I was born with cataracts, which were removed (along with my lenses), leaving me with decent vision. I was then diagnosed with glaucoma at age 7. When I was 15, I had a trabeculectomy in my right eye, and then a tube implant in the same eye at age 19. I’m 33 years old now. I also recently had a cornea transplant in the right eye because it decompensated. Somewhere amidst those glaucoma surgeries (10+ years ago) I lost functional vision/acuity in my right eye although the tube has kept the pressure low. My left eye has been fairly stable with eye drops until recently, but the pressure is creeping up and I may require surgery in that eye. I’m obviously nervous to lose functional vision in that eye following surgery, and would like to know the impact that modern tube surgery has on vision. What should I should I expect? Also, when medications are changed, how long should it take for the new medication to start lowering pressure? [ 07/07/12 ]
Thank you for your question. I am sorry that you are having so many problems with your eyes. It sounds as though you have quite a complex history. Unfortunately, given the complex nature of your problem, the fact that I have not examined your eyes, or the fact that I have not seen any of the test results from previous exams, it will be nearly impossible for me to give a completely accurate assessment; however, I can give you some general thoughts. These are questions that you should directly ask your surgeon prior to your glaucoma surgery.
First, ask about the impact of modern tube surgery on vision. Any time eye doctors discuss surgery, they should talk about the risks, benefits, and alternatives to each surgery that is recommended. In the case of glaucoma tube surgery, they discuss things like the risks of bleeding, infection, pain, the pressure not being low enough (requiring further surgery or medications), the pressure being too low (requiring further surgery or medications), decrease in vision, or loss of the eye. While these are some of the risks, this is not meant to be inclusive because each case is different. While these side effects can occur, the more serious complications, such as vision loss, happen in a minority of patients. Most patients notice only minimal changes (if any) in vision. If vision does change, the vision loss can occur immediately after surgery because of the stress the surgery places on the eye. In addition, simply inserting a tube into the eye can cause the cornea to change its refraction slightly; therefore, a glasses prescription may be needed (or it may need to be changed) to obtain the best visual acuity. Finally, some patients can notice some double vision because the glaucoma tube implant is near the muscles of the eye.
In your particular case I do not think this will be a problem given the poor vision in your left eye. Some vision loss may also happen later in life. Often a glaucoma tube, if placed into the anterior chamber, can cause cornea decompensation and the need for a cornea transplant. These would be the primary reasons for a change in vision after the glaucoma tube is implanted. Again, overall, most people do not notice much change in vision, but it is something that you should discuss with your doctor.
Finally, you asked about the length of time it takes for glaucoma medications to take effect. In most cases you can tell if a medication is working within a few days; however, there are a few medications, such as prostaglandin analogs, that may take a few weeks to have their full effect. I hope this helps and I wish you the best of luck.
I’m 49 years old and nearly three years ago I was told that I have advanced glaucoma in my left eye. I have pretty much tried all classes of eye drops for glaucoma, including some combination drugs, without sufficient eye pressure reduction. A laser procedure was tried but there was no significant effect at all. I eventually received a trabeculectomy in October 2010, which initially decreased the eye pressure to 13-14; however, the readings went back up to 18-20 a few months after the surgery, so the doctor tried Lumigan and Brimonidine. The eye pressure was kept around 18, but starting earlier this year the irritation and redness of my left eye got worse and increased over time. [ 07/05/12 ]
My ophthalmologist finally told me to stop all eye drops and prescribed oral methazolamide. I have not started on the pills yet as I'm very nervous about all the potential side effects. Is there data concerning the percentage of patients that experience severe side effects from this drug? What are the long-term health effects from taking methazolamide?
I am sorry to hear about your intolerance of eye drops and your glaucoma. Methazolamide is certainly an option, and for glaucoma patients who do not desire to have surgery (which is still an option for you), eye doctors sometimes offer them long-term methazolamide treatment, if it is tolerated.
As you know, many medications have side effects, and when you read the package insert of any medication, the list of side effects can be quite daunting. Methazolamide is typically better tolerated than the other oral medication in the same class, called acetazolamide. Some common side effects of this class of medication (carbonic anhydrase inhibitors) are: nausea, loss of appetite, change in taste, diarrhea, frequent urination, dizziness, and tiredness. These often improve with time. Other side effects that are more worrisome include blood in the urine, numbness or tingling of hands/feet, painful urination, sudden decrease in amount of urine, and ringing of the ears. There are also other rare side effects that are more serious, including a very serious (but also very rare) allergic reaction or decreased blood cell production.
I cannot give you a strict percentage of patients who have these side effects, but I can tell you that as long as you and your doctor monitor any changes after you begin therapy, the drug can always be stopped if you are experiencing intolerable side effects.
As for your question about long-term health effects, unfortunately that has not been well-studied; however, many of these side effects can be monitored and are related to the dose you are taking. One option for you is to start with a low dose (discuss with your ophthalmologist first) and then increase the dose upwards if the eye pressure is not low enough and you can tolerate the medication.
I was diagnosed with glaucoma ten years ago, at the age of 43, and had been taking daily eye drop medications since that time. I had used approximately five different types of eye drops, the last being Azopt, which I took twice a day. I recently saw a specialist consultant at a local hospital and was told I didn't have glaucoma, so I was stunned and very pleased; however, now I wonder about long-lasting effects of taking these eye drops. The consulting eye doctor said that I could have had pigment dispersion glaucoma that has “blown out.” I had changed my lifestyle and filled in job applications stating that I had glaucoma. The more I think about this, the more upset I become. Why did take so long to obtain a proper diagnosis. [ 04/05/12 ]
Thank you for your question. It is difficult to evaluate your diagnosis by just hearing your story, but it does sound like you may have had pigment dispersion causing elevated eye pressures, which required eye drop medications. Over time, high eye pressures can cause damage to the optic nerve, or glaucoma, which is likely why you were started on treatment. Sometimes, as the consultant doctor mentioned, pigment dispersion can “burn out” and eye pressure may be normal. Some patients, indeed, do have pigment dispersion but no evidence of elevated eye pressures or changes to the optic nerve. However, since glaucoma is also an age-related disease, I recommend that you continue follow-up and be monitored for this disease. Lastly, glaucoma often is difficult to diagnose when patients have various risk factors, such as elevated eye pressures, abnormal appearing optic nerves, or strong family history. It sounds like you had risk factors that may have made your previous doctors suspicious for glaucoma. I follow many patients whom I consider “glaucoma suspects” and it is only over time that we can determine whether the patient definitely has glaucoma requiring treatment.
I am 33 years old and have had three glaucoma surgeries. I had the 350 mm Baerveldt implant seven weeks ago and now I have double vision. I feel like the eye that had the surgery is not looking in the same direction as my other eye. Will I need to have surgical intervention for the eye muscles? Is the insertion of a different implant possible or likely? Has anyone had strabismus surgery following an eye implant? If so, what were the results? I have exhausted the ophthalmologist resources in my local area and feeling desperate at this point! [ 02/04/12 ]
Thank you for your question. I am sorry that you are having double vision after your Baerveldt implant. Double vision can be disabling and I urge you to seek further help. Because the Baerveldt implant is a larger one, it is implanted under the eye muscles, and sometimes, although usually rarely, cause eye muscle problems that either require removal of the implant or strabismus surgery. Sometimes the eye muscle issues can improve over time as the capsule over the implant remodels, which may be why you have not been recommended for either of those options. You mention that you have exhausted ophthalmologist resources in your area, but a surgeon who performed the Baerveldt's implant knows about the potential eye muscle issues, and should be able to help you, either by referring you to another glaucoma specialist and/or a strabismus surgeon. To answer your last question, there are patients who have had strabismus surgery after glaucoma implants, and it showed that the problem can be addressed, but requires the expertise of both glaucoma and strabismus surgeons. Therefore, you may want to seek your doctor's advice and ask for a referral to an academic center where both glaucoma and strabismus surgeons have likely worked with patients who have had this problem before.
Someone told me that if someone is diagnosed with glaucoma, a dilated pupil exam can make this eye disease worse. Is this true? Also, I was also told to get an MRI of my head using a dye? Why are they doing this test? [ 02/03/12 ]
Thank you for your question. A dilated pupil exam is a routine part of any comprehensive eye exam, and is important when we manage patients with glaucoma. However, in patients who have narrow angles, sometimes the doctor will defer dilating the patient in the initial visit until that issue is addressed because dilating a pupil in a patient with narrow angles can cause the eye pressure to increase. For patients who have open angles (the majority in the U.S.), there is no harm from dilating the pupils, and, in fact, it is important for glaucoma diagnosis and management. For your second question, without knowing more of your clinical history and exam, it is difficult for me to speculate why you are having an MRI of your brain. Sometimes glaucoma specialists will order this test because they are not sure whether a patient's optic nerve appears the way it does because of glaucoma, or another reason that may be found in the brain. However, this is a question best asked of the doctor who ordered your test.
Do you know of any side effects or negative outcomes from the use of VESIcare combined with recent laser trabecular surgery? [ 02/02/12 ]
Vesicare is an anticholinergic, which are a class of drugs that can cause problems in patients who have narrow angles. If you have had recent laser trabecular surgery, then you most likely have open angles, but I would check with your doctor. Additionally, if there is a question about whether you have slightly narrow angles, you can always start the medication and have your doctor recheck your angle anatomy. In addition, you should be aware of the side effects that an anticholinergic can have if you indeed have narrow angles (for example, halos around lights and eye pain). Lastly, if you have narrow angles, your doctor can perform a laser iridotomy, which is a small opening in your iris. This reduces the risk of an angle closure glaucoma attack, although not completely. Eye doctors perform this procedure as a preventive measure for patients who have narrow angles and need to take medications that can cause narrow angle issues, however.
I am 58 years old and had a trabeculectomy in my right eye. In July of 2011, my pre-surgery eye pressure was about 35 (without drops). Three months after the surgery, the eye pressure was 14, and now it is 5. Is that kind of variation normal? Also, I have tearing in my eye, and would like to know if there are there any drops to help with this issue? [ 02/01/12 ]
Thank you for your question. It is difficult to answer it without being able to examine your eyes and review your complete history, but there can be different causes for fluctuations in your eye pressure after surgery. If the intraocular pressure is currently 5 mmHg, your vision is stable, and your trabeculectomy is working well, then I would consider that a success. With regards to your tearing, I would be sure to mention this to your surgeon because given your low eye pressure, your surgeon would want to make sure that your trabeculectomy site is not intermittently leaking. If that is not the case, the tearing may be caused by irritation, and some artificial tears may help. Also, if you are still using any drops in your right eye that might be causing irritation, you should talk with your doctor about this.
I'm 48 years old and have been going to glaucoma specialists for the past two years. I am considered a "suspect " glaucoma patient and I have an “acquired pit” in my right eye. My eye pressure has been good at 16 and I also have 20/20 vision in both eyes. Can anything be done to correct an “acquired pit”? [ 01/27/12 ]
Thank you for your question. This is an interesting subject and while it is not something that we encounter daily, it is not incredibly rare. There have been a few scientific studies that have focused on examining the association between acquired optic nerve pits and glaucoma. It appears that optic nerve pits are an increased risk factor for progression of glaucoma (i.e., those that have optic nerve pits are at an increased risk of progressing compared to open-angle glaucoma patients without pits). In addition, it appears that optic nerve pits are more prevalent in low-tension glaucoma (i.e., glaucomatous optic nerve damage in patients that have never had a recorded intraocular pressure above 21 mmHg) compared to patients that have open-angle glaucoma with increased pressure.
There are no known treatments specifically for optic nerve pits at this time other than simply reducing the eye pressure (as would be done for the treatment of glaucoma). In your case specifically, I would recommend that you have routine eye examinations that include intraocular pressure checks, dilated exams of the optic nerve (including photos if possible), visual fields, and possibly OCT studies. If you have any evidence of visual field defects, I would suggest discussing the possibility of treating your case as normal-tension glaucoma even if your pressures are never above 21 mmHg. This could include a discussion of initiating the use of pressure lowering drops versus watching for any evidence of advancement in the visual field defects prior to starting treatment. I wish you the best of luck.