Ask an Expert about Glaucoma
If someone has had the following procedures and/or treatments in their right eye, can you please talk about what a patient should and should not do in the post-surgical period? Procedures include: phacoemulsification, foldable intraocular lens, trabeculectomy, and mitomycin C. [ 12/09/10 ]
Thank you for your question. You have undergone what we call a combination phaco-trab. Basically, I provide all of my patients with the same general guidelines. The first day, in most cases, will be the most uncomfortable and vision will not be very good. Over time, you should slowly notice less pain and increased vision. If you notice increased redness, decreased vision, increased pain, pus-like discharge, or any bleeding you should be seen by your eye doctor immediately. During the first week, you will need to wear an eye shield at night to keep from rubbing the eye. When you are awake during the first week, you can either wear glasses or your eye shield. No lifting, bending or straining of any type will be allowed. You should not lift anything heavier than a gallon of milk. Your head should stay above your heart at all times (no bending over to tie your shoes or bringing your feet up to your chest to them, for example). You must take all of your medications exactly as prescribed. If you run out of drops, you should contact your eye doctor immediately to get refills. After one week, you will likely begin to change your drop regimen. Follow your eye doctor's instructions very carefully. Often the surgery is not difficult, but the post-operative care of the eye is the primary determinant of success or failure. These are the general guidelines I share with all of my patients, but I also add different guideline based on the individual patient sometimes. You should discuss this exact question with your own eye doctor so that they can add any other restrictions based on your specific case. I wish you the best of luck.
I have heard of a new procedure called canaloplasty; it is apparently like an angioplasty for the eye to relieve pressure. Is this a sound procedure? [ 12/08/10 ]
Thank you for your question. Canaloplasty is a newer procedure developed and promoted by the company iScience. There are many well regarded ophthalmologists doing this procedure, and I was trained to complete these surgeries during fellowship. I have assisted in approximately 8-10 cases, but have not yet signed any of my patients up for the procedure. It is a surgically sound procedure and it does lower the intraocular pressure in most cases. Often this is accompanied by either no bleb (like a traditional trabeculectomy) or there is a very low, nearly imperceptible bleb. My only concern, and the concern of many other ophthalmologists, is the longevity of this type of procedure. In our hands, we had excellent results for approximately 1 year but then had a few patients that had pressures begin to increase again. Other patients continued to do well after 1 year. The long-term data is not yet out since this is a newer procedure, and we are awaiting that data to come out in the medical literature. Overall, it is a sound procedure, but just like any other procedure, we need longer-term data before any definitive projections on long term success can be made. If you are interested in the procedure, I suggest that you discuss the risks, benefits, and alternatives of canaloplasty, for your particular case, with your eye doctor.
Is there an over-the-counter eye drop that I can use? My prescription is too expensive and my insurance does not cover it. [ 12/07/10 ]
Thank you for your question. I am sorry that you are having difficulty obtaining your prescription medication. This is a problem for many of our patients. Unfortunately, there are no over the counter medications to treat glaucoma. All the medications that have a proven benefit must be obtained with a prescription from an eye doctor. There are several alternatives that I can suggest, however. Ask your doctor if there are any generic drugs available. If you are taking a beta blocker, you should be able to obtain the generic timolol at Walmart or CVS, etc. for $4/month. Generics for the prostaglandin analogs (Xalatan, Travatan, and Lumigan) will most likely be available within 1 year and will hopefully be much cheaper that than they are now. There are also generics for some of the combination medications (Cosopt, for example). If no generics are available, I suggest that you first determine if you qualify for assistance under Medicare or Medicaid. Next, if you served in the armed forces, you may qualify for benefits through the Veterans Administration Hospitals. Often, these hospitals are staffed by the same physicians that staff the large well known University hospitals. Finally, if you do not qualify for Medicare, Medicaid, or VA benefits, see if there is a free/reduced fee clinic at either your county hospital or somewhere in the state. These clinics are often run by medical universities and their residency training programs, where you will be seen by multiple specialists at different levels of training during a single visit. These may include medical students, residents, fellows or a fully trained-board certified ophthalmologist. Finally, the drug companies often have free drug programs for those that cannot afford the medication. Ask your eye doctor to find out if the company that makes your medication has this type of program. They will require you to provide evidence of your income and last year's taxes, but I have a lot of patients that qualify. They are great programs, and many of the drug companies do not get enough credit for establishing these types of programs for our patients. I hope this gives you some direction and new avenues to consider for obtaining your medications. If these do not work, I suggest that you discuss this with your eye doctor. It may be possible to recommend a surgical procedure that can reduce the number or drops that you need to take. This is an option that could be discussed.
I have normal-tension glaucoma with optic nerve damage in my right eye that has caused a loss of peripheral vision. I need cataract surgery and have two different conflicting answers on what is best to do. One specialist says that I should have cataract surgery and endoscopic cyclophotocoagulation at the same time. Another specialist suggests having cataract surgery and trabeculectomy at the same time. What is the difference in these two glaucoma surgeries and which is the safest? [ 12/06/10 ]
Thank you for your question. Unfortunately, without having personally examined your eyes, knowing your eye history, or personally looking at the results of your eye tests from your previous office visits, it would be nearly impossible for me to make a recommendation on which of these two alternatives to pursue. I can tell you that combination cataract surgery and ECP (endoscopic cyclophotocoagulation) or combination cataract surgery and trabeculectomy are both excellent options for our glaucoma patients that also have visually significant cataracts. I have done both of these combinations in many of my own patients in the past depending on their individual presentations and individual cases.
In general, the goal of cataract surgery is to remove a cloudy lens and implant a new clearer lens so that it maximizes your chances of getting clearer vision. The primary risks that I discuss with my patients having cataract surgery are pain, bleeding, infection, decreased vision, need for further surgery, loss of the eye, or death. Each of these risks has different probabilities. The risk of post-operative discomfort (gritty feeling in the eye, etc) in the few hours after surgery is probably near 95%. When you make an incision on the eye, it cannot be avoided. It is usually short lived and by the next day most patients having just cataract surgery feel back to normal. The risk of death is probably 1 in a million or more, but when any type of anesthesia is administered there is always the risk of death. The potential for all of the other risks fall somewhere in between. The goal of endocyclophotocoagulation is to use a laser to destroy the ciliary body. The ciliary body is responsible for making the fluid inside the eye that keeps the eye blown up like a water balloon. I tell my patients that glaucoma is like having a sink that has a drain that does not work well and a faucet that is constantly dripping too fast and filling the sink up. Essentially the ciliary body is like the dripping faucet and the trabecular meshwork is like the clogged drain. Our treatments do one of two things:
- Turn down (or turn off) the faucet
- Open up or create a new drain
The ECP turns off the faucet by destroying the ciliary body. The tricky part is doing enough to turn down the faucet but not turn it off completely. That is a risk of the surgery (the pressure dropping too low). Overall, the risks of endocyclophotocoagulation are pain, bleeding, infection, inflammation, decreased vision, eye pressure dropping too low, eye pressure increasing because of inflammation or other causes, double vision, need for further surgery, loss of the eye, and death. The goal of a trabeculectomy is to provide a new drainage system for the fluid (i.e., we are building a new drain for the sink). If that new drain works too well, we can have pressure that is too low again and if the drain does not work well enough the pressure may not be low enough. The risks for trabeculectomy are nearly the same as those for ECP (probably slightly different rates of complications because the procedures are different). Again, I suggest that you discuss your particular case with your eye doctor and they can give you a better idea of the risks, benefits, and alternatives in your particular case. Hope this answers the first part of the question.
Discussing all of these risks can sound a bit dramatic considering that most of our patients do perfectly fine and have great outcomes. However, the second part of the question touches on a key issue that all of our patients need to understand. Every surgery that we do has potential risks and potential benefits. I never tell any of my patients that any surgery is "safe." Surgeries just have greater or lesser risks. Your job is to determine when the potential benefits outweigh the potential risks (this is when you should decide to go ahead with surgery). I often tell my patients that if a surgery carries a 1 in 1 million chance of going blind, it sounds "safe." However, if you are the one person that does go blind, you will not care about the other 999,999 that have good outcomes. You will just be upset that your surgery did not go well. That is why you need to understand the risks associated with each surgical option and you need to have a reasonable expectation of the benefit that you plan to get out of it. If you have end-stage glaucoma, you cannot expect to come out of a surgery with perfect vision. The benefit that we may be able to offer is simply slowing or stopping the progression of the vision that you have lost in the past. You need to discuss the risks of each combination surgery with your eye doctor because they know your individual case the best and be able to provide an accurate goal of the benefits that you may receive from the surgery. You always have the alternative plan of doing nothing and waiting, but this can also carry a risk of causing progressive vision loss and blindness as well, if the glaucoma worsens. Again, your goal is to determine when you think the potential benefits of surgery outweigh the risks.
I am a 62-year-old Caucasian male and was diagnosed with glaucoma within the last 6 months. I have been taking Lumigan eye drops faithfully in both eyes, and I have lowered my pressures from 22 to about 19. My eye doctor recommended that I close my eyes for about 1 minute after instillation of the drops to ensure the medicine is absorbed into my eyes. I do this before bedtime while I'm brushing my teeth, but my head is face down. Does this head-down position prevent good absorption into my eyes? Also, after about 3 or 4 minutes, to minimize eye lid skin darkening and eyelash lengthening, I rinse my closed eye lids with cold water. Could this lessen the affect of the drops? Thank you for your help. [ 11/18/10 ]
Thank you for your question. The proper installation 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. It is probably best to either recline or sit upright. You can remain facedown as long as you do not notice tearing or the medication running out of your eyes, but I would probably recommend either the reclined or upright position. 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 of the drug 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. Finally, we typically tell our patients to wait a full 5 minutes between drops or wait 5 minutes after the last drop before cleaning the eyelids. Most of the medication that will be absorbed into the eye will have done so within 5 minutes. Finally, I always recommend that my patients bring their eye drop bottle to the clinic so that I can watch them put in at least one drop just to make sure they are doing it correctly. You would be amazed at the things that I have seen patients do. We often take for granted that patients know how to instill drops and we simply should not. I highly recommend that you take your eye drop to your doctor and ask them to watch you put in a drop to make sure you are doing it correctly.
I had an Ahmed implant with a shunt 9 weeks ago. The eye pressure is now down to 24, and my vision with glasses is good; however, there is never a day without discomfort. I also now have ‘flashes’ in both eyes that were never present prior to the shunt surgery. I would appreciate your input. [ 11/18/10 ]
Thank you for your question. Let's divide this into two separate pieces. First, after having a glaucoma implant procedure, it is not uncommon to experience some discomfort. While glaucoma implant surgery is not the most technically difficult procedure, it is still a surgical procedure that requires a healing period. While the majority of patients notice the discomfort for less than a month, I have also had patients that take several months until they no longer notice problems. This often depends on how quickly you heal. In general, almost everyone eventually recovers without any problem or the need to revise the surgery (although there are exceptions to every rule). I would discuss this with your doctor and describe the discomfort to them. If you are having a scratchy feeling, that may be related to a small piece of suture that still present and may be poking underneath the eyelid. That can easily be fixed in the office. If you are simply noticing a 'fullness' in the area of the implant, it may simply need to allow the implant to encapsulate (heal) fully. Again, that can take anywhere from 1 to 3 months depending on how quickly your body naturally heals, if you are taking steroids, etc. Finally, if your eye pressure is “down” to 24 that is still a bit high for someone with glaucoma. I would be curious to know if the pressure is elevating throughout the remainder of the day causing you some discomfort. You may need to have your pressure taken at different times of the day to determine if the pressure is going up beyond 24 sometimes.
The second part of your question is difficult to answer without examining your eyes. You can have flashes of light for many different reasons, but if it is in both eyes, it is most likely not related directly to the surgery and the timing may just be coincidental. In general, flashes of light or new floaters are usually related to a process in which the vitreous or gel inside the eye begins to condense and pull away from the attachments to the back of the eye along the retina, retinal vessels, optic nerve, and the front part of the eye called the vitreous base. This is known as a posterior vitreal detachment and is often associated with flashes of light and onset of seeing new floaters. Any time new flashes of lights or new floaters are seen, you should have a dilated eye exam to make sure there is no evidence of a retinal tear. While retinal tears are rare in these cases, they are important to diagnose and treat appropriately. Another possibility is that these lights could be related to migraine headaches. Often patients describe a shimmering or jagged line in their peripheral (side) vision that grows for approximately 5-10 minutes and then slowly goes away. For many people with migraine headaches, this is the "prodrome" or "visual aura" that happens just before the migraine headache starts. I suggest you have an eye exam to help determine the cause of the flashes of light. It is most likely benign, but we cannot know that until a dilated exam is completed.
My daughter, who is 19 years old, has glaucoma in her left eye. Can this disease also affect her right eye? [ 11/17/10 ]
Hello and thank you for your question. I am sorry that your daughter is struggling with glaucoma at such a young age. In general, glaucoma is thought to be a "bilateral" disease because the majority of the time it does affect both eyes. There are some exceptions to this however, and your daughter's particular case makes me wonder if she might be one of these special cases. First, I would want to figure out why, at a young age, your daughter has one eye (and not both) that shows possible signs of glaucoma. Glaucoma typically does not affect young individuals, and when it does, the majority of the time it is both eyes. A couple of exceptions to this are if she had trauma to the eye. Did your daughter ever have a black eye on that side that you can remember? If so, her doctor should be looking for any evidence of damage to the angle structures of the eye and possible angle-recession glaucoma. This type of "traumatic" or "angle-recession" glaucoma often affects one eye only. Secondly, I would want to know if you have been using any steroid drops or other medications with steroids in them (like nasal sprays). This can lead to a secondary steroid-induced glaucoma on the treated side.
In general, when a young person presents with glaucoma in a single eye (or asymmetry), you need to figure out why. I suggest that you make sure she is being seen by an ophthalmologist that has completed a glaucoma fellowship, and if her eye doctor is not a glaucoma specialist you may want to consider a second opinion. If she has glaucoma, this is not likely a routine case. Someone with specialized training is the most likely to be able to correctly diagnose this and also give you a better idea if the other eye is also at risk. I wish you the best of luck.
I am 62 years old and have a strong family history of glaucoma (both parents were diagnosed when they were elderly and my oldest brother was diagnosed at age 40). My optic nerve has always looked "suspicious" and I have visual fields tests annually, always with normal results. Two years ago, my pressures were 22 and 23. My ophthalmologist said these were borderline readings and gave me the option to start on Travatan, which I did. I have experienced the side effects of longer, darker lashes and I my irises have also become darker, which is not a problem from my perspective. However, I am having a more difficult time adjusting visually when I go outside into bright sunlight (it seems extremely bright to me) and I see less contrast between light and dark. For example, when I look down a shady street I am less likely to see a bicycle approaching if it's in the shade. Is that a result of normal aging or could that be a side effect of Travatan? If it is a side effect, would it reverse if [ 11/11/10 ]
Thank you for your question. The prostaglandin analog medications (Travatan, Lumigan and Xalatan) do have a variety of side effects. Determining which of these are from the medication and which are from either progression of the glaucoma or aging can sometimes be difficult. Without having examined your eyes, the results of your previous tests, the results of new tests, and your chart history, it would be impossible for me to accurately give an answer to this question. I will have to make a lot of assumptions. First, the possible side effects listed from the Travatan insert include the following (translations of the technical medical terms are in italics):
The most common adverse reaction observed in controlled clinical studies with TRAVATAN (travoprost ophthalmic solution) 0.004% and TRAVATAN Z® (travoprost ophthalmic solution) 0.004% was ocular hyperemia (redness of the eyes) which was reported in 30 to 50% of patients. Up to 3% of patients discontinued therapy due to conjunctival hyperemia (redness of the eyes). Ocular adverse reactions reported at an incidence of 5 to 10% in these clinical studies included decreased visual acuity, eye discomfort, foreign body sensation (feeling of sand, grit or dirt in the eye), pain and pruritus (itching). Ocular adverse reactions reported at an incidence of 1 to 4% in clinical studies with TRAVATAN® or TRAVATAN Z® included abnormal vision, blepharitis (similar to dandruff of the eyelashes), blurred vision, cataract, conjunctivitis, corneal staining, dry eye, iris discoloration (change in the color of the eye), keratitis (changes in the cornea of the eye), lid margin crusting (similar to the blepharitis), ocular inflammation, photophobia (sensitivity to light), subconjunctival hemorrhage (a blood vessel between the conjunctiva and sclera breaking and bleeding a little) and tearing. Nonocular adverse reactions reported at an incidence of 1 to 5% in these clinical studies were allergy, angina pectoris (chest pain), anxiety, arthritis, back pain, bradycardia (slow heart rate), bronchitis, chest pain, cold/flu syndrome, depression, dyspepsia (upset stomach), gastrointestinal disorder, headache, hypercholesterolemia (high cholesterol), hypertension (high blood pressure), hypotension (low blood pressure), infection, pain, prostate disorder, sinusitis, urinary incontinence and urinary tract infections. As you can see, this is quite a list, and the reality is that Travatan does not cause all of these problems. The FDA is obligated to include any symptom that any patient has during the trial of the drug and list it as a side effect. If the patient was taking the medication during the trials and their child came home with a cold from daycare and passed it to their parents, the FDA would list cold/flu syndrome on the side effect list even though there was really no reason that the drug caused it. This being said, your symptoms of photosensitivity (sensitivity to light) is definitely something that I have seen in my patients on prostaglandin analogs.
Secondly, the difficulty with contrast and adjusting to light (going inside to outside or vice versa) could also be a sign that the glaucoma is progressing. As glaucoma progresses, contrast sensitivity decreases. An alternative explanation may be that you are developing cataracts. This could account for many of the symptoms that you are noticing as well. I suggest that you discuss these symptoms with your eye doctor and have a complete eye exam to look for the cause. I would first want to rule out the fact that your glaucoma is not progressing. Then, I would make sure that you are not developing cataracts. After that, you would need to discuss whether or not you still believe any of these symptoms are from the drops and whether they are bothersome enough to try a different medication or if you would like to continue knowing that you do have some side effects. Do not stop taking any of the drops prescribed by your eye doctor until you have discussed it with your doctor and they have a plan. A thorough discussion with your doctor and a thorough examination should help get to the bottom of your problems. I wish you the best of luck.
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Last Review: 04/28/13