Ask an Expert about Glaucoma
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.
I am a 66-year-old white male, who is in good health and physically fit. There is no history of glaucoma in my family. My linear cup/disk ratio is .72, and I would like to know if I should have concerns about glaucoma or other eye disorders? My eye doctor suggested taking Xalatan eye drops. Would this medication help me? [ 03/05/11 ]
Unfortunately, there is not enough information to give you a definitive answer as to your chances of having glaucoma. With a slightly enlarged cup to disc ratio, many people might tell you that it is a definite sign of glaucoma; however, this is not always the case. Cup-to-disc ratio alone is not helpful. The size of the nerve in conjunction with the nerve cup-to-disc ratio is the most important. The reason for this is the fact that nerves come in different diameters (sizes). A very large nerve (2.3-2.4mm) could have a cup-to-disc ratio of 0.75 and be perfectly normal whereas a smaller "normal sized nerve" could have a cup-to-disc ratio of 0.75 and may be glaucomatous. Further, a nerve that is quite small (1.0-1.1mm) should have very little cup therefore even a cup-to-disc ratio of 0.4-0.5 could quite possibly be glaucomatous. In most cases, there is no single test that can tell you that you definitely have glaucoma. That is the reason that we often do a battery of tests before making a recommendation. I highly suggest that you see an eye doctor that can complete a full glaucoma evaluation. Take time to open a dialog with that physician regarding what each of the measures mean and whether or not the doctor believes that you have glaucoma. 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 to see if there is any evidence of glaucoma that presents in the future. Once they complete the first evaluation, they will make a recommendation for follow-up or treatment if necessary. I wish you the best of luck.
I am 40 years old and have glaucoma. My eyes have been operated for four times, and recently I have been diagnosed with cataracts. One doctor said that I cannot be operated on for the cataracts because I have had too many glaucoma operations. Is that accurate? [ 03/04/11 ]
Thank you for your question. It is not accurate, but that may be very misleading. It does not necessarily matter how many glaucoma surgeries you have had in the past, the cataract can almost always be taken out. However, you do need ask about the risks, benefits, and alternatives of having cataract surgery after having had four glaucoma surgeries. That answer is probably quite complex. First, you have the general risks associated with cataract surgery that everyone else would have: Pain, infection, bleeding, etc. In addition, cataract surgery causes some inflammation in the eye (just like any other surgery would cause inflammation). That inflammation can put your previous glaucoma surgeries at risk for failure (i.e., after your cataract surgery, the eye pressure may go up and your glaucoma could progress). Often in these cases, I tell my patients that I am willing to take the cataract out when it has become visually significant. This means that the cataract is having a dramatic impact on their quality of life and it is stopping the patient from doing their normal activities of daily living (self care, reading, watching TV, etc). Typically in these cases I wait as long as possible until we all agree that the benefit of potentially having more clear vision outweighs the risk of cataract surgery and possibly worsened glaucoma. For every patient (and family) the answer to that question is often difficult to answer. I suggest that you either discuss the risks, benefits and alternatives with your doctor or get a second opinion from a glaucoma specialist that also does cataract surgery. I wish you the best of luck.
I am 75 years old and developed glaucoma 20 years ago. I have had many treatments, including trabeculectomies in both eyes. My right eye has a propensity to heal over. Can vitamins cause this to happen? My daily routine consists of taking 2000 units of time release vitamin C, glucosamine chondroitin msm, 1000 units of vitamin D, a general vitamin for seniors, and PreserVision. [ 03/03/11 ]
Thank you for your question. Except for rare cases, I never recommend doses of vitamins higher than the recommended dietary allowances (RDA) for any of my patients. The general reason for this is the fact that there are some side effects associated with high levels of vitamin intake (such as increased risk of bleeding with doses of vitamin E greater than 400 IU/day). In fact, we often ask about this specific vitamin in our patients prior to doing surgery. In addition, vitamins and supplements are not regulated by the FDA therefore the research literature is quite difficult to follow (or develop good recommendations from). Because the FDA does not regulate the market, there is no guarantee that vitamins marketed by two different companies will 1) have the same units even though they are advertised as such, or 2) be absorbed by the body in the same way even if they do have the same units. This makes recommendations in this area rather difficult just based on the pharmacology. Therefore I will only recommend taking the RDA as documented by the government or NIH. The research is just too messy right now to make any further recommendations.
I would never recommend against taking the recommended dietary allowance of vitamins as long as you and your primary care doctor agree that this will promote your general health. This can include better overall health and hopefully a prolonged life. In the case of patients that need surgery, it may also improve wound healing. It is an academic argument, but one might suggest that the improved wound healing could lead to problems if the trabeculecomy heals too quickly. After the surgery, our goal is to slow the wound healing process slightly so that the trabeculectomy flap does not re-seal itself. At this point, there is no conclusive research showing that people taking vitamins heal quicker or have more poor outcomes after glaucoma surgery, so I would never recommend stopping vitamins after surgery. We have medications that can slow wound healing and for your general health, using vitamins has a better chance of maintaining your general health and hopefully increasing your lifespan. Consult with your doctor if you are taking doses of vitamins higher than the recommended dietary allowances to get their input. Overall, I think you are over the limit on a few, but I don't think the primary side effect that you would notice is scarring and failing of your trabeculectomy. I hope this helps.
I presently use Timolol in both eyes in the morning, Lumigan in both eyes during the evening, and dorzolamide in the right eye in the morning and in the evening. My right eye is not responding to treatment and the eye pressure is hovering around 42. I need to carry the three bottles on my person during the day and each medication has different temperature range requirements. The pouch that contains the bottles has a thermometer in it, which helps me keep the medications in the proper temperature range. How important is it to keep the medication in the proper temperature range? Summer is coming and I don’t want the medication to “spoil.” I would appreciate your input concerning this topic. [ 03/02/11 ]
The following storage information is what I could find for each of your medications from the package inserts:
- Dorzolamide (Trusopt): Store solution at 15-30°C (59-86°F). Protect from light.
- Timolol: Depends on the brand, but most recommend storage below 25-30°C (77-86°F). Do not freeze. Protect from sunlight and moisture.
- Lumigan: Should be stored between 2-25°C (36-77°F).
Depending on your job situation, you can attempt to best store each of these as indicated. Room temperature is about right for each of them. Obviously, it sounds as though you may work outside and may experience higher temperatures. If that is the case, then I would suggest getting a small thermos that you could put them in. You can even put a small amount of ice in a baggie in the bottom with a towel between the drug and the ice to keep it from freezing. This should keep it relatively cool all day long and protect it from light. There is no need to keep the medications on you, but keep them in the car or somewhere close by. The next option is to keep it in your lunch pail, which is usually at room temperature (or slightly cooler), but not freezing. The lunch pails often do not get as hot as the outside temperature because they are insulated.
In general, it is fine to take your eye drops at meal times. So, you could take timolol and dorzolamide at breakfast and dinner. You can keep your Lumigan with your toothbrush in the bathroom, so that will likely be at room temperature. Then, when you are getting ready for bed, you can also take your Lumigan eye drops.
In general, we try to use timolol and dorzolamide two times per day and Lumigan before bedtime. Often it is possible to simply keep them in the house and use them upon wakening in the morning and then when you get home in the evening. Unless you work shifts or are away from home for an extended period of time, it is not usually necessary to keep the bottles on your person. Assuming that you sleep each night (no strange shifts) then keep the Lumigan by your pillow or in the bathroom.
Each person's situation can be quite different, but hopefully this gives you some direction and ideas to discuss with your eye doctor.
I'm a 51 yr. old female, and was diagnosed with glaucoma caused by irido-corneal endothelial (ICE) syndrome. Conventional treatments are not consistently lowering my eye pressure, and they make my cornea hurt and worsen my edema, which causes me excruciating pain and loss of vision. Recently, I underwent laser trabeculoplasty in Lyon France. The Dr. said that laser therapy was not the ideal treatment, but that surgery would only complicate my case more and cause weakening of my cornea. The day after the laser trabeculoplasty, my eye pressure decreased from 28 to 9. However, 36 hrs. later it went back up to 32. I ended up at an emergency room, and after treating me with a wide variety of drops and a diuretic pill, the doctors were only able to bring the eye pressure down to 28. My eye pressure is now 22, but my vision is blurry and my cornea is terribly sore and swollen. My ophthalmologist says that my eye condition is progressive and there is nothing that can stop it. Any suggestions? [ 03/01/11 ]
Thank you for your question. First, I appreciate that your condition is quite complex. I think you have done the right thing by seeking out an expert that is comfortable managing very complex cases of glaucoma. My only additional comment would be that you seek a glaucoma specialist who has a partner cornea specialist partner, and is comfortable treating patients with ICE syndrome. The chance of you finding a single eye doctor who is experienced in treating both conditions is probably pretty low. If you find a glaucoma specialist and a cornea specialist who can work together, I think your chances of a better outcome will increase. It would be ideal if they were in the same practice (or at the same academic institution). I know that you have seen many people, but I would caution that seeing “several prominent ophthalmologists around the world” may not be as helpful as narrowing it down to one excellent glaucoma specialist and one excellent cornea specialist who are willing to be cautiously aggressive with your treatment, if that is what you desire after knowing the risks, benefits and alternatives. In many cases, a lack of continuity of care (long-term care with one physician) can dramatically decrease the level of care provided to you. In many cases, developing a history with a single ophthalmologist who you trust will be more beneficial in the long run because every time you visit someone new they have get up to speed on your history, and they can only do that by looking at charts and speaking with you. While this is often acceptable, knowing a patient and having first-hand experience watching one person's eyes respond to different treatments can only be gained after establishing a patient-doctor relationship of several years duration. Sometimes finding an expert can be the answer, but other times there are no answers to be found and just finding a new doctor confuses the issue. So my first and likely best piece of advice is find one doctor (or one glaucoma doctor and one cornea doctor in the same practice/university) who you really trust and stick with that doctor for a while.
Second, your case is so complex that without examining your eyes myself and reading more about your history, I am afraid that I cannot provide an accurate recommendation concerning the next logical steps. If your case were so simple that an answer could be given after reading one paragraph of history, your case would have already been solved by one of the experts. If medications are not reducing the pressure adequately enough, then the only other options are laser therapy and surgery (trabeculectomy, tube shunt, endocyclophotocoagulation or even one of the newer procedures like canaloplasty). I think a traditional tube shunt is likely a poor choice in your case as there is ample evidence that the tube can rub on the back of the cornea and cause further corneal damage. If after examining your eyes, I thought a tube were the next best choice, I would consider working with a retina specialist to consider inserting the tube behind the iris instead of in front of it. This surgery is more complex and takes two different specialists working together on their different areas of expertise (i.e., the retina specialist to do a very clean vitrectomy including trimming the vitreous base, and a glaucoma specialist to insert the tube behind the iris instead of in front of the iris). This would protect the cornea a bit more. I think canaloplasty or trabeculectomy are options, but only after a thorough examination to see if there is any potential risk from these surgeries. I wish I could be more specific, but again, this is a very complex case and without examining your eyes, it is nearly impossible to give you an accurate recommendation. I wish you the best of luck.
Is a “shallow chamber” a risk factor for glaucoma? Is it considered a precautionary treatment to have a “hole” created in the eye to relieve eye pressure? [ 02/28/11 ]
Thank you for your question. Let me re-phrase your question so that it is a bit more specific, and easier to answer! Is a “narrow angle” a risk factor for glaucoma? The reason that I re-phrased the question is the fact that you can have a shallow chamber without necessarily having narrow angles. If the angle is narrow, then you are at an increased risk for angle-closure glaucoma. The fluid that keeps the eye blown up like a water balloon is created behind the iris (the colored part of the eye) and it has to travel around the pupilbetween the cornea and the iris to get into the drainage system of the eye. If that area is narrow, there is a potential that it can close off and the fluid cannot get around the pupil to the drainage system. In these cases, the pressure can go up dramatically in the eye and can cause loss of vision rather quickly. We can put in a laser peripheral iridotomy (LPI or PI) or hole in the iris to help prevent the attack of angle closure. Essentially, it creates an escape valve for the fluid to travel to the drainage system without going around the pupil. As with any procedure, there are risks, benefits and alternatives. You should discuss these completely with your eye doctor before proceeding. I wish you the best of luck.
My son is 12 years old and has glaucoma, and he has no vision in his left eye. His eye pressure has been as high as 58 and sometimes he gets bad headaches. A doctor suggested Motrin, but this does not help him. What should I do? [ 02/27/11 ]
I am sorry that you are both going through all of this, especially with your son being so young. 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 son, 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 son has no vision at all in the left 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.
First, increasing the strength of pain medication (narcotic pain killers, for example) is never a good option in these patients. 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.In a young individual, 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 personal physician; however, I encourage you to also open a dialog with your eye doctor to determine the best steps for your son and your family. Do not hesitate to get a second opinion (or even a third if it makes you feel better) before making a final decision. This is something that your entire family will need to be at peace with once you make a decision. I wish all of you the best of luck.
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Last Review: 04/28/13