Ask an Expert about Glaucoma
I have had high eye pressure and have been categorized as a ‘glaucoma suspect’ for many years. When I was a teenager, just a few years ago (LOL), I went to a doctor who told me that I do not have glaucoma, but I did have funny looking nerves. Recently, a new doctor bullied me into getting eye drops because he felt that I did have glaucoma, and that other doctors were wrong. I started using the drops, and within 1 week I was having problems with my vision and failed the field vision test, which had never happened before. I told the doctor about this, and he told me there was no way that the eye drops would cause problems. I forgot to take the drops when I recently went to my sister’s home, and noticed within a few days that my eyes were getting better. I then stopped taking the drops completely and my vision improved. Is it possible for the drops to trigger a reaction and cause vision problems? I am afraid to take the eye drops because of this. Do you have any suggestions? [ 02/26/11 ]
Thank you for your question. It is a bit difficult for me to answer this exactly as I do not know the name of the drops that you were taking. In general, most of the drops that we use do not cause a change in vision; however, it is not impossible for the drops to cause some minor changes. I think there are a few options. First, get a second opinion by a glaucoma specialist that is used to watching and evaluating glaucoma suspects and recognizing progression to glaucoma. Any time you use the words “a new doctor bullied me,” it immediately indicates that there is not a trusting relationship between the patient and the physician. It is not the fault of either party in most instances, sometimes personalities just don't mesh. I suggest getting a second opinion and finding a doctor that you trust. It is quite possible that you do need treatment, and if that is the case you need to trust the doctor that is giving the advice. Second, the easiest way to test whether or not the drops are causing a change in your vision is to have a baseline exam either on or off the medications (if you have been prescribed the medications, do not stop them without consulting with your eye doctor). Once a baseline exam has been completed, you can either stop the drops or restart the drops and return for a second exam within a few weeks to see if there is a change in the prescription, vision, or surface of the eye. Often the prescription required for good vision may not change, but the drops irritate the front of the eye and cause a slight decrease in vision. This can often be alleviated by adding artificial tears to the regimen. The only way to tell for sure is to have one exam while taking the eye drops and another eye exam after stopping the eye drops; the results of the two exams can then be compared. I hope these suggestions are helpful, and I wish you the best of luck.
There was a recent study at Glasgow Caledonian University indicating that playing bagpipes can increase pressure inside the eyes and possibly lead to glaucoma. Does this sound accurate, and can playing other instruments (a trumpet, for example) lead to a similar increase in the risk of developing glaucoma? [ 02/25/11 ]
Thank you for your question. This is actually not the first time this subject has come up in my career. During my training, we discussed this at length in regard to brass instruments and some woodwind instruments. I have actually had a couple of patients that were music professionals with similar questions. The study may very well be correct. In general, eye pressure can be transiently increased by any exercise or activity (playing instruments) 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 nervous control 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 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 with increased intraocular pressure and exercise, 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, as physicians we would all recommend that our patients follow an exercise regimen for your general health. Avoiding prolonged heavy weight lifting or inverted yoga positions may be reasonable until we have definitive studies to examine their long-term effects. If you play a musical instrument and you are concerned about your pressure increasing while you play, I suggest that you consult with your eye doctor to see if they would be willing to check your pressure while you play the instrument. You can simply bring the instrument in (or even just the mouthpiece for brass instruments) and "play." They can check the pressure before and during "playing" and tell you if the pressure in your eye increases. They may not be able to use the standard applination tonometer at the slit lamp to measure your eye pressure, but I have successfully used a Tono-Pen to test the pressure in one of my patients under these circumstances.
My 5-year-old son has glaucoma and is awaiting shunt surgery. His cup-to disc ratio has gone up from 0.3 to 0.7. What does this mean? Does he have irreversible damage, or can the cup-to-disc ratio go back to normal at some point since he is so young? [ 02/10/11 ]
Thank you for your question. I am sorry that you are having these problems with your son at such a young age. Without knowing the history of your son's eye problems a bit better, having completed my own exam, or looking at the results of various tests, it is difficult to give a completely correct answer; however, I will do my best to give you an accurate response with the information that I have.
To answer your first question, glaucoma causes damage to the optic nerve. In general, when we look at the optic nerve we try to identify how much nerve tissue is present. The normal nerve looks a bit like a cup with a thick rim on end. The nerve tissue makes up the thick rim and there is an indentation in the middle (the cup). If we measure the size of the cup and compare that to the total distance (diameter) across the optic nerve (disc), we get the cup-to-disc ratio. If we looked at a nerve that had equal parts top rim, cup, and bottom rim (i.e., each took up 1/3 of the diameter) the cup to disc ratio would be 1/3 or 0.33. If the cup took up1/2 of the disc space (i.e., the top rim took up 1/4 of the diameter, the cup was 1/2, and the bottom rim was 1/4) the cup-to-disc ratio would be 0.50. In general, as glaucoma gets worse, more nerve tissue is lost, more cup is lost, and the cup to disc ratio gets larger. In adults, typically we say that optic nerve damage is not reversible and any damage that occurs is permanent (although in rare cases this can be incorrect). Interestingly, in children, there are a few patients that have "reversal of cupping" after glaucoma surgery. We still do not know the reason for this, and many scientists are doing research exploring this phenomenon. I cannot tell you for sure if the damage that has occurred is irreversible or if he will have "reversal of cupping" after the surgery; that is impossible to predict. I wish you and your son the best.
I am 39 years old and recently went for an eye exam due to increased pain in my right eye. I also feel that there is very minute deterioration in my vision. I often get headaches around this eye and always assumed that it was sinus related due to an existing sinus condition. The optician said that I had exceptional vision; however, my eye pressure was high. The pressure is 27 in my left eye and 30 in the right eye. The optic nerve and visual field tests were fine. They sent a letter to my doctor indicating that they should not be concerned and that another eye test is scheduled in 2 years. Does this sound reasonable or should I push back on this? Would it be better if I had a follow-up examination in a few months? [ 02/09/11 ]
Thank you for your question. While every patient diagnosed as having glaucoma or 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 or to begin treatment. All of this depends on how advanced the glaucoma is and how much damage has been done to the eyes.
As an example, immediately after surgery, I may see my patients 1-2 times per week until they are stable. For those patients with advanced glaucoma and uncontrolled intraocular pressure, I may see them several times per month if we are making changes to their eye drops or we are considering surgery. Other patients that are glaucoma suspects or patients with mild glaucoma that has been stable for several years with no changes in intraocular pressure may be seen 1 or 2 times per year.
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 how advanced the glaucoma is and how well you are responding to treatment.
Given that your pressures are elevated, I would not suggest waiting 2 years. I would personally have you return in 1-2 months for a quick pressure check to see if the pressure is remaining elevated or if it just happened to be up on that day. If it remains elevated, I would continue to see you every 3-4 months until we determined whether you had glaucoma or were a glaucoma suspect with ocular hypertension (elevated eye pressure but no glaucoma). If the pressure was back to normal, I would probably still see you in another 6 months to make sure the pressure has not elevated again. If it is normal for a couple exams, then going back to yearly exams would be fine. If you go a couple of years with normal exams, you could then stretch back out to 2 years. In short, no, I would not wait 2 years to be seen again. 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 have a worsening glaucoma problem and high pressure in both eyes. I am going to an eye surgeon for treatment and wonder what questions I should ask. [ 02/08/11 ]
Thank you for your question. Unfortunately, without knowing a bit more about your history, the treatments that you have tried, and the results of past tests, it is nearly impossible for me to know what questions you should ask the doctor. I am sorry that your glaucoma is getting worse and that you now appear to need surgery. Sometimes, depending on the type of glaucoma that a patient has, medications do not work as well in one type as they do another. The other problem is that even in patients with the same type of glaucoma (primary open-angle glaucoma, for example) every patient responds differently to the treatment. I have some patients that need one drop a day for the rest of their lives and they never have any further problems. I have other patients who try all of the medications, yet none of them seem to work. If you have used all of the medications available and you have tried laser therapy, the next option is probably surgery (trabeculectomy or glaucoma shunt tube). The good news is that most patients do very well. I suggest that you have a discussion with your new eye doctor about the risks, benefits and alternatives of each surgical option that they offer. It is very possible that after your exam with the new doctor you will get home and have more questions. I always tell my patients to write the questions down and either call me or bring them to the next exam. I know this may not exactly answer the question, but without knowing more, the best advice I can give you is to fully understand the risks, benefits, and alternatives of any or all surgical options that are available. I wish you the best of luck.
One year ago, I had a battery of tests, which indicated that I had glaucoma. I have been taking eye drops daily since then. I had my annual vision field test recently and there was only one little black box at the bottom of the grid. One year ago, the shape of a "big L" was present. The recent tests indicate that nothing is wrong. What happened to the "big L-shaped black boxes" that were present one year ago? [ 02/07/11 ]
Thank you for your question. Unfortunately, without examining the visual fields, it is nearly impossible for me to give you an accurate answer as to why the "big L" disappeared. In general, we do not believe the results of one single test in most cases, and ask patients to take the exam a couple of times to ensure that the defects are reproducible, or in your case that the lack of any indication of glaucoma is correct. Often the first time that a patient takes the test, the results are not all that accurate because there is a learning curve to taking the test accurately. It is not unusual for someone with minor defects on the first exam to actually show no defects on later exams. If your doctor is concerned, they could consider doing a special visual field test known as a SWAP visual field. In some cases, this will pick up very early glaucoma defects that the normal visual field will not (although the SWAP test is not as reliable as the standard visual field test). Also, if you have had a cataract surgery since the last test, this can clear up the entire field of vision and this could account for the change in the pattern of defects. I suggest that you repeat the exam again in the future, and make sure that you are also having dilated eye exams. If your doctor is uncertain as to whether or not you have glaucoma, I suggest that you see a glaucoma specialist for a second opinion. Often these types of cases are difficult to interpret.
During the last 5 years, my top eyelids will intermittently start to drain fluid, which streams down my face. I always use the same makeup and face cleanser. Do you know what causes this symptom? [ 02/06/11 ]
Thanks for the question. While I usually get to answer glaucoma questions, it is always fun to change gears and answer a general ophthalmology question. Tearing (also known as epiphora) happens for a couple of reasons.
First, it is possible that your eyes are creating too many tears and your tear drainage system cannot drain them off quickly enough (the tear drainage openings are located on each eyelid at the corner of the eyes nearest the nose). This is like a sink that has an open drain, but the faucet is on too high and overwhelms the capacity of the drain to take tears away. The sink eventually overflows. This can occur any time the eye is irritated and produces "reflex tears." The body doesn't know how to produce "just few extra" tears; it only knows how to turn the reflex tears on "full blast." If something is irritating the eyes (allergies) or they are dry, a tear reflex is stimulated and too many tears can be made. Yes, dry eyes can cause the eyes to water and over-run!
The second possibility is that the tear drainage system is intermittently getting clogged. This can occur at various times due to colds, sinus problems, allergies, or other problems. You can go to your eye doctor and they can test the amount of tears that you are producing, and test the tear drainage system. They will numb the eye and then irrigate the tear drainage system with some salt water. If you taste the salt water, they will know that the system is open. This is something that any eye doctor can perform, and they can also provide suggestions to alleviate the problem. I wish you the best of luck.
Does massage affect glaucoma in any way? [ 02/05/11 ]
To my knowledge (and after a quick literature search) there are no randomized clinical trials or even case reports of either benefits or adverse effects of having a massage for someone who has glaucoma. As long as you do not have a massage in which your head is lowered significantly below your heart (i.e., you are not inverted) then you should be fine. I say treat yourself and enjoy.
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Last Review: 04/28/13