Theres a well-known adage that any lawyer who represents himself has a fool for a client. Similarly, any doctor who attempts to care for himself has a fool for a patient. Im living proof of this. My own diagnosis of glaucoma was delayed for several years, and I was noncompliant with glaucoma medications.

Eventually, I elected to undergo selective laser trabeculoplasty. Here, Ill offer an account of what our patients may experience when we refer them for this procedure.

A Late Diagnosis
I was diagnosed with open-angle glaucoma five years ago, but I probably should have been diagnosed much sooner. When I was a student at Pennsylvania College of Optometry (class of 1974), I was diagnosed with a very large physiologic cup. My IOP measured in the high teens at most checkups but occasionally spiked to the high 20s. At that time, we did not know about the risk of IOP spikes and diurnal variation in glaucoma patients. Furthermore, my visual fields (which then was the gold standard in diagnosing glaucoma) were always within normal limits.

When I was an optometry student, I was diagnosed with a very large physiologic cup, as shown here in my left eye.

I received my first real clue that I might have glaucoma about seven-and-a-half years ago. Thats when I decided to add frequency-doubling technology (FDT) to my practice. The FDT perimeter revealed that I had a small inferior defect, yet a standard Humphrey 24-2 threshold visual field still showed a full field. Because FDT was still new technology, I wasnt fully confident in its findings. So, I had a false sense of security that I did not have glaucoma.

FDT perimetry (above) revealed a small inferior defect in my left eye more than seven years ago, yet a standard 24-2 threshold visual field of the left eye still showed a full field. This gave me a false sense of security that I did not have glaucoma.

In late 2000, when I was considering buying the Heidelberg Retina Tomograph-II, I had the test performed on myself. The 3-D image of my own optic nerve showed a suspicious neuroretinal rim. (This was the first time I ever saw my own optic nerve in 3-D.) I repeated my Humphrey threshold field, which this time showed an inferior field defect in the left eye, a similar defect to what the FDT showed three years earlier.

In late 2000, I had the Heidelberg Retina Tomograph-II performed on myself. My left optic nerve, as seen here, showed a suspicious neuroretinal rim.

After suspicious findings on the HRT-II, I repeated standard 24-2 threshold visual field testing, which revealed a similar defect in the left eye to that previously seen on FDT.

My Own Worst Patient
After I noted this inferior defect, I initiated glaucoma treatment with Travatan (travoprost, Alcon), which reduced my IOP by about 20%. However, my IOP eventually started to rise again, especially in my left eye, so I added Betoptic-S (betaxolol, Alcon). Both medications failed to bring my IOP below the low 20s, so I added Trusopt (dorzolamide, Merck) to the regimen. Despite all the medication, there was some progression of visual field loss.

One key reason the medications failed to reduce my IOP: I was noncompliant, especially after adding a third drop to the regimen. Sure, you would expect a fellow practitioner who has IOP in the 20s and visual field damage to comply with his glaucoma treatment, but I probably forgot to instill my drops more often than I remembered. This was especially true with the Betoptic S and Trusopt, both of which are dosed b.i.d. At times, I forgot to instill them at least once daily.

I realize this was a poor example to set for patientsalthough I have more empathy for noncompliant patientsbut I did not want the aggravation of instilling multiple drops daily. I also did not like some of the side effects of the medications, namely the ocular irritation.

These factors led me to start looking into SLT about eight months ago. I went to Courtland Schmidt Jr., M.D., a surgeon at Wills Eye Hospital in Philadelphia, to whom Ive referred other glaucoma patients. Given that my IOP was not controlled despite using three medications and that I already had visual field damage, Dr. Schmidt agreed that I was a good candidate for SLT.

Back to the Teens
I underwent SLT in May 2005. My goal was to become less dependent on drops and to achieve better control of my glaucoma. Dr. Schmidt chose to treat more aggressively at 360 degrees, because I was already on three medications and had sustained visual field damage, and placed some 70 to 80 laser spots.

The procedure was very brief and very comfortable. My eyes were anesthetized, so I felt nothing during the procedure, except for the gonio lens, which was somewhat uncomfortable.

Immediately after SLT, my IOP dropped to the teens in both eyes. At one-week follow-up, my IOP was 17mm Hg in the right eye and 15mm Hg in the left. I was fortunate because some patients experience a pressure spike following SLT. Also, I had no redness or any other reaction following the procedure. Dr. Schmidt instructed me to instill Pred Forte (prednisolone acetate 1%, Allergan) q.i.d. for about three days, a regimen typically prescribed to SLT patients immediately following the procedure.

I presented for my one-month follow-up exam on June 3. At this visit, my IOP measured 13mm Hg in the left eye, which has more severe glaucomatous damage, and 15mm Hg in the right. I now require just one medicationTravatan (travoprost, Alcon)but the once-daily dosage of this drop makes compliance easier.

A New Perspective
My own experiences gave me a new perspective on caring for my glaucoma patients. A day before my one-month follow-up visit, I saw a female patient whose IOP was in the mid-20s in both eyes. (Her IOP was in the high 20s at her previous exam.) I explained that she was at great risk of developing glaucomatous damage, even though no damage was evident at this visit.

We discussed all the risks and benefits of various treatment options, including SLT. The patient, who already used several systemic medications, refused to even consider medical therapy, so SLT became an attractive option to her.

I told her she might benefit from SLT and have since referred her to Dr. Schmidt. I might have been a fool for a patient, but I wont be one as an optometrist.

Dr. Cole is in private practice in Bridgeton, N.J., and is an assistant professor at Pennsylvania College of Optometry.