I’m 31 yrs. old and have been diagnosed with primary open-angle glaucoma. In ’07 my eye pressure was at 18 bilaterally, 20 bilaterally in ‘08 and it increased to 25 in ’09, but the optometrist didn’t give me drops or perform any follow-up tests. In Jan. of ’10, my pressure was at 36 in the right and 30 in the left. A visual field test revealed slight vision loss in both eyes, but more on the right. I was put on Travatan and referred to an ophthalmologist. The ophthalmologist added timolol in the right eye. My pressures have come down to 25 in both eyes. My Dr. has recommended laser surgery (ALT or SLT). I read online that some Drs. don’t even attempt trabeculoplasty on people younger than 60 because success rate is low. I also read that the surgery can cause more harm in younger people. I would like to know what your thoughts are. I’m curious if there is any research about trabeculoplasty success rates and complications in younger people. [ 03/18/11 ]
Thank you for your question. Answering your question may be slightly difficult as I have not personally examined your eye, reviewed your history, or seen the results of your previous tests. Given your young age, it would be slightly unusual (but not impossible) for you to have “run of the mill” open-angle glaucoma. Typically, open-angle glaucoma presents in much older individuals. I would be curious to know if you had a subset of open-angle glaucoma such as pigmentary glaucoma, pseudoexfoliation glaucoma, or another type altogether. In any case, you are correct, your course or response to treatment may not be similar to an elderly patient with glaucoma that received identical treatment. It likely also depends on many other factors including the amount of pigment in the trabecular meshwork, which can be seen using gonioscopy.
The information that you read online concerning glaucoma treatment in younger individuals (and provided to me as part of your question) is interesting, and I think there may be some truth to these observations. Unfortunately, I found it difficult to find studies in the literature fully supporting this notion. This may be a result of the fact that we do not have many “young” patients with glaucoma and we simply have not studied it closely enough. From my own personal experience, I agree that sometimes laser does not appear to work as well in younger patients. Given that, a search of the literature actually shows a few studies that state age is not a predictor of success or failure. Some of these studies had patients in their 30s. I think it is fair to say that studies on the subject are inconclusive.
So without definitive evidence in the current literature, it essentially comes down to the fact that you have to discuss the risks, benefits, and alternatives of having either laser or surgical intervention and then decide how you would like to treat your eyes. There are risks with every procedure, so please share all of the information that you have obtained with your eye doctor and have a thorough discussion. You will have to decide which treatment provides the best benefit with reasonable risks in your opinion. That is a decision that only you can make (and two different people with the same options may make different choices based on their willingness to assume certain risks). That is why you must sign an “informed consent” before any procedure is completed. It states that you have been given the risks, the potential benefits and understand that you have alternate choices.
I wish I could provide a more definitive answer, but unfortunately I don't think there is one. If there was definitive information showing that laser in young patients was contraindicated, your doctor would not have offered it as an alternative. I wish you the best of luck.
My wife has glaucoma, which is under control; however, she is now having problems with a tic in her left eye lid, which is driving her crazy. Is the tic related to the glaucoma? [ 03/17/11 ]
Thank you for your question. I have had a similar tic on occasion and it nearly drove me crazy too! Fortunately, this likely has nothing to do with the medications or the glaucoma. These are usually termed “myokymia” and last only a short time (although it can be several weeks). Often they occur when individuals are under increased stress, and it doesn't help that having the tic stresses you out more! The best advice is to ignore it and it will soon go away on its own. In addition, increasing exercise, increasing sleep, and decreasing caffeine or any other stimulants may help. To be safe, if it lasts more than a couple of weeks, you should probably stop by the eye doctor to just make sure it is this type of muscle twitch and not something related to other medical conditions. I know this can be aggravating, and I do wish you the best of luck.
Is there a relationship between blood pressure and eye pressure? I have no family history of glaucoma, so I would like to know why I have developed glaucoma. [ 03/16/11 ]
Thank you for your question. You bring up a point that many of my patients ask. Let's first take the case of high blood pressure. Unfortunately, the only real answer that I can give you is that I believe there is possibly a link between elevated blood pressure (hypertension) and elevated eye pressure, but the studies that have looked at this association have come up with various answers. Some support a link between the two and others do not find a link. Many of the studies were not designed the same and the outcomes were very difficult to interpret. I would say that because the data in the studies has been so inconclusive, I cannot give you an accurate answer. I think that more very well controlled studies, which are in progress, need to be completed before we will have a definitive answer. Regardless of the connection, it is always in your best interest to treat both hypertension and glaucoma.
While the association with hypertension (elevated blood pressure) is not as clear, I think there is more conclusive evidence to show that low blood pressure (hypotension) is associated with a very special type of glaucoma known as “normal-tension glaucoma.” In these patients, the intraocular pressure is not elevated but they still have signs of glaucoma. In some cases, it is believed that raising the blood pressure to a normal level may be of some benefit, and the eye doctor will then work with the primary care physician regarding ways to safely increase the blood pressure.
You should know that you can still get glaucoma even though no one in your family has had this eye disease before. In fact, a good number of my patients do not have family members with glaucoma. In the same respect, this is also good because it also means that if they have children, there is a good possibility that the children may not be affected. Just because something is “genetic” does not always mean that every person in the family will have the disease. It is often much more complex than that. I hope this helps, and I wish you the best of luck.
When I had glaucoma surgery several years ago, I suffered a severe problem, whereby my retina became ruffled and my vision became very impaired. Is this a common occurrence? I have had many further surgeries since that time, including one where my doctor sewed a piece of tissue on the bleb to stop the fluid from leaking out. The pressure is now holding at 14, but my vision is still impaired. [ 03/15/11 ]
Thank you for your question. I am sorry that you had these troubles. Without having examined your eyes, looked at your chart history, and known more about your post-operative recovery, it is very difficult for me to guess what happened inside your eye after the surgery. It sounds as though you had a trabeculectomy (filter) completed. Before any surgery, I always discuss the risks, benefits and alternatives of the surgery with the patient. In general, regardless of the surgery that you had, I always include infection, pain, bleeding, loss of vision, loss of the eye, intraocular pressure staying too high, intraocular pressure falling too low, need for further surgery, and death (due to anesthesia) among the risks. The chances of these happening to any individual are relatively low, but as I tell my patients: “If your risk of an adverse side effect is one in one million, that does not sound bad….unless it happens to you. Then, you don't care about the 999,999 people who did not have that side effect—you are not happy that it happened to you.” Risks and side effects are real and they are not usually the fault of the doctor that performed the surgery. It is simply part of the risk you take when operating on a very sensitive organ. In your case, it sounds as though the intraocular pressure dropped too low (one of the known risks) and the retina developed folds or choroidals. This causes a decrease in vision (another known side effect). It sounds as though the fluid was draining too quickly out of the eye and the trabeculectomy flap did not heal down as it usually does (you may not heal quickly). He likely put the tissue back over the trabeculectomy flap in order to slow the fluid from escaping to help stabilize the pressure. Again, this is all a guess from what you provided me. It sounds as though you had some side effects from the surgery, and while they may not be common, they are also not completely unexpected. It sounds as though your doctor recognized what was happening and used the appropriate intervention to bring the pressure back up. I hope this helps.
Xalacom brought my daughter's pressure down from 40 to 30, but no lower. We now also use Azopt, which has lowered the pressure to 16. Why do we need both types of drop to successfully reduce pressure and would like to know which drug is safer for long-term use. My daughter is only 2 years old and is aphakic due to congenital cataracts. [ 03/14/11 ]
Thank you for your question. Xalacom is a combination of the drugs timolol (a beta blocker) and latanoprost (a prostaglandin analog). Azopt is a carbonic anhydrase inhibitor. Your eye constantly makes fluid (aqueous humor) that keeps the eye blown up like a water balloon. However, in glaucoma, the pressure in the eye is often too high and it needs to be lower. I tell my patients that the eye is a bit like a sink that has a dripping faucet. The water continues to drip into the sink and then it runs out the drain at the bottom. When you have glaucoma, it is similar to having a clog in the drain and the sink backs up (i.e., the pressure builds up). The medications that we give to patients essentially do two different things. Either they turn the dripping faucet down (we call this aqueous suppression) or they allow more water to flow out of the eye by a couple of different methods (the traditional pathway and the uveoscleral pathway). Timolol and Azopt essentially work as aqueous suppressants (turning down the faucet), but they may also cause the traditional drainage system to work slightly better as well. The latanoprost works by increasing the outflow through the uveoscleral pathway. Essentially, when one medication alone does not work (does not turn the faucet down enough or does not open the drain enough) the doctors will add medications that work on different parts of the eye to have an effect greater than just one drug. At this time, all three drugs appear to be well tolerated in children and may possibly be used the rest of her life if it keeps the pressure stable. We never say that drugs are “safe,” because every drug has side effects, but your doctors will be watching for those side effects, and if they become an issue, other treatment options will be given to you. I wish the best of luck to both you and your daughter.
It was determined that I had eye pressures of 55 and 27. I was given oral medication and eye drops to reduce the pressure. After starting the medications, I noticed that my vision was dim the next day. Can you explain why this happened? [ 03/13/11 ]
Without having examined you myself, seen the results of some of your tests, and knowing a bit more about your history and the specific medications that you took, it is nearly impossible for me to explain what happened. In general, if the eye pressure is above 50, it needs to be brought down rather quickly. Pressure this high can begin to cause significant vision loss in a rather short amount of time. If I had to make a guess, I would think that your vision was impaired during the time that the pressure was 55 and you simply did not realize it was becoming dimmer. Once the pressure was returned to normal and your vision began to clear, I would guess that this is when you noticed the worsening of your vision. It is also possible that you noticed the dimness because some of the optic nerve was damaged with the pressure being that high. Again, this is all speculation. The medications themselves would not likely have caused the vision to dim. Unless there was a progression of a cataract because of the increased pressure (and this would be relatively rare), I cannot necessarily think of any direct linkages. You may want to let your doctor know that you now notice the dimness and discuss it further with him/her.
I am a 51-year-old female and have a family history of glaucoma. I have had glaucoma for about 5 years now. I was treated with Lumigan for 4 years, and now take one drop of DuoTav in each eye at bed time. I also take thyroid and blood pressure medication. My eye doctor has recently suggested laser treatment. I don't know what kind of glaucoma I have, and have very little knowledge about my condition. After reading the questions in this section of the website, I now have so many questions that I want to ask the doctor before having the surgery. Can you please give me some advice as to what kind of questions I could ask him and also please write about the potential side effects of the laser treatment. Finally, can my blood pressure increase my eye pressure? [ 03/12/11 ]
Thank you for your question. To answer the first part of your question, I will assume that you are having a selective laser trabeculoplasty (SLT) or argon laser trabeculoplasty (ALT) to help lower the pressure, and not a laser peripheral iridotomy (LPI) for treating narrow angles. There are very few precautions that will have an impact on your activities of daily living after glaucoma laser surgery. I think you should ask your doctor any questions that come to mind because it is your right as a patient to be informed. It is our job as physicians to help you understand the disease. Your eye doctor should discuss the risks, benefits, and alternatives of any procedure before you agree to have any procedure performed in the office or in the operating room.
For any glaucoma laser surgery, you will have a few drops of medication put into your eye prior to the procedure to help with your comfort level. In addition, a few drops may be put in your eye after the procedure to decrease the amount of inflammation that might occur. After the procedure has been completed, you will likely be asked to wait approximately 20-30 minutes to have the intraocular pressure checked again. There is a small risk that the laser procedure can cause an increase in the eye pressure. This can often be reversed in the office with a couple of additional pressure lowering drops, and in most people the eye pressure increase does not last long. It is very common to have a slight headache after the laser procedure, so you may not feel like doing much that evening. Other than that, there are no real restrictions to your activities. There is often a small amount of inflammation that occurs in the eye after the procedure, so you will likely be given an anti-inflammatory eye drop for approximately 1 week. There is a very small chance that any of the following might also occur:
- Inflammation could continue longer than one week
- Pressure could actually go up
- Vision could decrease
- Further incisional surgery could be required
All of these are relatively rare, but you should discuss them with your physician.
I often see my patients 1 week after the procedure to make sure that the eye is no longer inflamed and the patient is comfortable. We would not expect the pressure to be reduced at that time because the full effect of the laser is often not complete until at least 4-6 weeks after the laser procedure. You will likely be seen again 1-2 months after the laser procedure to see if the treatment reduced your eye pressure to the target that your eye doctor set.
Concerning your blood pressure medications, they should not have a harmful effect on your eyes. In fact, a beta blocker (an oral medication commonly used to control blood pressure) is also used in DuoTrav (timolol). We use beta-blockers to help lower eye pressure and treat glaucoma all the time. I wish you the best of luck.
My brother lost the vision in his right eye due to glaucoma, and his doctors told him that he needs surgery to remove the eye completely. Is it possible to save his eye without that kind of surgery? Please help us to make a right decision. Thank you. [ 03/11/11 ]
I am sorry that you are both going through all of this. This is often a very difficult topic to address with our patients and it is often a discussion that cannot be done in one exam. Without having examined your brother, seen the results of his tests, and knowing more about his history, it is nearly impossible for me to provide completely accurate advice. The advice that I am going to give you is based on the assumption that your brother has no vision at all in the right eye, has no potential for ever having vision in that eye, and that is the eye that has uncontrolled pain as a result of an increase in pressure causing pain that is uncontrolled with over the counter medications.
Any eye that is categorized as “No Light Perception (NLP),” meaning that even when a bright light is shined into the eye, the patient cannot perceive any light, is usually not treated with any further pressure lowering surgery; however, there are some rare exceptions. There are currently no surgeries available to help NLP eyes see again, so this treatment strategy is not usually suggested. Surgery to lower the pressure and prevent pain would only be done to help prevent pain, but not to correct vision. Often this surgery simply puts the patient at risk for side effects (infection, bleeding, pain, loss of the eye, complications from anesthesia, etc.) with very little gain. If the eye has no vision and no hope of ever regaining vision, there are a few more realistic things that can be discussed:
- First, either an alcohol or thorazine block can be performed.This is an injection of medicine behind the eye that kills the nerve endings of the eye and stops the pain, and is effective in many patients.
- Second, you can consider having the eye removed and a prosthetic eye implanted.This step has many implications and can be quite complex (both medically and socially). This is the reason I usually take several visits to discuss the options and plan with the patient and the entire family. That discussion is way beyond the scope of this website and should only be undertaken face to face with a physician. This is essentially a step that cannot be reversed.
My patients (especially our young patients) have many years ahead of them, and I cannot guarantee that surgeries to correct NLP eyes may become available at some point. At this time, these surgeries are so far away that the discussion is difficult to entertain, but we always want to hold out hope for as long as possible. I can tell you that my patients that have gone on to have prosthetic eyes implanted often tell me that they wish they would have done it sooner. Again, this full discussion should be handled with your brother's personal physician and his eye doctor to determine the best course of action. Do not hesitate to get a second opinion (or even a third) before making a final decision. I wish all of you the best of luck.