Ask an Expert about Glaucoma
I'm a 51 yr. old female, and was diagnosed with glaucoma caused by irido-corneal endothelial (ICE) syndrome. Conventional treatments are not consistently lowering my eye pressure, and they make my cornea hurt and worsen my edema, which causes me excruciating pain and loss of vision. Recently, I underwent laser trabeculoplasty in Lyon France. The Dr. said that laser therapy was not the ideal treatment, but that surgery would only complicate my case more and cause weakening of my cornea. The day after the laser trabeculoplasty, my eye pressure decreased from 28 to 9. However, 36 hrs. later it went back up to 32. I ended up at an emergency room, and after treating me with a wide variety of drops and a diuretic pill, the doctors were only able to bring the eye pressure down to 28. My eye pressure is now 22, but my vision is blurry and my cornea is terribly sore and swollen. My ophthalmologist says that my eye condition is progressive and there is nothing that can stop it. Any suggestions? [ 03/01/11 ]
Thank you for your question. First, I appreciate that your condition is quite complex. I think you have done the right thing by seeking out an expert that is comfortable managing very complex cases of glaucoma. My only additional comment would be that you seek a glaucoma specialist who has a partner cornea specialist partner, and is comfortable treating patients with ICE syndrome. The chance of you finding a single eye doctor who is experienced in treating both conditions is probably pretty low. If you find a glaucoma specialist and a cornea specialist who can work together, I think your chances of a better outcome will increase. It would be ideal if they were in the same practice (or at the same academic institution). I know that you have seen many people, but I would caution that seeing “several prominent ophthalmologists around the world” may not be as helpful as narrowing it down to one excellent glaucoma specialist and one excellent cornea specialist who are willing to be cautiously aggressive with your treatment, if that is what you desire after knowing the risks, benefits and alternatives. In many cases, a lack of continuity of care (long-term care with one physician) can dramatically decrease the level of care provided to you. In many cases, developing a history with a single ophthalmologist who you trust will be more beneficial in the long run because every time you visit someone new they have get up to speed on your history, and they can only do that by looking at charts and speaking with you. While this is often acceptable, knowing a patient and having first-hand experience watching one person's eyes respond to different treatments can only be gained after establishing a patient-doctor relationship of several years duration. Sometimes finding an expert can be the answer, but other times there are no answers to be found and just finding a new doctor confuses the issue. So my first and likely best piece of advice is find one doctor (or one glaucoma doctor and one cornea doctor in the same practice/university) who you really trust and stick with that doctor for a while.
Second, your case is so complex that without examining your eyes myself and reading more about your history, I am afraid that I cannot provide an accurate recommendation concerning the next logical steps. If your case were so simple that an answer could be given after reading one paragraph of history, your case would have already been solved by one of the experts. If medications are not reducing the pressure adequately enough, then the only other options are laser therapy and surgery (trabeculectomy, tube shunt, endocyclophotocoagulation or even one of the newer procedures like canaloplasty). I think a traditional tube shunt is likely a poor choice in your case as there is ample evidence that the tube can rub on the back of the cornea and cause further corneal damage. If after examining your eyes, I thought a tube were the next best choice, I would consider working with a retina specialist to consider inserting the tube behind the iris instead of in front of it. This surgery is more complex and takes two different specialists working together on their different areas of expertise (i.e., the retina specialist to do a very clean vitrectomy including trimming the vitreous base, and a glaucoma specialist to insert the tube behind the iris instead of in front of the iris). This would protect the cornea a bit more. I think canaloplasty or trabeculectomy are options, but only after a thorough examination to see if there is any potential risk from these surgeries. I wish I could be more specific, but again, this is a very complex case and without examining your eyes, it is nearly impossible to give you an accurate recommendation. I wish you the best of luck.
Is a “shallow chamber” a risk factor for glaucoma? Is it considered a precautionary treatment to have a “hole” created in the eye to relieve eye pressure? [ 02/28/11 ]
Thank you for your question. Let me re-phrase your question so that it is a bit more specific, and easier to answer! Is a “narrow angle” a risk factor for glaucoma? The reason that I re-phrased the question is the fact that you can have a shallow chamber without necessarily having narrow angles. If the angle is narrow, then you are at an increased risk for angle-closure glaucoma. The fluid that keeps the eye blown up like a water balloon is created behind the iris (the colored part of the eye) and it has to travel around the pupilbetween the cornea and the iris to get into the drainage system of the eye. If that area is narrow, there is a potential that it can close off and the fluid cannot get around the pupil to the drainage system. In these cases, the pressure can go up dramatically in the eye and can cause loss of vision rather quickly. We can put in a laser peripheral iridotomy (LPI or PI) or hole in the iris to help prevent the attack of angle closure. Essentially, it creates an escape valve for the fluid to travel to the drainage system without going around the pupil. As with any procedure, there are risks, benefits and alternatives. You should discuss these completely with your eye doctor before proceeding. I wish you the best of luck.
My son is 12 years old and has glaucoma, and he has no vision in his left eye. His eye pressure has been as high as 58 and sometimes he gets bad headaches. A doctor suggested Motrin, but this does not help him. What should I do? [ 02/27/11 ]
I am sorry that you are both going through all of this, especially with your son being so young. This is often a very difficult topic to address with our patients and it is often a discussion that cannot be done in one exam. Without having examined your son, seen the results of his tests, and knowing more about his history, it is nearly impossible for me to provide completely accurate advice. The advice that I am going to give you is based on the assumption that your son has no vision at all in the left eye, has no potential for ever having vision in that eye, and that is the eye that has uncontrolled pain as a result of an increase in pressure causing pain that is uncontrolled with over the counter medications.
First, increasing the strength of pain medication (narcotic pain killers, for example) is never a good option in these patients. Any eye that is categorized as “No Light Perception (NLP),” meaning that even when a bright light is shined into the eye, the patient cannot perceive any light, is usually not treated with any further pressure lowering surgery; however, there are some rare exceptions. There are currently no surgeries available to help NLP eyes see again, so this treatment strategy is not usually suggested. Surgery to lower the pressure and prevent pain would only be done to help prevent pain, but not to correct vision. Often this surgery simply puts the patient at risk for side effects (infection, bleeding, pain, loss of the eye, complications from anesthesia, etc.) with very little gain. If the eye has no vision and no hope of ever regaining vision, there are a few more realistic things that can be discussed:
- First, either an alcohol or thorazine block can be performed.This is an injection of medicine behind the eye that kills the nerve endings of the eye and stops the pain, and is effective in many patients.
- Second, you can consider having the eye removed and a prosthetic eye implanted.In a young individual, this step has many implications and can be quite complex (both medically and socially). This is the reason I usually take several visits to discuss the options and plan with the patient and the entire family. That discussion is way beyond the scope of this website and should only be undertaken face to face with a physician. This is essentially a step that cannot be reversed.
My patients (especially our young patients) have many years ahead of them, and I cannot guarantee that surgeries to correct NLP eyes may become available at some point. At this time, these surgeries are so far away that the discussion is difficult to entertain, but we always want to hold out hope for as long as possible. I can tell you that my patients that have gone on to have prosthetic eyes implanted often tell me that they wish they would have done it sooner. Again, this full discussion should be handled with your personal physician; however, I encourage you to also open a dialog with your eye doctor to determine the best steps for your son and your family. Do not hesitate to get a second opinion (or even a third if it makes you feel better) before making a final decision. This is something that your entire family will need to be at peace with once you make a decision. I wish all of you the best of luck.
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.
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Last Review: 04/28/13