Ask an Expert about Glaucoma
I have glaucoma that is related to uveitis. I have had filtration surgery in both eyes and a shunt in my left eye. How effective is the shunt, how long does it last, and have there been any long-term problems associated with its use? My uveitis is currently under control, and I wonder if that will be a beneficial factor with regard to my glaucoma progression. [ 09/02/10 ]
Thank you for your question. A complete answer to the question "What are the short-term and long-term outcomes of glaucoma shunt surgery?" and "What are the possible complications of glaucoma shunt implant surgery?" would take a very long time to answer. There are individual studies published that discuss the effectiveness and complication rates of the Baerveldt 250, Baerveldt 350, Baerveldt 500, Ahmed S-2, and Ahmed FP-7 shunts as well as others (but these are the most commonly quoted and used in practice). Without knowing which shunt you had implanted, it is impossible to give you a completely accurate estimate of the effectiveness or complication rates associated with your implant. Depending on the study definition of success, shunts have a generalized success rate of approximately 80% to more than 95% at one year post-surgery. At approximately 5 years, that success rate drops to approximately 50-80% depending on the type of shunt and the type of glaucoma. Many patients can have shunts that function 5-10 years or longer. Complications most commonly listed are cornea decomposition, formation of choroidals (blood or fluid between the white part of the eye and the retina), double vision, uveitis, a membrane on the retina that can cause it to wrinkle, retinal detachment, blockage of the tube, low eye pressure, bleeding, erosion of the tube through the conjunctiva (tube exposure), loss of vision, etc. The rate of these complications varies. Your surgeon should know the type of implant that he/she used during the operation and they should be able to give you a better idea of the typical success rates for a patient with uveitic glaucoma and your specific glaucoma shunt implant. I suggest you discuss this question with your doctor, and prior to any further surgery make sure you have a discussion regarding the risks, benefits, and alternatives of any procedure that is done.
In regards to whether or not your uveitis being under control has an impact on the progression of your glaucoma, I would say yes. It probably depends mostly on how much damage has been done to the natural drainage system from the previous bouts of uveitis. In general, if any of the normal outflow pathways are still functional, another bout of uveitis could cause enough inflammation to shut down the remaining normal pathway and cause an increase in your eye pressure. It is also possible that your uveitis is advanced enough that it has completely closed off the natural drainage system. Additional inflammation may not damage the natural drainage system further in this case, but the inflammation could cause the shunt to work less efficiently or even clog the tube if the inflammation is severe enough. Maintaining control of the uveitis and inflammation should be your ultimate goal, but I know it can be a very difficult task. I wish you the best of luck.
My doctors suspect that I have glaucoma, and I was given Travatan to put in my right eye once a day for a week. I was also informed that I may not always need to use the drops. I was wondering at what point the doctors will be sure that I have glaucoma. [ 08/31/10 ]
Thank you for your question. Because I have not been able to examine your eyes personally or review your test results, it is difficult to give an accurate assessment. It sounds as though your doctor believes that you have some risk factors for developing glaucoma or may be seeing possible signs of this eye disease based on your exam. This is why your eye doctor has given you the diagnosis of being a "glaucoma suspect." This means that they do not yet believe you have glaucoma, but that you should be watched closely for the development of glaucoma in the future. Fortunately, some patients never progress and are considered "glaucoma suspects" the rest of their lives. Other patients progress to having glaucoma; however, each patient progresses at a completely different rate. This is why it is important to follow-up with your eye doctor and not miss any scheduled appointments.
In some cases, determining that a patient has glaucoma is very easy because it is quite advanced. In subtle cases, it is often much more difficult and often there is no exact point that defines the start of having glaucoma. It is difficult to predict when, if ever, you will be diagnosed as truly having 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, OCT, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future. Glaucoma is classically defined as a stereotypical pattern of damage to the optic nerve and certain layers of the retina. Elevated intraocular pressure is a risk factor for glaucoma, but just because the pressure is elevated this does not mean you have glaucoma. Often people with elevated intraocular pressure alone, and no other signs of glaucoma, are given the diagnosis of ocular hypertension. Similarly, just because the intraocular pressure is normal, this does not mean that someone cannot have glaucoma. I encourage you to continue having routine exams with our eye doctor, and if you are concerned please do not hesitate to ask for a second opinion from a glaucoma specialist that has completed a glaucoma fellowship.
I am 49 years old and last week I went for an eye exam because it is now getting hard to read small print. The doctor told me that I have possible signs of glaucoma. She scheduled me for further testing, which is 2 months away. Is this too long to wait? From what I have been reading, if you have glaucoma you should start treatment as soon as possible to prevent any further vision loss. [ 08/29/10 ]
Thank you for submitting this question. This is a concern for many of our patients that have been told that they may have "signs" of glaucoma. The follow-up for every patient diagnosed with glaucoma or diagnosed as a glaucoma suspect is completely different based on the findings of the exam. Once you have been diagnosed as either a glaucoma suspect or a patient that has glaucoma, 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 if you are simply a "glaucoma suspect" or if you have been diagnosed with glaucoma. If diagnosed with glaucoma, it also depends on how advanced the glaucoma is and how much damage has been done to the eyes. As a glaucoma suspect, your doctor simply feels that there are parts of the exam that make them curious to know if you are beginning to develop glaucoma. This does not mean that you have glaucoma. Waiting a couple of months to re-examine your eyes and complete some more testing is very reasonable. In fact, I have many patients that are either "glaucoma suspects" or are patients with mild glaucoma that have been stable for several years with no changes in intraocular pressure, and I see them only once or twice a year; however, this is only after a pattern of stability has been established. 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. 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 acceptable to ask for a second opinion from a glaucoma specialist.
My husband has been treated off and on for 5 years with steroid drops for shingles of the eye. He now has a cataract in his right eye. He is currently having eye inflammation and taking Lotemax to calm the eye down before cataract surgery can be preformed. In addition, the pressure in his “good” left eye is 22. Testing in 2 weeks will include views of the optic nerve to make sure there is no damage, and if the pressure is still high, the doctor will have my husband start eye drop medication. We know that the cataract in the right eye was caused by the long-term steroid use, and I would like to know if there is a chance that he will also develop glaucoma in the left eye eventually. [ 08/27/10 ]
Thank you for your question. Unfortunately, the short answer to your question is that no one will be able to predict whether or not your husband will eventually develop glaucoma in either of his eyes. You are correct in the assertion that steroids can cause cataracts to develop more quickly. In addition, use of steroids can cause a "secondary glaucoma" known as steroid-induced glaucoma. It is most often seen in the eye that steroid drops are being used in, but in rare cases, the pressure can increase in both eyes. Some patients can even have an increase in eye pressure when taking oral or inhaled steroids. Interestingly, there may be an explanation as to why the pressure appears normal in the right eye at this time; however, this is only speculation. The increase in pressure may be masked in the right eye because of the inflammation in that eye. Inflammation in the eye is known as "uveitis," and this inflammation often causes a decrease in aqueous humor production as well as a decrease in eye pressure. I suggest that you continue with your scheduled exam in 2 weeks for a complete workup. If the pressure is still elevated, using drops to reduce the pressure is fine. After your husband's cataract surgery and after getting off the steroid drops, you can see if the pressure in both eyes decreases. In a case as complicated as this, I would not hesitate to seek a referral to a glaucoma specialist for their thoughts. I wish the best of luck to both of you.
My doctor made a small incision to drain the fluid out of my eyes. A bleb is visible in my left eye, but not in the right eye. Also, one of my eyes is larger than the other and I am wondering if this is a result of the surgery. Is there anything the doctor can do right now to fix this problem? [ 08/25/10 ]
Thank you for your question. Whether or not the bleb is visible may depend on how "cystic" the bleb is. This often depends on how you heal from the surgery and in some cases it also depends on how the surgery was completed. In most cases, if the trabeculectomy worked in lowering the pressure, there is often a bleb present but it may be a very low lying, unnoticeable bleb. Without examining your eye after the surgery, it is impossible for me to tell if the trabeculectomy and bleb are functioning through a low bleb or not.
The second part of your question is a bit more difficult to answer without actually examining your eye. I can think of a couple of different reasons that the eyes might look different sizes. While glaucoma or an increase in ocular pressure rarely cause a change in size of the adult eye, this is somewhat common in an infant with glaucoma. A few things can cause the adult eye to either change size or look like they are different sizes. One eye may in fact become smaller if it has had so much damage that it is no longer able to create the aqueous fluid that usually keeps it blown up like a water balloon. This process of shrinking is called phthysis (pronounced "Tie-sis"). Your eye doctor should be able to tell you if your eye has begun this process. I think the most likely answer to this question is that your eyes are, in fact, the same size but appear different because of the position of your eyelids. After surgery, there is always the possibility that the eyelids will droop (some of the muscles that hold the eyelid up can be stretched during the surgery, and this is a known complication). The other possibility is that the eyelids are in different positions because one eye has a large bleb and the second does not. This can cause the eyelids to lie at different heights making one eye look larger. If this is an eyelid positioning problem and the appearance is bothersome to you, I suggest that you get a referral to an occuloplastic surgeon for a consultation regarding surgery to reposition the eyelids.
Approximately 5 years ago, my ophthalmologist sent me for a yearly visual field test and optical coherence tomography (OCT), which had always yielded normal results. Around 6 months ago, I had Mohs surgery for a basal cell carcinoma that was located near the interior corner of my left eye. The surgery left me with annoying sensations of burning in my eye as well as tearing. Last week, I went for an annual visual field/OCT, which showed changes to the visual field as well as to the optic nerve in my left eye; although, the IOP is 16.5. I was prescribed Travatan, but requested a medication that would not potentially change my eye color and pigmentation. I am now taking Timoptic XE, and I haven't been using it long enough to know whether it is working. My ophthalmologist also said that there was damage done to the tear duct during the Mohs surgery, but that I should not bother to get it fixed. Do you believe there is a relationship between the tear duct damage and the vision changes? [ 08/23/10 ]
Thank you for your question. I am sorry that you have had to endure so many problems with your eyes recently. In general, I would tell you that there is minimal to no association between the functioning of your tear drainage system and your glaucoma. The tear drainage system normally drains the tears from the front surface of the eye down into the nose and into the back of the throat. The fluid created inside the eye (aqueous humor) drains back into the body through an entirely different pathway. Mohs surgery for basal cell carcinoma on the eyelid often requires a plastic surgeon on hand to reconstruct the eyelid after the cancer is removed. In many cases, when the surgery involves the inner parts of the eyelid, the tear drainage system cannot be salvaged. In some cases, after surgery, patients can continue to have some eyelid positioning problems as well as disruption of the normal surface tears. A decrease in the tear production and dry eyes can often result in the burning sensation and tearing that you are describing. In response, the eyes will then create too many tears as a reflex reaction. This usually results in tears running down your cheek. Often our first line of therapy in treating dry eyes is artificial tear eye drops or ointment to help soothe the eyes and re-establish a normal tear film layer. If this does not help and the patient still is not making enough tears, we often will plug the tear drainage system on purpose. In your case, I would suggest seeing an occuloplastic surgeon and they can determine whether or not you are experiencing dry eyes or tearing related to the damage to your tear ducts. In either case, fixing the tear drainage system or leaving it alone will have absolutely no impact on your eye pressure or progression of glaucoma.
As for the glaucoma diagnosis in the same eye, I would again think that the chance of a connection between the two is highly unlikely; however as doctors we never say "never." I suggest that you consider a second opinion from a glaucoma specialist considering you have these findings in the setting of recent surgery and a normal eye pressure. It may not be a bad idea to possibly repeat the visual field test after the cornea irritation is under control. Severe dry eyes, eyelid malposition, and several other things can give you a false positive visual field test. While this does not explain the "optic nerve damage," I think it warrants a second look. Until then, I would suggest continuing your Timoptic XE and follow up with your eye doctor as scheduled. Best of luck and it sounds as though you deserve to have a little good luck coming your way!
I had a blow to the head when I was in my 20s, and I was wondering if this could cause glaucoma. [ 08/20/10 ]
Thank you for your question. Depending on the severity and location of the blow to your head, you could be at risk for one type of glaucoma. We will often ask our patients if they have ever had head trauma, black eyes, been knocked out, etc. to determine if they are at risk for angle recession. The fluid that is made inside the eye (aqueous humor) flows around the pupil into the drainage system where the colored part of the eye (iris) meets the white part of the eye (sclera). The fluid must drain through the trabecular meshwork into Schlemm's canal before it returns to the blood stream and is reabsorbed by the body. If the eye receives direct or indirect trauma in this location, there can be damage near the drainage system. If this damage is present, you can be at risk for developing glaucoma in that eye at any time in the future. This could even be years or decades after the trauma. If you are concerned about possibly having glaucoma as a result of trauma to the head or eye (i.e., angle recession glaucoma), I would highly recommend that you see a glaucoma specialist that is comfortable doing a complete eye exam that includes gonioscopy. This is a special exam that is done so that the eye doctor can look at the drainage angle to determine whether or not there is any damage. Once the exam is complete, they can tell you if you are at increased risk for glaucoma in the future.
I am a 52-year-old female, and was diagnosed with advanced normal-pressure glaucoma 2 years ago. I had a trabeculectomy in both eyes. The left eye is fine with a pressure of 9; however, the right eye has been troublesome since the initial surgery. The bleb was needled approximately 6 months after the initial surgery, resulting in a now functioning bleb with a pressure of 10, but it is large. This is causing extreme eye pain as a result of dry eyes, and areas of the cornea are becoming ulcerated. My eye doctor has placed a contact lens bandage patch on this eye, which is changed monthly. I use antibiotic drops for several days after the patch is changed. This seems to be the only way I can get relief. I have used drops and ointment to no avail. Will the use of this bandage patch cause other eye conditions or am I on the correct treatment path? [ 08/19/10 ]
Thank you for your question. I am sorry that you have had some difficulty with your right eye, but unfortunately an excellent functioning bleb can sometimes be quite large and cause the problems you are describing. It sounds as though the surgery was successful in lowering the pressure, but you are now dealing with one of the known side effects of this surgery. The pain that you describe is known as bleb dysesthesia (bleb discomfort). Often because the bleb is so large it will disrupt the tear film and prevent the eyelids from dispersing the tears evenly over the surface of the cornea. This often leads to dry eye syndrome as well as an excavation of the cornea near the edge of the bleb where the tear film is disrupted. This excavated area is known as a dellen. Often we try drops or ointments as the first line therapy. However, if this is not sufficient, we will resort to using a bandage contact lens. I typically try not to use the bandage contact lens as a long-term solution, but that is my personal preference. I worry about bacteria growing on the contact lens and causing a corneal ulcer. If I choose to use a bandage contact lens, I will often keep my patients on a low level of antibiotic drops the entire time that they are using the lens to help prevent ulcers. Many cornea specialists says that this is not always necessary and I do know many doctors that do use bandage contact lenses long-term in their patients without too much trouble. Again, this is only my personal preference. I think this treatment path is fine as long as there are no other side effects that emerge. Otherwise, you may need to consider doing a bleb revision surgery. This is a difficult decision considering the pressure is now well controlled and your vision is stable. Often, blebs do not function as well after revision. I recommend that you and your doctor have a discussion regarding the risks, benefits and alternatives of continuing the current treatment vs. considering bleb revision surgery. After you know your alternatives, you can make a decision on how long you would like to continue using the bandage contact lens.
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Last Review: 04/28/13