Ask an Expert about Glaucoma
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.
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.
My father has lost his eyesight in one eye due to a retinal detachment. Years later, he suffered the same problem in the other eye. Fortunately, an operation saved his vision. However, he cannot see clearly and now he is suffering from glaucoma. What should he do to prevent his eyesight from deteriorating further? [ 11/07/10 ]
Thank you for your question, and I am sorry that your father is having these problems. It is not unusual to develop glaucoma after other eye surgeries. Your father should be seen regularly by a retina specialist to make sure that the retinal detachments do not reoccur. Further, I would suggest that your father be seen by an ophthalmologist that has finished a glaucoma fellowship. The glaucoma specialist will need to complete a full eye exam and likely do several different tests to determine what caused the glaucoma to develop (it is possible that it is not related to the previous eye surgeries). This is a special circumstance that warrants the care by a specialist that is familiar with complicated glaucoma cases. Once they examine your father's eyes, the glaucoma specialist will create a plan of care. The goal of the glaucoma specialist will be to reduce the eye pressure to the point that the glaucoma damage does not progress. This may require eye drops, laser treatment, or surgery. He or she will work with the retina specialist if needed as well. It will be important for your father to be seen regularly by both of these doctors for the rest of his life. I wish the best of luck to you and your father.
I am a Vietnam veteran who was exposed to Agent Orange. As a result, I have diabetes, peripheral neuropathy, and was recently diagnosed with glaucoma in both eyes. None of my family has suffered from these disorders. I have been told that there are studies linking glaucoma and diabetes, and was wondering if this was the case. If so, is the research available to the public? The reason for asking is that my Veteran Service Officer would file for additional benefits if we can produce what is called a "Nexus Letter," which I presume is a written doctor's opinion. Thank you! [ 11/06/10 ]
First, thank you. As the son of a Vietnam veteran and the grandson of a WWII veteran, I have a great admiration for all of the men and women who have served our country.
Currently, the VA recognizes the following conditions as being related to Agent Orange exposure:
- Acute and Subacute Peripheral Neuropathy
- AL Amyloidosis, Chloracne (or Similar Acneform Disease)
- Chronic Lymphocytic Leukemia and Other Chronic B Cell Leukemias
- Diabetes Mellitus (Type 2)
- Hodgkin's Disease
- Ischemic Heart Disease
- Multiple Myeloma
- Non-Hodgkin's Lymphoma
- Parkinson's Disease
- Porphyria Cutanea Tarda
- Prostate Cancer
- Respiratory Cancers
- Soft Tissue Sarcoma (other than Osteosarcoma)
- Kaposi's sarcoma
Some new associations are being examined currently, but no ruling has been made to my knowledge. To date, I do not believe that the VA recognizes that Agent Orange exposure is a primary cause of glaucoma. Your question pertains to whether or not patients with type 2 diabetes (which is recognized by the VA) is an independent risk factor for glaucoma (hence a possible connection). There are several studies that do support this conclusion, but they are slightly controversial. In general, the more often a patient goes to the eye doctor the more often the doctor can examine the eyes and catch glaucoma if it is present. It is possible that because patients with diabetes go to the eye doctor more often (to have their eyes dilated for diabetic eye exams); their doctors are seeing them more often and can make the diagnosis more often. The problem with glaucoma is that approximately ½ of the people that have glaucoma do not know it because they do not go to the eye doctor for regular eye exams. For your benefit, I have included references to the three primary studies that argue for a connection between diabetes and glaucoma. They were all published in the medical journal "Ophthalmology" hence they are available to the public.
- P. Mitchell, W. Smith, T. Chey and P.R. Healey, Open-angle glaucoma and diabetes: the Blue Mountains Eye Study, Australia, Ophthalmology 104 (1997), pp. 712–718
- L.R. Pasquale, J.H. Kang and J.E. Manson et al., Prospective study of type 2 diabetes mellitus and risk of primary open-angle glaucoma in women, Ophthalmology 113 (2006), pp. 1081–1086
- B.E. Klein, R. Klein and S.C. Jensen, Open-angle glaucoma and older-onset diabetes: the Beaver Dam Eye Study, Ophthalmology 101 (1994), pp. 1173–1177.
I will caution you that these studies are suggestive, but not conclusive of a link between the two. Further, my willingness to provide this information is by no means a physician's written opinion stating that I believe that the connection exists. If asked, I would have to say that the evidence is suggestive but not conclusive for the reasons I stated above. At this time, there is no definitive evidence proving a connection. It is possible that a connection exists, but we just don't have the data to support it conclusively quite yet. We are still looking and hopefully that information will be available in the near future. I wish you the best of luck.
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Last Review: 04/28/13