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.
My mother-in-law has glaucoma, but it is more severe in one of her eyes. Both of the eyes drops that the doctor gave her cause her eyelids to turn bright red and swell. The doctor said not to worry; however, she feels that anything that causes her eyes to become severely red is not helping. [ 01/04/11 ]
Thank you for your question. It is not unusual for the glaucoma to be slightly worse in one eye compared to the other. Often, one eye will develop glaucoma first and then the second will follow. Your eye doctor should have a plan for treating and following both eyes. Specifically addressing your question about the reaction to the medications is a bit more difficult. Without having examined your mother-in-law, it is difficult for me to judge whether or not she is simply experiencing a known side effect of some of the glaucoma medications (i.e., the eyes become a bit red or "injected") or if she is actually having an allergic reaction to the medications. This is something that can only be determined in the doctor's office via an examination. She should visit her eye doctor while she is experiencing the symptoms of "swelling" and "redness." If you are still concerned, it is always acceptable to ask for a second opinion from another eye doctor.
My doctor wants me to start taking Crestor. Will this medication have an impact on my glaucoma? What kind of side effects will I experience? [ 01/03/11 ]
Thank you for your question. Crestor (rosuvastatin) is in the statin family of drugs used to treat high cholesterol. There is very little information on the effect of statin use on glaucoma. However, new studies are being done to determine if there is an effect. One study suggests that statin drugs may induce the cells lining the trabecular meshwork to reduce resistance to aqueous humor outflow, and, thus lower intraocular pressure. These studies were done in a laboratory and not in the clinical setting with patients. Another study, performed in patients, has revealed that statins, if anything, may reduce the risk of developing open-angle glaucoma while another suggests that these drugs may be protective against progression of glaucomatous optic nerve damage. However, the effect of blood pressure, serum cholesterol and cardiovascular disease in general on glaucoma is poorly understood, with many studies providing conflicting answers. Although these uncertainties prevent us from drawing firm conclusions, the available evidence at this time does not indicate that using statin drugs will exacerbate glaucoma.
I am 21 years old, and have had myopia and astigmatism since I was 12. My eye pressure readings recently were 15 for the left eye and 18 for the right eye. These numbers are within a normal range; however, I am wondering what could be done to reduce the pressure in the right eye, since I am beginning to feel pressure there. [ 12/26/10 ]
Thank you for your question. I would recommend that you do absolutely nothing to your right eye at this time. It is physiologically impossible for you to feel a pressure difference of 3 mmHg (millimeters of mercury) between the eyes (especially when they are in the normal range). In fact, the pressure in each of your eyes naturally fluctuates between 2-4 mmHg each day. This is called a diurnal or circadian rhythm. Until the pressure elevates into the range of 30mmHg or higher you will not likely feel anything at all, and only at these quite elevated pressures would you begin to feel pressure or pain. Any sensation of pressure or pain in or around the eyes when the pressure is in the normal range is most likely related to sinus pressure or other issues.
In addition, the instrument that we use to check the pressure in the eye has some error, and the pressure reading may be 1-2mmHg different each time you take it. You will be well served to watch the pressures in your eyes. If the right eye is constantly several mmHg higher, your eye doctor may want to watch the eye more closely for any early signs of glaucoma. At this time, as glaucoma specialists, we do not routinely recommend prophylactic treatment of eye pressure unless there are some very special circumstances. In this case, starting you on eye drops would simply put you at risk for the side effects of the medications when there is very little chance that anything is wrong with the eyes. That is simply not good medical practice and can actually cause more damage than good if we are not careful. Have your eye doctor keep track of the pressure differences, but I would not recommend starting any drops at this time.
Does glaucoma cause one to feel fatigued to the point that they almost pass out and only want to sleep? After I wake up in the morning, my eyes are blurry and dry. I am tired and stressed to the point that where I am nodding off and closing my eyes or going back to sleep. Is this a common symptom of glaucoma? If not, what might be causing these symptoms? I suppose that only my doctor would know the answer, but he usually just says to keep applying the eye drops to relieve the pressure. I would appreciate it if you could provide me with any answers or helpful solutions. [ 12/25/10 ]
Thank you for your question. Glaucoma itself (i.e., pressure inside the eye that is high enough to cause damage to the optic nerve) does not cause fatigue or the feeling that you need to sleep. However, it is possible that the medications that you are taking to treat the glaucoma can cause some of these symptoms if they are absorbed into the body. The proper installation and use of eye drops is a very important thing to discuss and demonstrate for patients. Not only can it increase the efficacy of the medication but it also decreases the side effects. The most efficient method of instilling eye drops is to place a drop in the eye and then close the eyes. The other thing that we often teach our patients is to place gentle pressure on the nose just next to the lower part of the eye. Ask your doctor to demonstrate this the next time you are at the office for a visit. This helps block the tear drainage system and does two things.
- First, the drug stays in contact with the cornea longer and allows more absorption into the eye.
- Second, it decreases the amount that drains into the nose and throat. When the medication drains into the nose and throat it can be absorbed into the body, and the risk of side effects from the medication increases.
One of the side effects of timolol (a beta blocker found in Timoptic, Cosopt, Combigan, and a few other brands) is to decrease blood pressure and possibly heart rate. If decreased enough, it could make you feel sluggish. Your eye doctor or family doctor could take your blood pressure and heart rate before and after taking the medication to see if it is causing any changes. Brimonidine (Alphagan) can have some central nervous system effects that can cause changes in alertness as well. These tend to occur in our more elderly patients, but could occur in anyone. These are not typically symptoms that we see with prostaglandin analogs (Xalatan, Travatan, or Lumigan), but some people react differently to medications than others. It is possible under close physician supervision to change some of your medications or temporarily stop some of the medications to see if the symptoms go away or if they remain. Chances are that these episodes of extreme fatigue are likely related to something other than your medications, but you could explore this further with your eye doctor. As a note, DO NOT stop any of your medications or make changes to your drop regiment without contacting your eye doctor first and agreeing to a plan. This is only something that can be tested in the office setting and should not be done on your own.
I had a trabeculectomy almost 5 years ago at the age of 49. I have developed ptosis since the surgery. The doctor's technicians always tape my eyelid up for the visual field test. Would I be a good candidate for blepharoplasty? Could the cosmetic surgery have negative effects on my functioning bleb? Would it have been possible for me to have both surgeries at once 5 years ago? [ 12/24/10 ]
Answering the first part of your question is somewhat difficult to answer since I cannot see your eyes, the trabeculectomy site and the position of your eyelids. Depending on how far down your eyelids droop, you may be a good candidate for a blepharoplasty. However, I would caution that you only allow an occuloplastics trained ophthalmologist do the procedure. More importantly, it should be someone that is comfortable working with glaucoma patients and understands the importance of allowing the lid to continue to cover the trabeculectomy bleb. You would not want to have the lids raised too much because that could expose the bleb. This could cause problems in the future. Again, in my opinion, you need an occuloplastics specialist that is comfortable and experienced in evaluating patients with trabeculectomies and performing blepharoplasties on patients with trabeculectomies.
To address the last part of your question, the answer is unfortunately "no," you cannot have both at the same time. Regardless of whether the ptosis was present prior to the trabeculectomy or was caused by the trabeculectomy, you would never do both procedures at the same time. Ptosis can either happen naturally due to aging or in some cases it can be caused by the surgery itself. When we do surgery on the eye, we put an eyelid speculum in to help retract the eyelids. Without the speculum in your eyes, you would naturally want to close your eyes during surgery. Unfortunately, any time an eyelid speculum is used, it can stretch the muscles in the eyelid and cause the eyelid to droop afterward. However, you would not know that it was drooping until after the surgery had been completed. Even if you had ptosis caused by aging prior to the trabeculectomy, you cannot have a blepharoplasty and a trabeculectomy at the same time because you need the trabeculectomy to heal without any other complicating factors.