Glaucoma Suspect Has Been 'Suspicious' for 15 Years With No Progression, Doctor Starting to Feel Foolish

Optometrist Dr. Applanation Tonick has monitored patient Ruth Steady as a 'glaucoma suspect' for fifteen consecutive years without observing any progression, conversion, or change of any kind — a streak that has caused him to question both his diagnostic criteria and his general approach to risk assessment. 'In 2011, I noted borderline intraocular pressures of 22 millimeters of mercury and cup-to-disc ratios of 0.5, and I classified her as a glaucoma suspect,' Dr. Tonick said, reviewing a stack of charts. 'Reasonable, right? Textbook criteria. So I started monitoring. Annual visual fields. Annual OCT. Annual pressures. Every year: the same. Exactly the same. For fifteen years.' Ruth's intraocular pressures have measured between 21 and 23 at every visit. Her cup-to-disc ratios have not changed. Her Humphrey visual fields show no defects. Her retinal nerve fiber layer thickness, measured by optical coherence tomography, has been stable to within the instrument's measurement error. 'She is the most boringly stable patient I have ever monitored,' Dr. Tonick said. 'And yet every year I write glaucoma suspect in her chart and schedule another follow-up, because what if next year is the year? What if I stop watching and she converts? I can't take that risk. But also, she's 74 now. At some point, the probability of progression within her lifetime approaches zero. Am I just... scheduling appointments to make myself feel responsible?' Ruth views the situation philosophically. 'He tells me every year that my eyes look exactly the same,' she said. 'I say that's wonderful. He says yes, but we should keep watching. I say okay. Then I come back next year and we do the whole thing again. It's very comforting, actually. Like a ritual.' Dr. Tonick has consulted with a glaucoma specialist, who reviewed Ruth's records and recommended 'continued monitoring.' Dr. Tonick sighed audibly during the retelling of this advice. 'I'll see her again next October,' he said. 'And her pressures will be 22. And her fields will be normal. And I will write glaucoma suspect and schedule another follow-up. Because that is what we do.'