My doctor says that I have mild glaucoma in one eye, for which he prescribed Lumigan. I also have mild high blood pressure and take 1 Ramipril tablet nightly. My doctor expressed concern that the two drugs may counteract each other if taken at the same time, and wants me to take the Ramipril during the middle of the day. It seems to me that the drugs are complementary, and there's good reason to take both at bedtime. Are you aware of this particular issue concerning Lumigan and Ramipril? [ 01/13/11 ]
Thank you for your question. In general, the two drugs will not necessarily counteract each other. Lumigan is a prostaglandin analog used to lower intraocular pressure through the uveoscleral pathway. Ramapril is an ACE inhibitor used to lower blood pressure and treat congestive heart failure. To my knowledge, there are no contraindications to using these two medications. This was confirmed by my search for drug interactions at Drugs.com which indicate "No Results Found" when looking for adverse interactions. What your doctor may be referring to is the fact that we often prefer our glaucoma patients to be quite careful about lowering their blood pressure too much at night. The Lumigan is used at bedtime to lower eye pressure, and if Ramipril is used at bedtime as well, it can lower the blood pressure quite substantially. If blood pressure decreases too much at night, there is a small chance of adverse effects on the eye. In general, I ask my patients to try and avoid taking the blood pressure medications right before bedtime unless their primary care doctor or cardiologist is opposed to them taking them earlier in the evening (dinner time). I hope this sheds some light on the subject. I wish you the best of luck.
My 5-year-old son is waiting to receive a Baerveldt shunt to treat his glaucoma. After the operation, how long should he stay out of school? When can he engage in normal activities again, such as running or swimming? [ 01/12/11 ]
Thank you for your question. I am sorry that you and your family are going through this with your child. You should plan on your son being out of school for 1 week at a minimum. The time period could be longer if for some reason the healing process is slowed, or there are complications after the surgery. During this week, he should avoid lifting, bending or straining (I know this is a bit difficult for 5 year old boys, but do your best). I typically give them “couch duty” with all of the video games, movies, and TV they can stand. You just want to avoid problems, if possible. Your eye doctor will have to let you know when he can go back to routine activity. This is often quite variable depending on how the surgery is performed (is the tube tied off, is a “ripcord” put in the tube, etc.) and how the individual patient heals. There is never an exact answer, unfortunately. I would assume that he will be back to his routine activities within a month or so, but again this depends on how he heals. Play it by ear and follow the directions of the doctor that does the surgery. At each exam, the directions will likely change and he will slowly get back to his routine activities.
Is glaucoma directly correlated with having a retinal detachment? [ 01/10/11 ]
Thank you for your question. I am not exactly sure that I understand your question, but let me try to clarify. The two possibilities are as follows:
- “If I have glaucoma, am I at an increased risk for developing a retinal detachment?”
The answer to this question is “maybe,” but it is not common. Primary open-angle glaucoma itself does not predispose you to developing retinal detachments in the future; however, one of the medications that we use to use to treat glaucoma has a known side effect of causing an increased risk of developing retinal detachment. The medication pilocarpine (it has a green cap) has long been known to have an increased association of retinal detachments, but we now have much better medications and pilocarpine is no longer commonly used to treat this eye disease. Secondly, there are a couple of special cases in which patients might develop retinal problems that can lead to both glaucoma and a retinal detachment (neovascular glaucoma from uncontrolled diabetes, for example). In these cases, they would likely occur because of the new blood vessel growth in the angle of the eye and on the retina, but the glaucoma itself still does not cause retinal detachments.
- “Can a retinal detachment cause a secondary glaucoma?”
The answer to this question is “yes.” There is a special type of glaucoma called “Schwartz-Matsuo Syndrome” in which a retinal detachment occurs and the photoreceptors (small light sensing cells in the retina) are dislodged from the retina. They float in the vitreous and aqueous inside the eye and eventually get clogged in the trabecular meshwork drainage system. If the trabecular meshwork get clogged enough, it is possible for the pressure to elevate and cause glaucoma.
I am a glaucoma suspect according to the doctors, and I recently had laser surgery in both eyes for narrow angles. After the surgery, I developed a ‘horizontal line,’ which the doctor says can be fixed with sutures; however, she does not want to do this procedure. Also, my eyes seem tired and red quite frequently. Last year, I had my eyes dilated and for 3 days I saw halos and had a bad headache; it was horrible. This year, the doctors said that they cannot dilate my eyes because there is a change in the angles. I am confused concerning whether or not the surgery helped me. Do I have to worry about getting glaucoma now? [ 01/09/11 ]
Thank you for your question. Since I have not been able to examine your eyes or view your chart with old exam notes and test results, it is nearly impossible for me to give you an accurate answer. If you had narrow angles that required a laser procedure, I would have to assume that you had a laser peripheral iridotomy (LPI or PI). One of the potential side effects of that laser procedure is seeing a line like you describe. It is usually in the lower portion of your visual field. This occurs because light is passing through the LPI hole and hitting the retina (similar to the way light goes through the pupil and hits the retina). Unfortunately, this can cause a line in the vision or even double vision. Your doctor is correct, it can be fixed with a suture, but that would reverse the laser procedure and put you back at risk for developing angle-closure glaucoma. The LPI is done to help prevent pupillary block angle closure and in most cases helps prevent the development of angle-closure glaucoma in the future.
If an LPI was completed and the angle did not deepen you may have a special anatomic variation called “plateau iris configuration.” If this is the case, then yes you are at an increased risk of developing glaucoma in the future. If your doctor feels that you have had a change in the angle and they are concerned enough that they are not willing to dilate your eyes, you need to ask for a referral to an ophthalmologist that is a glaucoma specialist. It is possible that you have a narrowing of the angle because a cataract is getting larger or it is possible that you have “plateau iris” or chronic angle closure that is slowly getting worse. In either case, you are best served by being examined by an ophthalmologist that is comfortable diagnosing and treating complex types of glaucoma. I wish you the best of luck.
My eye pressure is 22; however, my doctor has not put me on eye drops. I have an eye appointment every 4 months and my doctor is watching me closely. Should I be concerned about taking these eye drops? [ 01/08/11 ]
Thank you for your question. Because I have not examined you myself or seen the results of your tests, I have to make a few assumptions. It sounds as though your doctor has diagnosed you as having “ocular hypertension” and is following you as a “glaucoma suspect.” Follow-up for every patient diagnosed with glaucoma or diagnosed as a glaucoma suspect is completely different depending on what you find during the eye exam and the results of periodic tests. Once you have been diagnosed as a glaucoma suspect, a plan for follow-up should be established. This can be either a plan to watch your eyes closely (for the majority of patients) or to initiate treatment (for a minority of patients). All of this depends on the findings at the exam and the results of those tests. If your exam and tests are normal except for the slightly elevated pressure, then you may simply be a glaucoma suspect and have “ocular hypertension.” Following you every 4 months for a pressure check during the first year or so is reasonable. I would suggest a visual field and dilated exam every year at some point, and I would probably not recommend starting drops at this time. If you remain stable for a couple of years, I would spread your visits out to every 6 months for a while, and if you continue to be stable for a couple of years after that, I might consider going to yearly exams. If I ever saw anything of concern, I would continue to monitor you more closely and consider starting pressure lowering drops at that time. Overall, it sounds as though your eye doctor has a good plan established for you.
Our goal as eye doctors is to identify glaucoma before you, as a patient, ever notice any changes. Your eye doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves at different intervals to see if there is any evidence of glaucoma that presents in the future. If you have questions or concerns, do not hesitate to start an open dialog with your eye doctor and ask them to explain why they have chosen the particular monitoring plan that they have prescribed for you. If you are still concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist.
My mother is 76 years old and has lost vision in one eye, which was previously operated on. She has glaucoma and had an operation to remove a cataract. Also an Ahmed valve implant was placed in her eye. We were told that the retina is still attached; however, she can no longer see out of that eye. The other cataract will be removed in a few weeks but she's concerned that the vision will be lost in that eye as well. What else can be done? [ 01/07/11 ]
Thank you for your question. I am sorry that your mother is having these difficulties. Because I have not evaluated your mother's eyes, giving advice in this situation is difficult. It sounds as though your mother may have had both advanced glaucoma and visually significant cataracts. Very few people go blind after cataract surgery, so I have to assume that her advanced glaucoma is the reason that can no longer see out of that eye. We always wait until cataracts are “visually significant” before recommending that they be removed. This usually means that her decreased vision is affecting her activities of daily living (for example, the ability to get around the house, see things clearly, do hobbies she enjoys, read, or watch TV). In my patients with only one eye that can see well, I try to put off doing cataract surgery until it is absolutely necessary. Unfortunately, cataract surgery is the only way to definitively treat cataracts (there are no randomized controlled trials showing that medications, supplements, or vitamins reduce cataracts). When any physician discusses the possibility of surgery with a patient, they will discuss the risks, benefits, and alternatives of any surgery they are planning. In addition to the normal risks associated with cataract surgery, when doing cataract surgery in a patient with very advanced glaucoma and very little nerve tissue remaining, there is a very small risk of damaging the remaining nerve tissue. This occurs because of the changes in eye pressure that occur during cataract surgery. This is known as "snuffing out" the nerve. After the surgery, the vision can be decreased instead of improved. While this is a small risk, it is still very real.
I tell my patients that if the risk of a certain side effect during surgery is 1 out of 10,000, that often does not sound too bad. But, the one patient that does get the side effect is a real patient, they are not a number. If you are the 1 patient that has the side effect, you no longer care about the 9,999 that got through the surgery without problems, you only care that the side effect happened to you. When you agree to have surgery, you sign a form called an "informed consent." This means that you understand that there are risks to the surgery beyond the doctor's control but that you want to proceed with the surgery knowing that these side effects are possible. Most glaucoma specialists also perform cataract surgery. I would suggest getting a second opinion from a glaucoma specialist that feels comfortable doing cataract surgery in patients with advanced glaucoma, if your surgeon is not a glaucoma specialist already. They can discuss the risks and benefits of cataract surgery in patients with advanced glaucoma and you can make an informed decision on the route that you would like to take. These decisions are often not easy to make and often there is not one single "right" answer. You and your family will need to weigh all of the potential risks against the potential benefits and determine what you are comfortable doing. I wish you the best of luck making this decision; I know it can be difficult.
I take Azopt and Xalacom eye drops. Can I put either of these in my luggage that will go in the hold of a plane? [ 01/06/11 ]
Thank you for your question. The following are the storage information from the package inserts for Azopt and Xalatan eye drops:
- Xalatan: Storage: Protect from light. Store unopened bottle(s) under refrigeration at 2° to 8°C (36° to 46°F). During shipment to the patient, the bottle may be maintained at temperatures up to 40°C (104°F) for a period not exceeding 8 days. Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks.
- Azopt: Storage: Store between 4 and 30 °C (39 and 86 °F)
Because the cargo hold of a plane can occasionally dip below 36 degrees, I typically recommend that my patients carry on their medications. In addition, airlines do their best to ensure that your baggage makes it to the same destination as the traveler, but this does not always happen! If your eye drops are in your bag and it does not make it to the final destination, you will be without them until you can either contact your doctor to get a new prescription or your bag arrives. You are always better off keeping your medications with you. The TSA continues to allow prescription and non-prescription eye drops to be taken onto a plane through carry-on baggage. They state the following on their website:
“Additionally, we are continuing to permit prescription liquid medications and other liquids needed by persons with disabilities and medical conditions. This includes: All prescription and over-the-counter medications (liquids, gels, and aerosols) including petroleum jelly, eye drops, and saline solution for medical purposes.”
Simply place your eye drops into a zip-lock bag and take them with you. This is the safest and easiest method.
I am a thirty-year-old female. Both of my parents developed glaucoma before the age of 50. What are the odds that I will get this eye disease? How frequently should I have my eyes checked? I want to be as vigilant as possible within reason. [ 01/05/11 ]
Thank you for your question. Given your family history, you should be cautious and have regular eye exams. It is difficult to give you an exact risk assessment because I do not know the type of glaucoma each of your parents have. If they both have primary open-angle glaucoma, then you are at an increased risk that is several fold higher than the average person. However, even with this increased risk, there is a better chance that you will not develop glaucoma in the future than the chance that you will. Less than half of the children (closer to 10-20%) of parents with primary open-angle glaucoma will eventually develop the disease. Because you do have this increased risk, you should still consider having a yearly eye exam completed by an eye care specialist that is comfortable looking for the signs of glaucoma. If you have siblings or half-siblings, they should also be checked regularly. I wish you and your family the best of luck.