If a glaucoma patient has an EX-PRESS™ mini-shunt, can they still scuba dive and skin dive? [ 01/26/12 ]
Thank you for your question. In general, you should be somewhat cautious about swimming in open water especially if you have had a trabeculectomy surgery (with or without an EX-PRESS™ mini-shunt). Swimming and diving will likely expose the eye and bleb to open water in which bacteria could be growing. If you are thinking of doing any scuba diving or snorkeling, you should discuss these types of dives with your eye doctor. There are no good data showing exact intraocular pressures during the dives, but changes in pressure because of the mask or goggles may alter eye pressure transiently depending on the type of mask, the depth of the dive, and the duration of the dive.
There are dive techniques (equalizing mask pressure) that can alleviate this, but should be taught by a dive master. I would consider discussing your desire to go diving with your eye doctor and discuss whether or not they feel that precautionary use of an antibiotic eye drop may be useful prior to and after the dive. Several of my patients do dive and have not had any problems, but we do discuss the risks of bleb-related infections because of exposure to open water. I hope this is helpful.
I'm a 61-year-old female and I have had pigmentary glaucoma since I was 28. My pressure had been well controlled with eye drops such as Travatan Z, until I had cataract surgery this past summer. Following the cataract surgery my eye pressure spiked to 32 in both eyes. My left eye has stabilized at a pressure of 17 with the addition to Alphagan P. My right eye continues to have pressure spikes even though it has been five months since I had surgery. It appears that my eye is inflamed because it is red all the time. My eye doctor doesn't seem to have an explanation of why my eye pressure has gone from 19 to 26 since I am using two drops (Travatan Z and Azopt). Is it possible that the inflammation is a result of the surgery? Is the inflammation a possible cause of the increased pressure? [ 01/25/12 ]
I am a steroid responder, so I am on Lotemax, which I tolerate well, but I'm concerned because my pressure is going down so slowly. Could I now have inflammatory glaucoma in my right eye in addition to the pigmentary glaucoma? I was under the impression that the cataract surgery might lower my eye pressure; is this still possible?
Thank you for your question. Without having examined your eyes or having seen the results of previous tests and exams, it is nearly impossible for me to give a completely accurate recommendation. Pigmentary glaucoma is caused by the release of pigment from the back of the iris. This is usually caused by the zonules that hold the natural lens in place rubbing on the back of the iris and releasing the pigment. It is not uncommon to have spikes of pressure in pigmentary glaucoma and it can often be associated with increased physical activity that might jar the eyes (exercise, for example). This releases additional pigment that gets trapped in the trabecular meshwork (the natural drainage system) and causes a spike in pressure.
It is possible that during your cataract surgery, additional pigment was released simply because of the process of trying to remove the lens. This would not be uncommon. There is a significant amount of saline that is flushed through the eye to help wash the lens through the phacoemulsification hand piece during the surgery. This fluid flow or the ultrasound could cause pigment to be released from the iris. Your doctor should be able to do a gonioscopy to determine if there is now increased pigment in the angle.
It is also possible that there is some residual inflammation that could be causing a trabeculitis, which can influence the resistance to outflow of eye fluid, and subsequently increase the pressure. Your doctor should be able to tell if there are still some inflammatory cells floating around in the front of the eye.
If you are still on steroids to help reduce inflammation, it is also quite possible that you are a steroid responder. It does not have to be a large dose of steroids; it can simply be a low dose of steroids over a long time frame (five months would be a relatively long time to be on steroids). The only way to find out if you are a steroid responder is to stop the steroids under the direction of your eye doctor and to check the pressure again after you are off the steroids.
If the eye doctor believes that pigment is still being released, you might consider having an ultrasound biomicroscopy (UBM). This is an ultrasound of the eye that will allow the doctor to look at the location of the “arms” holding the lens in place. Those “arms” should be secured within the original bag that held the natural lens. If there is evidence that they are outside the bag, they could be rubbing on the iris and releasing additional pigment and cause inflammation of the iris. I wish you the best of luck.
I am 42 years old and totally blind from glaucoma. Is high eye pressure harmful for our nervous system? [ 01/24/12 ]
Thank you for your question. The answer to this question may not be as straight forward as you might think. Let me try to answer your question as directly as I can first. When you say “I am 42 years old and totally blind…,” I have to assume that you mean that you cannot even perceive a bright light when it shines directly in your eye. In that case, high pressure in a totally blind eye is not harmful to the nervous system or any other part of your body. However, this does not preclude the fact that the increase in pressure can cause pain or headaches if the pressure gets high enough. If, on the other hand, you mean that you are “legally blind” (i.e., your vision is worse than 20/200 or you have less than 20 degrees of vision but still have ability to see some objects or at least light), then the high eye pressure can continue to cause further optic nerve damage and eventually lead to absolute blindness (i.e., inability to even see light). If you have any vision remaining (even just the ability to detect light) I would suggest attempting to maintain that level of vision as long as possible by controlling the intraocular pressure. I hope this helps.
Do you know about the UBM ultrasound exam with the clear scan cover for examining angle problems? [ 01/21/12 ]
Yes, UBM (ultrasound biomicroscopy) is used by glaucoma specialists to examine the angle, including the angle anatomy and positioning of various structures. Often it is used to diagnose plateau iris syndrome in patients who still have narrow angles after laser iridotomy. Ophthalmologists can also see the position of the lens relative to the pupil and angle structures. The clear scan cover is used where I see patients and they do find it comfortable during the exam.
I just had a "routine" progress check for my glaucoma yesterday. As usual, the visual field test was traumatic because so much rides on its results. I got so nervous that I am pretty sure that it had an impact on the test. In fact, when the doctor went over the results with me he agreed that they didn't seem right. This is not the first time that this has happened. Is there any alternative way to test peripheral vision? This standard test just seems so prone to inaccuracy! [ 01/20/12 ]
Yes, your frustration with the visual field test is shared among many of my patients. Having taken it myself, I can see how patients would feel that the test is inaccurate. But one thing that I have observed is that patients usually get better at taking the test over time because they understand how to take the test and are less anxious about it. I do believe that it is important for you to be relaxed during the test, which is easier said than done! Alternatively, there are other algorithms for testing that are often faster, which sometimes helps if patients become inattentive during the test (although that does not seem to be your issue). Other types of visual field testing require a person to “map” out your visual field defect, and most ophthalmologists will not have that type of equipment (although academic centers often will). My advice to you is to try to relax and realize that visual field testing, while important, is only one part of your glaucoma management, and that your physician will be taking into consideration many factors when treating you.
I have glaucoma in the left eye. I am using one drop of Xalatan each night and one drop of Combigan during the evening and in the morning. If I accidently put in more than one drop, would that cause any harm? [ 01/02/12 ]
Thank you for submitting your question. First, you should know that this happens to many of our patients at one time or another, so you are not alone. There may be two possible ways to interpret your question, so let me answer both.
If you squeeze the bottle hard enough that more than one drop comes out and a couple of drops get into your eye, there is no problem medically when this happens. The eye only holds so much fluid (tears, medications, etc.) at one time and if there is too much fluid in the eye, when you blink, it will push out the excess and you will feel it run down your cheek. The drawback is that if you put more than one drop in at a time and you are blinking out the extra, it is a waste of medication and it can cost you money because you will need to refill your medications more frequently. In these cases, sometimes we suggest having someone assist you in putting in the medication, if that is possible.
On the other hand, if you are supposed to take Combigan two times, and sometimes you put in an extra drop because you think that you previously forgot to put the correct number of drops in, that means that you might occasionally put in three drops of Combigan throughout the day instead of two. This is a slightly different issue. If it only happens once in a great while, there is a pretty good chance that nothing bad will happen. It is best to avoid doing this because there is a very small chance you could get some additional side effects from taking too much of the medication. It is similar to taking an extra dose of any oral medications that you might take. If you notice that you are taking extra drops, I would suggest using a tally system on a piece of paper. As soon as you put a drop in, put a mark on piece of paper that reminds you that you took the drop. If you forget, you can always go back and look at your tally sheet. I hope this helps, and I wish you the best of luck.
I have been using Xalatan to reduce high eye pressure for the last six years. My new doctor said we should see if I still need to take the medication, so I stopped using it and took an eye pressure test after one month and then again at three months. The readings were fine. Is it possible for glaucoma to improve like that? Thank you for your help. [ 01/01/12 ]
Thank you for your question. It sounds as though you have been followed for some time and have maintained good follow up with a glaucoma doctor. It is difficult to predict what course your glaucoma will take over time and the path for every individual is different. Because of this variability, it is important to see the eye doctor regularly. Once a thorough eye exam has been completed, eye doctors will often set a target or goal intraocular pressure. This was probably done by your first doctor and it took using Xalatan to get the pressure to that target. The question you should ask your doctor is whether they still think you have glaucoma and what the goal intraocular pressure is in your case. The other possibility is that you are considered a “glaucoma suspect” and the doctor thinks that you might be at risk of eventually developing glaucoma but may not yet have it. In these cases, different doctors have either more aggressive or more conservative treatment strategies. One doctor may start a medication almost as a preventative measure while others may wait and see if glaucoma ever develops before suggesting that a medication be started.
In general, if you have glaucoma, the only variable that we can change to slow or stop the progression of your glaucoma is the intraocular pressure. To achieve this goal, there are essentially three different tools that doctors can use to treat glaucoma: medicated eye drops, laser treatments, and surgical methods. Your doctor will follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how your eyes respond. 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. If the pressure is well below the goal intraocular pressure it is always possible to stop or reduce the medications in order to see if the medication is still needed. I would highly suggest that if you are reducing your medications that you make a plan for follow up visits to your eye doctor and keep all of your appointments. If you ever see any signs of progression, restart the medications immediately. I wish you the best of luck.
Can the SLT procedure cause neovascularization of the iris? [ 12/31/11 ]
Thank you for your question. SLT should not cause neovascularization of the iris. Neovascularization (neo” meaning new and “vascular” meaning vessels) occurs when new blood vessels begin growing inside the eye. Typically, these new blood vessels grow in response to ischemia (a lack of oxygen to the tissues in the eye). Because enough oxygen is not getting to the tissue, the eye tries to get more blood (and hence more oxygen) to the eye by creating new blood vessels. Unfortunately, in many of these cases the new blood vessels are not healthy vessels and can cause bleeding in the eye. SLT is a laser that causes a restructuring of the trabecular meshwork that reduces the resistance of flow through its channels (and hence reduces intraocular pressure). In no way should the SLT laser treatment cause neovascularization. The most typical reasons for neovascularization are diabetes or ocular ischemic syndrome. If you are concerned about why the blood vessels began to grow, please ask your doctor for an explanation. I wish you the best of luck.