Ask an Expert about Glaucoma

Thank you for your question. Because I have not been able to personally examine your eyes and I have not been able to see the results of the glaucoma tests (that you have already taken or might take at your future appointment), it is nearly impossible for me to give you an accurate answer. Glaucoma is classically defined as a stereotypical pattern of damage to the optic nerve and certain layers of the retina. Elevated intraocular pressure is a risk factor for glaucoma, but just because the pressure is elevated this does not mean you have glaucoma. Often people with elevated intraocular pressure alone, and no other signs of glaucoma, are given the diagnosis of “ocular hypertension.” Similarly, just because the intraocular pressure is normal, as in your case, this does not mean that someone cannot have glaucoma. Doctors often see patients with glaucoma that have never had increased intraocular pressure, and they call this "normal tension glaucoma." If the results of your test are not conclusive enough to give you the exact diagnosis of glaucoma, your eye doctor may give you the diagnosis of being a "glaucoma suspect." This means that they do not yet believe you have glaucoma, but that you should be watched closely for the development of glaucoma in the future. The goal of eye doctors is to identify glaucoma before you ever notice any changes. Your eye doctor will likely follow the intraocular pressure, vision, visual fields, OCT, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future. Essentially, you will have to wait until you complete your full exam and tests to get the correct diagnosis. I would advise you to try and not worry until you know more. I wish you the best of luck.

Thank you for your question. This is something that many of our readers inquire about. This simplest and most straight forward answer is that every patient with glaucoma progresses at a different rate. The goal of eye doctors is to identify glaucoma and treat it before patients ever notice any further changes. The only thing that doctors can do to slow or stop the progression of glaucoma is to reduce the pressure inside the eye. They use three different methods to decrease the pressure: medicated eye drops, laser treatments, and surgical methods. Unfortunately, neither I nor any other glaucoma specialist can predict how long a certain treatment will continue to work in an individual patient or how rapidly they will progress (or how long they will be stable with no signs of progression). In many patients, a single drop will continue to work for their entire life; however, there are also many patients that have used a drop for years and have done well, but suddenly the drop no longer maintains their intraocular pressure at the target. Your doctor will follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how your eyes respond to the treatment and ensure that you stay at your goal intraocular pressure. If the pressure is not reduced enough or your doctor ever notices advancement in your glaucoma, they will add more medications or use laser or surgery to help lower the intraocular pressure further. Unfortunately, eye doctors cannot predict if or at what rate a patient will lose vision because of the glaucoma. In some cases, despite their best efforts, eye doctors cannot stop the progression of the glaucoma and patients do eventually go blind, but this is the minority of patients. It will be important that you continue to visit your glaucoma specialist regularly, follow their advice, and maintain your eye pressure at the appropriate goal for the best chance of maintaining vision throughout the rest of your life.

Thank you for your question. First, let me say that I am incredibly sorry that you have gone through all of this. Without having examined your eyes personally and without reviewing the results of past exams, tests, and procedure notes (including the laser settings used), it is nearly impossible for me to give a completely accurate answer. I don't know if it was related to the laser alone, the use of the steroid eye drops (Durezol), or a combination of both. Laser treatments, either selective laser trabeculoplasty (SLT) or argon laser trabeculoplasty (ALT), are both commonly used as treatments for glaucoma.

The appropriate power that needs to be used varies for each patient, and is mostly related to the amount of pigment in the trabecular meshwork (i.e., the drainage system) of the eye. The more pigment in the trabecular meshwork, typically the less power is needed. When eye doctors perform SLT they typically start at a relatively low power and increase it until they see tiny bubbles form at the trabecular meshwork after about 50% of the laser spots are created. When performing ALT, doctors should see a blanching of the trabecular meshwork to know that they have used enough power. Again, you start at a lower power and work up until you see the blanching so that you know that you are not over-treating.

Laser surgery is relatively well tolerated; however, it is a surgery. Before any surgery, your eye doctor should discuss the risks, benefits, and alternatives before you agree to have any procedure performed in the office or in the operating room. There is a small risk that the laser procedure can cause an increase in the eye pressure and that is always something I discuss with my patients. I have my patients wait approximately 20-30 minutes after the procedure and I check the pressure before they leave to make sure that it has remained stable. If the pressure goes up immediately, this can often be reversed in the office with a couple of additional pressure lowering drops and in most people the elevated pressure does not last long. It is very common to have a slight headache after the laser procedure, and patients may not feel like doing much that evening, but extreme pain is unusual. There is often a small amount of inflammation that occurs in the eye after the procedure, and it is not uncommon that doctors prescribe an anti-inflammatory eye drop for approximately one week. Unfortunately, I am not sure if you will ever really know why the pressure went up. Hopefully your eye doctor can get the pressure under control and work to preserve as much vision as possible.

Thank you for your question. Without having examined your eyes personally and without reviewing the results of past exams and tests, it is nearly impossible for me to give a completely accurate answer. What I can say is that if your eye pressure was in the mid-20s in December of 2011 and March of 2012, and you continued using the same eye drop, it would be rather unusual for the pressure to drop to 10 or 11 in June of 2012 because of the drops alone. If you have been on the same drop regimen from December 2011 until now, eye pressure would not likely change that dramatically. Given that you went to a different clinic, I would wonder if the pressure was accurately taken at one or the other. I would recommend having the pressure taken again relatively soon and determine what the pressure really is. Secondly, I would ask the eye doctor to examine you for any signs of inflammation within the eye. It is always possible that there is inflammation that is decreasing the amount of fluid created in the eye (hence the lowering of the pressure). To reiterate, it is unusual to have intraocular pressure in the mid-twenties on multiple occasions, and then without changing medications have the pressure drop that much. If the readings were accurate, the doctor should be able to help you find a reason for the drop in eye pressure. I would highly advise continuing the eye drops until you can be re-examined by your eye doctor and at that point you can determine whether or not the drops should be continued. Do not stop the drops your own. I wish you the best of luck.

Thank you for your question. Without having completed an examination myself or having the opportunity to review your chart showing previous intraocular pressure readings, it is somewhat difficult to give a fully accurate answer to your question. I will have to make some assumptions. It sounds as though you had silicone oil placed inside the eye to keep the retina attached, and that is quite common. It would be important to know if the correct amount of oil was put inside the eye (too much oil can increase eye pressure, like overfilling a water balloon). The retina doctor can examine the eye and easily tell if the correct amount of oil is in the eye. While retina doctors are often very good about judging the correct amount of oil to use, and overfilling is rare, it is good to at least check this at one of your visits to rule this problem out.

I would also be curious to know if you had a scleral buckle placed on the eye as well. Depending on the location of the buckle, it can cause a slight change in the contour of the eye and the pressure in the eye to go up. If the correct amount of oil was used and the buckle is in good position, then you are correct that the increased pressure in the eye is likely related to the steroid (Tobradex). This is a “secondary” glaucoma known as “steroid-response glaucoma” and it is quite common. Doctors primarily see steroid-response glaucoma when patients take steroid eye drops after surgery or to treat a condition called uveitis; however, it is possible to get steroid response glaucoma from oral steroids or steroid creams. It is relatively rare that one needs to be on steroid drops/ointment for a long duration after retina surgery. Usually these are used immediately after surgery to decrease inflammation. At some point, I would expect the doctor to begin to taper off the steroids anyway; however, if your retina doctor feels like he/she would like to keep you on the steroids for a while, you could always try a less potent steroid (such as fluorometholone). The only way to determine whether or not you are a “steroid responder” (meaning that the pressure in the eye went up because of the steroids) is to do a trial off of steroids, if possible. Never stop any medications on your own without speaking with your doctors first. If you have been on steroids for a long time, it can be dangerous to stop them suddenly; you should taper off of steroids under medical supervision. I wish you the best of luck.

No, it is not harmful if you have spaced it less than 12 hours apart. But, like any medication, the dosing is designed to maximize its effectiveness, based on how long it lasts in your system. Of course, each patient is unique and different, so I would not worry too much about the scenario that you described. It is more important that you are using the medication consistently. If you can remember to space it 12 hours apart, that is ideal, but again, it is more critical that you take both doses in a given day.

Thank you for your question. I would first call and speak with the prescribing ophthalmologist and discuss with him/her whether it is appropriate to stop timolol; however, it is unusual to have glare symptoms from this medication. You could ask your doctor about using the medication only in one eye, and test out if it really is causing you to have the problems with glare. Sometimes patients notice problems coincidentally when they change their routine, and the glare may be caused by a different issue altogether. Certainly this is an important issue to discuss with your ophthalmologist and glaucoma specialist, and please do not make changes to your medication regimen until you talk with your eye doctor(s).

Thank you for your question. I am glad that you are seeing an ophthalmologist soon to help answer your questions. I am unclear about the light yellow excretion. If you are referring to discharge, that sometimes does build up overnight. First, it is important that you determine the cause of the excretion when you meet with the ophthalmologist and ask him/her if the following would be helpful to manage the discharge:

There are steps that I have provided to my patients to improve the condition of their eyelids and manage the discharge. The process is called “lid hygiene”—I think of it like flossing your teeth—and it is a step that one should take in the morning and at night, if possible. Sometimes my patients just start once a day, while they are in the shower, for example. They can take a warm towel and place it on their eyelids, to liquefy the secretions that the glands of their eyelids are excreting. Then, they take a cotton swab, dip it in warm water, and gently clean along the eyelid margin (both the bottom and the top eyelids). Some of my patients use a 1:1 mixture of warm water and baby shampoo. There are also over the counter products (look for “lid scrubs) but I think these simple steps explained above may help you.