Ask an Expert about Glaucoma

Thank you for your question. I am sorry that your grandmother is going through all of this now. The Oflop P is likely just being used in the immediate post-operative period and she will soon be off of that medication. Just for clarity, the laser surgery and any procedure or medication used to treat the glaucoma is not being done in order to improve vision; rather, it is being done to lower the eye pressure. Once a thorough eye exam has been completed, eye doctors often set a target or goal intraocular pressure. The only variable that they can change to slow or stop the progression of glaucoma is the intraocular pressure. To achieve this goal, there are essentially three different tools that they can use to treat glaucoma:

• Medicated eye drops
• Laser treatments
• Surgical methods

Her doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how her eyes are responding.  If the pressure is not reduced enough on Alphagan alone or her doctor ever notices advancement in the glaucoma, the doctor will add more medications, use more laser treatments, or try other surgical techniques to help lower the intraocular pressure further. In the majority of patients, it is possible to lower the pressure enough to stop or dramatically slow the loss of vision; however, this may take multiple surgeries, laser procedures, or medicines (and likely a combination of these three).

In specific regard to the vertigo and headaches, Alphagan is an alpha receptor agonist and can be absorbed by the body to cause some side effects related to the central nervous system (i.e., the brain and nerves of the spinal cord). In doing some research, I consulted www.drugs.com as it is a good resource to investigate medication side effects. Their recommendation is as follows:

Topically administered alpha-2 adrenergic receptor agonists such as apraclonidine and brimonidine (Alphagan) are systemically absorbed, with the potential for producing rare but clinically significant systemic effects. Although the interaction has not been specifically studied, the possibility of an additive or potentiating effect with central nervous system (CNS) depressants such as alcohol, barbiturates, opiates, anxiolytics, sedatives, and anesthetics should be considered. Additive hypotensive effects (i.e. low blood pressure which may cause a vertigo feeling) and orthostasis (i.e. low blood pressure when standing up which could also cause a feeling of vertigo) may also occur, particularly during initial dosing and/or parenteral administration of the CNS agent. Patients prescribed apraclonidine or brimonidine (Alphagan) ophthalmic solution with other agents that can cause CNS depression should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion, vertigo) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to avoid rising abruptly from a sitting or recumbent (lying down) position and to notify their doctor if they experience dizziness, lightheadedness, syncope (i.e., fainting or feeling faint), orthostasis (i.e., lightheadedness or feeling faint when you stand up), or tachycardia (i.e. a fast heartrate).

Finally, most patients do not need to dramatically change their lifestyle. There are multiple randomized studies currently looking at the effect of exercise on intraocular pressure. What we are finding is that it may depend on the type of exercise, the overall fitness of the patient, or other factors that we do not yet understand.

In general, eye pressure can be transiently increased by any exercise or activity that involves a Valsalva maneuver. The Valsalva maneuver, as defined by Wikipedia, "is performed by forcible exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervouscontrol of the heart, or to 'clear' the earsand sinuses (that is, to equalize pressure between them) when ambient pressure changes, as in diving or aviation." Holding your breath and bearing down to pick up a heavy object (heavy weight lifting) or even playing an instrument, such as the trumpet, are both methods of causing a Valsalva maneuver as well, and can transiently increase eye pressure. In addition, there is some evidence that certain yoga positions may also increase pressure inside the eye. Inverted positions that place the eyes below the heart for an extended period of time have the greatest potential for increasing the pressure inside the eye.

While some studies have shown an association between exercise and increased intraocular pressure, there are new studies showing that aerobic exercise may actually decrease intraocular pressure transiently. Overall, I do not believe that studies on exercise and intraocular pressure are consistent enough to draw many conclusions or provide a definitive recommendation. In general, physicians recommend that their patients follow an exercise regimen for your general health. Avoiding prolonged heavy weight lifting or inverted yoga positions may be reasonable until definitive studies have examined their long-term effects on eye pressure. I encourage you to consult with your eye doctor and your primary care doctor to determine an appropriate exercise regimen for you.

Thank you for your question. In general, eye pressure can be transiently increased by any exercise or activity that induces a Valsalva. The Valsalva maneuver, as defined by Wikipedia, "is performed by forcible exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervouscontrol of the heart, or to "clear" the ears and sinuses (that is, to equalize pressure between them) when ambient pressure changes, as in diving or aviation." Holding your breath and bearing down to pick up a heavy object (heavy weight lifting) or even playing an instrument, such as the trumpet, are both methods of causing a Valsalva maneuver as well, and can transiently increase eye pressure. If you want to know for sure whether playing the trumpet causes your pressure to go up, you could always bring the instrument in to your eye doctor's office and have him/her check the pressure before you start playing and while you are playing.

Your fears are understandable. The thought of having any surgery is often quite unnerving for anyone; however, I would not necessarily let your age be the deciding factor on whether or not to have surgery. As an example, my grandfather will be turning 96 this year. We cannot predict how long any of us will live, but if you live into your 90s, I would hope that you do so with your eyesight intact. Once a thorough eye exam has been completed, doctors often set a target or goal intraocular pressure. To achieve this goal, there are essentially three different tools that we can use to treat glaucoma: medicated eye drops, laser treatments, and surgical methods to lower the intraocular pressure. The eye doctor willfollow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if the glaucoma progression has stopped. If the pressure is not reduced enough or the doctor ever notices advancement in the glaucoma, they will add more medications, use laser therapy, or surgery to help lower the intraocular pressure further. It sounds as though your doctor has tried other non-invasive methods and is now recommending surgery. Unfortunately, the only way that eye doctors can prevent progression of glaucoma and the progression of vision loss is to lower the pressure. Without lowering the pressure, you are at a high risk of having the glaucoma progress and take more of your vision. Unfortunately, once vision loss occurs, is most likely permanent.

Prior to any procedure, the eye doctor should discuss the risks, benefits, and alternatives to any procedure that they are planning to do. Every surgery has risks; the question is whether you personally feel that the benefits (i.e., the chance of lowering the pressure enough such that the glaucoma does not progress and you do not lose more vision) outweigh the risks. I know it is not an easy decision and I often recommend that patients bring trusted family or friends with them to the doctor's office so that they can get input from those closest to them. I wish I had the perfect answer for you, but unfortunately this is a decision only you can make. I wish you the best of luck.

Thank you for your question. Unfortunately, it is not uncommon for the intraocular pressure to increase slightly over time. However, given that your pressure is still decreased by 66 percent from the pre-operative period, it sounds as though the trabeculectomies have not stopped functioning completely. In general, trabeculectomies tend to work, on average, for probably five to ten years. Some patients have better results and the trabeculectomy continues to work for decades. In some cases, the trabeculectomy begins to filter less effectively after a couple of years and the pressure can creep up over time.

Once a thorough eye exam has been completed, eye doctors often set a target or goal intraocular pressure. To achieve this goal, there are essentially three different tools that are used to treat glaucoma: medicated eye drops, laser treatments, and surgical methods to lower the intraocular pressure. 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 likely start by add more medications back to your regimen. If the medications themselves do not work sufficiently, the trabeculectomy can either be revised, repeated, or another surgery can be implemented.

To answer your second question, I am not sure that I would really say that your eye is “healing” from the surgery because it really healed in the few months after the procedure. It is possible, however, that the tissue is remodeling or that there are tissue changes either at the trabeculectomy site or in the conjunctival bleb that are not allowing as much fluid to be filtered through. Given that you are so young, it is good that you are keeping regularly scheduled appointments with your eye doctor and keeping track of your eye pressures. I am sure that if the pressure increases above the set goal, your doctor will begin to discuss additional treatment options.I wish you the best of luck.

Thank you for your question. I assume that you mean that you would like someone to use a laser to treat you for narrowing of the drainage angle, and not the cornea. While I personally do not know any glaucoma specialists that are in Athens, Greece, I might suggest contacting the Athens University Department of Ophthalmology. The department may be able to recommend someone in the area for a consultation.

Thanks for your question. Yes, it is acceptable for glaucoma patients to fly. Due to the fact that the cabin pressure is regulated during the entire flight, there is very little effect on eye pressure. However, patients who have had retina surgery, during which gas bubbles are often placed in the eye, do have air travel restrictions since the gas bubble can expand and raise the eye pressure. During air travel it would be wise to carry your eye drops with you so that you can use them during the flight as needed according to your usual schedule. Also, it might be helpful to have artificial tear drops with you as the cabin air can be very dry. Lastly, I am concerned by your question, because you indicate that your eye drops do not work and your eye pressure is very high. You should speak with your eye doctor about what alternatives there might be, including changing medications, laser therapy, or glaucoma surgery.

I am sorry to hear about your vision loss. With regards to your question, sometimes patients are functionally blind in one eye, meaning that will primarily rely on the eye that has better vision. Therefore, if you have any residual vision in your left eye, it may still be worth using the eye drops so that if something unfortunate were to happen to your right eye, you still have some vision (however little) in the left eye. However, if you are truly blind in your left eye (there is no ability to even detect light), then there probably is not any need to treat with the medication, unless without treatment your eye pressure is high and causes pain. In that case, you may want to continue using the Alphagan P. Lastly, there has been some suggestion from research studies that brimonidine (the generic of Alphagan-P) protects the optic nerve. However, if there is no vision in your left eye, it will not help since once the optic nerve cells die in glaucoma, they are unfortunately not recoverable. Please talk with your eye doctor concerning the level of vision in your left eye, and certainly do not make any changes to your treatment regimen before talking with him/her.

Thanks for your question; it is a complicated one, but I will try to answer it step-by-step.

Typically, when a patient has narrow angles, this means that they have an anatomic configuration of their drainage angle that predisposes them to an acute angle-closure glaucoma attack, which can be visually devastating. Additionally, some patients with narrow angles may experience intermittent angle closure, and may get headaches or notice halos around lights during this time.  In an acute angle-closure attack, the visual changes occur rapidly and there is pain and decreased vision, which prompts the patient to seek medical attention.  Initially, the decreased vision is a result of swelling in the cornea due to the high eye pressure.  If there has been damage to the optic nerve, then typically there is peripheral vision loss.  In chronic angle-closure glaucoma, the eye pressure slowly builds up and patients will not typically have pain or even notice their vision loss.  However, these patients will often have peripheral vision loss that that is often goes unnoticed.

Your question about whether an iridotomy is a permanent solution is a difficult one.  If you have a narrow angle configuration, then having an iridotomy is a preventive treatment and you are much less likely to have an acute angle closure attack.  However, it is still important to have follow-up examinations as an iridotomy is not necessarily a “permanent” solution.  It is beyond the scope of this discussion, but sometimes after an iridotomy the ophthalmologist may discover that the patient has another type of anatomic configuration that needs follow-up over time.

Thanks for your interesting question. I just started swimming myself, and I do wear goggles. Prolonged exposure to chlorinated water can definitely irritate your eyes; however, I do not know of any association between swimming with your eyes open in a chlorinated swimming pool and elevated eye pressure. Obviously, you do not want to apply your eye drops prior to diving into the pool!