Ask an Expert about Glaucoma
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.
If there is a build-up of aqueous humor in patients that have glaucoma, is it visible when you look in the mirror, or can it only be seen with specialized medical equipment? [ 11/10/10 ]
Thank you for your question, and interestingly this is something that many glaucoma patients are curious about. In the majority of patients with primary open-angle glaucoma, there are no external signs that you could see on the eye that would tell you that you have glaucoma. (This may be different in patients with acute angle-closure glaucoma because many of these patients have a rapid increase in eye pressure causing the eyes to become red, painful, and the pupil slightly dilated. In addition, the vision becomes cloudy and often has rainbow colored halos). In most cases of open-angle glaucoma, the eye looks and feels completely normal. The other problem is that glaucoma typically begins to damage the eye by hurting your peripheral or side vision. Because of this, many patients don't even realize that they have begun to lose vision. The reality is that without doing a complete exam with special instruments even the best trained ophthalmologist cannot just look at an eye to tell if it has glaucoma. In fact, a large number of patients are found to have glaucoma during a routine eye exam. That is why we recommend that all patients begin having routine exams once they hit middle age. If we can catch glaucoma before it is too advanced, hopefully we can stop or slow the disease to the point that they never know they have it. Best of luck, and please continue to see your eye doctor regularly.
What supplements should not be taken if one has glaucoma. [ 11/09/10 ]
First, before taking any supplement, you should consult with your primary care doctor as well as your eye doctor (or any other doctor that you have) to make sure that the supplements will not have any adverse reactions with prescribed medications that you are already taking. Many patients do not think of vitamins and supplements as medications because they do not need a prescription for them or because they are not regulated by the FDA. In fact, many vitamins and supplements are very potent medications and can have both beneficial effects as well as very bad side effects. Unfortunately, because they are not regulated by the FDA, this allows the producers of the vitamins and supplements to make claims regarding their usefulness for treating certain diseases that are not true. That being said, there are some exceptional studies that have shown that vitamins and supplements can have a positive effect on many diseases, one of the most well known being the AREDS study showing that vitamins and supplements can be beneficial in certain types of age-related macular degeneration. Z
To answer your question specifically, if you smoke or have a history of smoking, you should avoid beta-carotene. You should not take “high” doses of vitamin E as this can have deleterious effects on vision. Finally, we are looking into whether or not levels of selenium have any impact on glaucoma as well. There are a few studies that show increased selenium levels may be related to glaucoma; however, more studies need to be done before making a definitive statement on the issue. In general, you should not be taking any supplements without the consent of all of your doctors because they need to make sure that the vitamins or supplements will not react with your prescribed medications or cause you any harm.
I have had five surgeries in the last 2 years, including filtration surgery in both eyes, cataract surgery in both eyes and a recent shunt tube procedure in the left eye. Now, the pressure is around 25 in my right eye and the doctor said that I might need another surgery. Why didn’t the doctor do the tube surgery in the first place? I am beginning to have second thoughts about him now. [ 11/08/10 ]
Thank you for your question. Without having examined your eyes, viewed the results of all of your past studies, and viewed your chart myself, it is impossible for me to answer this exact question. I will tell you that both glaucoma shunt tube surgeries and trabeculectomy surgeries (filtration surgery) are used frequently as first line surgeries for glaucoma. In fact about ½ of my patients have gotten trabeculectomies as their first surgery while the other ½ have gotten glaucoma shunt tubes. I have had patients that do well with 1 trabeculectomy and never need any further intervention, but I also have patients that had a trabeculectomy that does not work and end up needing another trabeculetomy or glaucoma shunt. I also have patients that have gotten a glaucoma tube and it has failed to reduce the pressure enough and I have put in a second tube. During fellowship, I assisted a very well-known glaucoma specialist in taking care of one of his patients. This patient had 3 tubes in each eye (yes, 6 tubes!). In many instances the doctor has to examine the eye, know the patient history, the type of glaucoma, the patient's ability to comply with drop regimens, know the risks, benefits and alternatives for each surgery and then they have to make an educated decision on which surgery gives each patient the best “chance” at getting a low pressure and slowing or stopping the progression of glaucoma. There is never a guarantee that the surgery will work, so we always have a backup plan.
Unfortunately, glaucoma is a very difficult disease to treat, and it can be frustrating for both the patient AND the doctor. Just because the surgeries have not lowered the pressure enough, this does not mean that your glaucoma specialist is not doing an excellent job. In fact, it sounds as though they have kept a very close eye on you and have a plan of action for treating both the cataracts (a well known side effect of trabeculectomy surgery and glaucoma shunt tube surgery) and the high pressure that remains in the eye. I imagine that if you had this discussion with your eye doctor, you would find that they are equally as frustrated by the fact that the first surgery did not solve the problem. Best of luck, and I know this process is not easy.
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Last Review: 04/28/13