Ask an Expert about Glaucoma
I am a 60-year-old Chinese female. A few months ago, I noticed a floater in my left eye, so in October, I had my eyes checked for the first time. The eye doctor told me that my tear duct was blocked and he fixed it twice. He also told me I have an early-stage cataract and gave me eye drops (Kary Uni) to use 4 times a day, indicating that it could help delay the progression of the cataract. Is that true? What worries me most is that he said I am a glaucoma 'suspect.' The OCT, and other eye tests indicated that everything seems normal and my eye-pressure is in the 12 to 13 range. My father's elder sister had glaucoma and the doctor said I may have it too. He asked me to go back to have all the glaucoma tests again in 3 months. Is that a safe and reasonable measure? How often should I have my eyes checked? I asked him if I really have glaucoma would there be any treatment. He just said he would use eye drops. Do you think the drops will help? Thank you so much! [ 12/23/10 ]
Thank you for your question. Let's take these questions one at a time.
First, the use of Kary Uni (pirenoxine) for the treatment of cataracts is accepted in some countries; however, it is not the standard of care in the United States where I practice. To my knowledge, there have been no good randomized control trials to show its effectiveness.
A recent review article by Sekimoto and colleagues from Japan titled “Why are physicians not persuaded by scientific evidence? A “grounded theory interview study” states “Pirenoxine eye drops were first approved by the [Japanese] government in 1958 as a preventive drug for the initial stage of senile cataract. This approval was based on three studies [reference 6-8 in the Sekimoto et al manuscript], which used animal experiments and pathophysiological principles to conclude that eye drops have a preventative effect against senile cataract. The evidence-based guidelines reviewed data relevant to the treatment of cataract, recommending surgery as the definitive treatment and determining the effectiveness of eye drops to be uncertain (See Appendix of the manuscript). Based on a systematic literature review, the guidelines identified three clinical trials conducted in Japan that investigated the effectiveness of pirenoxine and glutathione eye drops, and concluded that neither demonstrated effectiveness [references 9-11 in the Sekimoto et al. manuscript]. Although these clinical trials reported that lens opacity was better in the eye drop group compared to its control, this assessment was based on a subjective measurement. There were no double-blind studies to evaluate the eye drops in terms of visual acuity and no adverse effects were reported in the trials.”
Again, no randomized control trials have been completed, so I cannot make an educated recommendation for or against their use. Until I have better evidence of its effectiveness in controlled human trials, I will not be recommending it for my patients.
Second, discussion on whether or not drops would work for you is quite premature. You don't need to worry about that until you have actually been told that you have glaucoma. Your doctor has simply stated that they are concerned that you could be at risk for developing glaucoma. Because your tests have been normal, their concern is likely because of your family history. Doctors would categorize you as a 'glaucoma suspect,' but this does not mean that you have glaucoma. Rechecking these exams in a few months is the same thing that I would do. This establishes a clear baseline so that we can identify any changes that may occur in the future.
Again, with your family history, your eye doctor is likely just being cautious. While the needs of every patient diagnosed with glaucoma or diagnosed as a glaucoma suspect is completely different, once you have been diagnosed, a plan for follow-up should be established. This can be either a plan to watch your eyes closely (for glaucoma suspects) or to begin treatment and examinations more frequently (for patients with 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 at different intervals to see if there is any evidence of glaucoma that presents in the future. The frequency of examinations will depend on whether or not they see any signs of progression from your baseline studies.
If you have questions or concerns, do not hesitate to start an open dialog with your eye doctor and ask them to explain why they have chosen the particular monitoring plan that they have prescribed for you. If you are still concerned, it is always fine to ask for a second opinion from a glaucoma specialist.
I was diagnosed with open-angle glaucoma in 2002 and am searching for the cause. I have had recurring iritis and was treated for kidney disease with 80 milligrams of prednisone for months in 1995. One doctor relates the glaucoma to the chronic iritis and another doctor says it was caused by the steroids. Can doctors determine if one or both of the factors caused the glaucoma? [ 12/22/10 ]
Thank you for submitting your question. Unfortunately, determining the exact cause in these types of cases is either very difficult or impossible. Chronic inflammation in the eyes (iritis or uveitis) and use of steroids are two well-known causes of what we call secondary open-angle glaucoma. This means that the glaucoma did not happen by itself but was related to another issue. On the other hand, primary open-angle glaucoma is not related to any other cause.
Secondary glaucomas such as uveitic glaucoma or steroid-induced glaucoma happen when there is a decrease in the ability of aqueous fluid in the eye to get through the trabecular meshwork. This causes a buildup of fluid and pressure in the eye. Determining the exact cause is more difficult. Uveitis is a well-known cause of secondary glaucoma and may have caused your problems. Steroid use can also cause secondary glaucoma, but it is much less common for oral steroids (compared to steroid eye drops) to cause this increased pressure. Further, in the majority of people, once they stop using the steroids, the ability of the aqueous fluid to get through the trabecular meshwork returns to baseline and the pressure decreases.
Your doctor could give you some steroid eye drops temporarily to see if the pressure increases (i.e., try a "steroid challenge" to determine if you are a "steroid responder"), but I would not necessarily recommend it. Even if you are a steroid responder, that would not prove whether or not the steroids caused the glaucoma in the first place (it may have been the uveitis that caused it and by chance you may also be a steroid responder). If your pressure did NOT go up, it might tell you that the steroids are less likely to have been the cause of the increase in pressure. Again, I would not necessarily recommend the "steroid challenge" at this point because regardless of the cause, the treatment is the same for both. I know that sometimes we like to know "why" something happened to us, but sometimes it is safest to just understand that you can narrow it down to a couple of possibilities.
I am 30 years old, and in April of 2010 I had my first trabeculectomy in the left eye. The pressure in that eye is now 4, which concerns my doctor. She said that she may need to re-stitch it. I have the same surgery scheduled for my right eye soon; however, due to the low pressure in my left eye, my doctor will be performing the surgery without "mito." What does this mean? [ 12/21/10 ]
Thank you for your question. Trabeculectomies are excellent surgeries, but they come with some drawbacks. One of those drawbacks or possible complications is that the pressure does not drop to the desired target range (i.e., the pressure either remains too high or it drops too low). Every time I discuss this surgery with my patients, I explain that we are making a new drainage system for the eye to help reduce the pressure. We do that by creating a trap door (the trabeculectomy flap) on the white part of the eye (the sclera) and we lift that door up. Once we have the door lifted, we create a hole into the eye so that fluid can exit the eye under the trap door and leak out onto the surface of the sclera. We sew the trap door down for a little while because if we did not, too much fluid might escape and the pressure can be too low. As the healing process occurs the pressure can start to creep up, so we cut a few of those stitches so that the trap door opens a bit more and we can get the pressure to our target. Because most people heal too quickly, we have started using a drug called mitomycin C ("mito") to help slow that healing process. All of our studies indicate that in most cases using that drug increases the likelihood that the surgery will be successful.
Unfortunately, not every person heals the same after a trabeculectomy. Sometimes patients heal too well despite our best efforts. Even though we have used mitomycin and we have cut all of the stitches on the trap door, some patients heal so well that the trap door seals itself back down and fluid cannot exit the eye. This causes the pressure to increase. The opposite can also occur. Sometimes, people simply do not heal well and there is too much fluid that escapes from the trap door. In these cases, we often have to re-stitch the trap door and make it a bit tighter. In addition, because we know that these patients have a tendency not to heal quickly, we may not use the mitomycin C on the second eye (just as your doctor has suggested). If you have a tendency to heal slowly, as you have already proven in the left eye, there is no need for the mitomycin C and using it would simply put you at risk for having pressure that is too low in that eye as well. It sounds like your eye doctor is doing a good job of recognizing your healing pattern and changing his or her plan accordingly. I wish you the best of luck.
After applying timolol and Azopt to my eyes, does water or soap from a bath have any impact on the effectiveness of the eye drops? [ 12/20/10 ]
Thank you for your question. 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 of the eye drop 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 using different eye drops (in your case timolol and Azopt) or wait 5 minutes after the last drop before cleaning the eyelids or getting water in the eyes (taking a shower or bath). Most of the medication that will be absorbed into the eye will have done so within that 5 minute window. After waiting those 5 minutes, you can gently clean your eyelids. Always avoid getting soap in your eye if possible because it hurts and it is irritating to the eyes.
I am a 31-year-old woman who has glaucoma and was told that I have a defective photoreceptor layer in the retina. What is a defective photoreceptor layer? [ 12/16/10 ]
Glaucoma is a disease that causes damage to the nerve that connects the eye to the brain, called the optic nerve. The optic nerve is composed of retinal nerve fibers, which often thin with glaucoma. The more retinal nerve fibers you lose, the worse your glaucoma. A defective photoreceptor layer can occur in a variety of retinal diseases, and is not usually related to glaucoma. The photoreceptor layer is part of the retina that converts light into an electrical signal, which then travels to your brain. A variety of diseases can cause a defective photoreceptor layer such a retinal dystrophy and retinal degeneration, so the best thing is to ask your eye doctor about what exactly is causing the defective photoreceptor layer.
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.
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Last Review: 04/28/13