\:
“ J u s t t o c h e c k t h a t I a m e x p l a i n i n g g l a u c o m a c l e a r l y , c a n y o u r e p e a t b a c k t o m e w h a t y o u
u n d e r s t a n d s o f a r ?”
. This is far better than only saying “ W h a t d o y o u u n d e r s t a n d s o f a r ?” as the onus is placed upon the quality
of your explanation rather than there being an issue with the patient’s ability to understand.

What are the patient’s concerns?

The patient’s concerns should never be overlooked. A diagnosis of glaucoma can be signi
worries. Asking the patient if they have any concerns before beginning your explanation allows you to speci
most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations) format,
can provide a useful structure for exploring this area further.

ICE

Ideas\:
What does the patient think is causing their vision changes?
What is their understanding of the diagnosis?
Concerns\:
What are the patient’s concerns regarding their symptoms and diagnosis?
Expectations\:
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What is the patient hoping to get out of the consultation today?

Explanation

After determining the patient’s current level of understanding and concerns, you should be able to explain their condition
clearly. Glaucoma and the various types can be confusing to medical students and doctors, let alone patients. Avoid medical
jargon so as not to confuse your patient.
You should begin by signposting what you are going to explain to give the patient an idea of what to expect.
“ I’ m g o i n g t o b e g i n b y t a l k i n g a b o u t h o w t h e e y e s w o r k a n d t h e n m o v e o n t o d i s c u s s w h a t gl a u c o m a i s a n d s o m e o f t h e r i s k
f a c t o r s . W e' l l t h e n d i s c u s s h o w w e c a n m a n a g e i t t o g e t h e r a n d I' l l s p e a k a b o u t s o m e c o m p l i c a t i o n s y o u n e e d t o b e a w a r e o f .
”
Tip\: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy and physiology

“ Y o u r e y e s p r o d u c e a w a t e r y
w i t h i n t h e e y e . I t a l s o m a i n t a i n s t h e e y e’ s n o r m a l p r e s s u r e a n d s h a p e . T h i s
f r o n t a n d l e a v e s v i a a s i e v e-l i k e d r a i n a ge s y s t e m .
”

What is primary open-angle glaucoma?

“ G l a u c o m a i s a n e y e c o n d i t i o n w h e r e t h e o p t i c n e r v e , w h i c h c o n n e c t s t h e e y e t o t h e b r a i n , c a u s e d b y
”
b e c o m e s d a m a ge d . I t’ s u s u a l l y
I f n o t d i a g n o s e d , o r i f l e f t u n t r e a t e d ,
“ T h e r e a r e m u l t i p l e t y p e s o f g l a u c o m a , t h e m o s t c o m m o n b e i n g p r i m a r y o p e n-a n gl e g l a u c o m a . T h i s t y p e d e v e l o p s s l o w l y o v e r
m a n y y e a r s a n d i s c a u s e d b y t h e d r a i n a g e c h a n n e l s i n t h e e y e b e c o m i n g gr a d u a l l y c l o gge d o v e r t i m e .
”
“ I t’ s a b i t l i k e a k i t c h e n s i n k . N o r m a l l y , i f y o u s w i t c h t h e t a p o n , w a t e r l e a v e s j u s t a s q u i c k l y v i a t h e d r a i n . H o w e v e r , t a p o n b u t t h i s t i m e y o u h a v e a c l o g ge d d r a i n , t h e s i n k gr a d u a l l y t h e n e r v e a t t h e b a c k o f t h e e y e .
”
i f y o u l e a v e t h e
t h e r e i s n o w h e r e

What are the risk factors and symptoms of glaucoma?

“ G l a u c o m a i s o f t e n p i c k e d u p a t a r e g u l a r e y e a p p o i n t m e n t w h e n t h e p r e s s u r e s i n y o u r e y e s a r e m e a s u r e d . W i t h o p e n-a n gl e
g l a u c o m a , t h e r e a r e u s u a l l y n o e a r l y w a r n i n g s y m p t o m s o r s i g n s . I t i s a d i s e a s e t h a t u s u a l l y d e v e l o p s s l o w l y a n d o f t e n y o u a r e
u n a w a r e y o u r s e l f o f t h e s i g h t l o s s . B y t h e t i m e y o u a r e a w a r e o f v i s i o n l o s s t h e d i s e a s e c a n b e q u i t e a d v a n c e d a n d c a n h a v e
p r o g r e s s e d t o t u n n e l v i s i o n . I f l e f t u n t r e a t e d i t c a n u l t i m a t e l y c a u s e b l i n d n e s s .
”
“ I t’ s u n c l e a r e x a c t l y w h y t h e d r a i n a g e n e t w o r k i n t h e e y e c l o gs b u t t h e r e a r e m u l t i p l e r i s k f a c t o r s f o r t h i s t y p e o f gl a u c o m a , t h e s e i n c l u d e \:
a n d
I n c r e a s i n g a g e
B e i n g s h o r t-s i g h t e d ( m y o p i c )
B e i n g o f A f r o-C a r i b b e a n e t h n i c i t y
S m o k i n g
H a v i n g a f a m i l y h i s t o r y o f g l a u c o m a”

Management

Aims of glaucoma management
“ T h e p r i m a r y a i m o f t r e a t i n g y o u r g l a u c o m a i s t o m i n i m i s e t h e i m p a c t o f t h e c o n d i t i o n o n y o u r e y e s i gh t . a p p r o p r i a t e l y , w e w o u l d e x p e c t i t i n m o s t c a s e s t o h a v e a m i n i m a l i m p a c t o n y o u r q u a l i t y o f l i f e .
”
I f g l a u c o m a i s m a n a g e d
Overview of glaucoma management
The main principles of glaucoma management include\:
Providing the patient with appropriate education to ensure good compliance with their medication and the importance of
regular glaucoma checkups
Checking for contraindications to medications (e.g. beta-blockers), for example, asthma
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Providing information on eye drops including method of application and common side e
Providing information management options if medical management (drops) do not work. For example, surgery and/or laser
treatment. This would ultimately be discussed and decided upon in a secondary care setting.
Example
“ W e w i l l d i s c u s s t h e m a n a g e m e n t o p t i o n s f o r y o u r g l a u c o m a a n d d e c i d e o n a s u i t a b l e t r e a t m e n t p l a n t o ge t h e r .
”
“ M a n a g e m e n t t y p i c a l l y i n v o l v e s t h e u s e o f e y e d r o p s a n d t h e r e f o r e e n s u r i n g y o u’ r e c o m f o r t a b l e w i t h w h e n a n d h o w t o p u t
t h e s e i n e
t h a t d r o p s a r e n’ t t h e o n l y o p t i o n . I f t h e y a r e n’ t w o r k i n g o r y o u’ r e u n a b l e t o u s e t h e d r o p s , w e c a n c o n s i d e r a s u r gi c a l a p p r o a c h
( m i n i m a l l y i n v a s i v e g l a u c o m a s u r g e r y o r a t r a b e c u l e c t o m y ) .
”
For more information on the topical therapies for glaucoma, see the Geeky Medics guide to common eye drops.
Regular check-ups
“ B e c a u s e o f t h e i n c r e a s e d r i s k o f d a m a ge t o y o u r e y e s , y o u w i l l b e i n v i t e d f o r r e gu l a r c h e c k -u p s e i t h e r a t y o u r l o c a l e y e
d e p a r t m e n t o r w i t h a n o p t o m e t r i s t i n t h e c o m m u n i t y . H e r e t h e y w i l l m e a s u r e t h e p r e s s u r e i n y o u r e y e s ( a t e c h n i q u e k n o w n a s
t o n o m e t r y ) a n d l o o k a t a n i m p o r t a n t p a r t a t t h e b a c k o f t h e e y e k n o w n a s t h e o p t i c d i s c . T h e y w i l l a l s o d o r e g u l a r v i s u a l
t e s t s ( t o t e s t ‘ a l l r o u n d’ v i s i o n ) , b u t t h i s w o n’ t n e c e s s a r i l y b e d o n e a t e a c h v i s i t .
”

Problems/complications of glaucoma

Outlining potential complications of glaucoma, including acute angle closure glaucoma, is necessary so that the patient can
recognise problems early and take appropriate action.
A patient’s ability to drive can also be a
work.
This information needs to be delivered in a sensitive manner, whilst ensuring the patient is aware of the importance of
treatment adherence and red
Acute angle-closure glaucoma
“ I f y o u d e v e l o p s u d d e n i n t e n s e e y e p a i n a n d r e d e y e o r r e d u c e d / b l u r r e d v i s i o n , y o u n e e d t o s e e k m e d i c a l a t t e n t i o n
i m m e d i a t e l y . I t c o u l d b e t h a t y o u h a v e a s u d d e n f o r m o f g l a u c o m a w h e r e t h e d r a i n a ge s y s t e m h a s q u i c k l y b e c o m e b l o c k e d ,
a n d t h e p r e s s u r e h a s i n c r e a s e d v e r y r a p i d l y . I t i s o f t e n a c c o m p a n i e d b y n a u s e a a n d v o m i t i n g , h e a d a c h e s a n d s e e i n g h a l o e s
a r o u n d b r i g h t l i g h t s .
”
Progression of glaucoma
“ P e o p l e w i t h g l a u c o m a a r e a t r i s k o f a w o r s e n i n g o f t h e i r s i gh t a n d e v e n t u a l l y i t c a n b e s e v e r e e n o u gh t o s i gn i
t h e i r q u a l i t y o f l i f e . I t i s i m p o r t a n t t h a t y o u u s e t h e d r o p s a s a n d w h e n i s a d v i s e d t o r e d u c e t h e r i s k o f d a m a g e t o y o u r e y e s a n d
t h e r e f o r e b l i n d n e s s .
”
Driving
“ B e c a u s e y o u r e y e s i g h t g r a d u a l l y w o r s e n s w i t h gl a u c o m a a n d y o u r b r a i n t r i e s t o a d a p t f o r a n y l o s s o f v i s i o n , y o u o f t e n h a v e
l i t t l e a w a r e n e s s o f y o u r b l i n d a r e a s . T h i s c o u l d l e a d t o s e r i o u s e v e n t s w h i l s t d r i v i n g. I t i s t h e r e f o r e i m p o r t a n t t h a t w e m a k e s u r e
y o u m e e t t h e D V L A e y e s i g h t r e q u i r e m e n t s , f o r b o t h t h e s a f e t y o f y o u r s e l f a n d o t h e r s .
”
Further support for glaucoma
“ T h e r e a r e m a n y w e b s i t e s t h a t c a n p r o v i d e m o r e i n f o r m a t i o n o n g l a u c o m a a n d p r o v i d e m o r e s u p p o r t . T h e s e i n c l u d e G l a u c o m a
U K a n d t h e R o y a l N a t i o n a l I n s t i t u t e o f B l i n d P e o p l e ( R N I B )”

Closing the consultation

Summarise the key points back to the patient.
“ W e h a v e d i s c u s s e d q u i t e a l o t t o d a y , i n c l u d i n g w h a t gl a u c o m a i s , t h e s y m p t o m s y o u m i gh t e x p e r i e n c e a n d h o w t h e c o n d i t i o n
i s m a n a g e d . I r e a l i s e t h i s i s a l o t o f i n f o r m a t i o n t o t a k e i n a n d t h e r e f o r e I h a v e a l e a
d i s c u s s e d . Y o u w i l l r e q u i r e r e g u l a r c h e c k s t o e n s u r e y o u r gl a u c o m a c o n t i n u e s t o b e w e l l c o n t r o l l e d . I t i s a l s o i m p o r t a n t t h a t y o u
s e e k a r e v i e w i f y o u n o t i c e y o u r v i s i o n w o r s e n i n g o r h a v e a n y o t h e r c o n c e r n s .
”
Ask the patient if they have any questions or concerns that have not been addressed.
“ I s t h e r e a n y t h i n g I h a v e e x p l a i n e d t h a t y o u’ d l i k e m e t o go o v e r a g a i n ?”
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“ D o y o u h a v e a n y o t h e r q u e s t i o n s b e f o r e w e
Direct the patient to further information about the condition using websites and lea
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Caroline Sheldrick

References

NHS. G l a u c o m a . 2022. Available from\: [LINK]
NICE. G l a u c o m a \: d i a g n o s i s a n d m a n a g e m e n t . 2022. Available from\: [LINK]
Source\: geekymedics.com
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