Ask an Expert about Glaucoma

Thank you for your question. Unfortunately, at this point in time, there are no doctors in the United States who perform stem cell transplants for glaucoma or transplants of retinal ganglion cells. There is much research in this area (including my own research) but we are still many years from being able to safely offer such a treatment. In fact, I would say that if you do find a doctor who claims he/she can perform such a transplant, be very careful. You may have heard of stem cell transplants for other eye diseases, such as macular degeneration. However, in glaucoma, the dying retinal ganglion cell extends all the way from the eye to the brain and a “cure” for blindness from glaucoma is not as simple as just transplanting replacement retinal ganglion cells. I encourage you to continue doing research into new treatments for glaucoma but always with a careful approach.

Thank you for your interesting question. There is no test performed during a routine ophthalmologic exam that can quantify vision in percentage points. The quantitative measurements that ophthalmologists use to follow a patient’s glaucoma include visual acuity, visual field testing, and optic nerve imaging. There are quantitative measurements associated with these tests and certainly following them over time after establishing a baseline is important to monitor for progression.

Thank you for your question. I am not sure what “PSA” refers to, but perhaps you are referring to “PAS,” or posterior anterior synechiae. These are abnormal adhesions from the iris to the “angle” that are one cause of chronic angle-closure glaucoma. Your farsightedness is one risk factor for having narrow angles, and the suggested preventive treatment for an angle-closure attack is a laser iridotomy, which creates a hole in the iris and allows an “escape route” for fluid to drain from your eye. Drops generally cannot manage the problem; however, sometimes ophthalmologists consider the use of topical pilocarpine to make the pupil small, but this does not always prevent an angle-closure attack.

When I counsel patients who need this laser iridotomy procedure to prevent an angle-closure attack, I weigh the risks and benefits. The benefit of preventing an angle-closure attack is enormous, and the damage from such an attack is quite profound and irreversible. The risk of laser surgery is quite small in comparison; sometimes there is an eye pressure spike so patients will wait for 30-60 minutes after the surgery to ensure this does not happened. Because we are making an additional hole in the eye for light to pass through, some patients complain of glare or haloes, but this is not common. The alternative is to do nothing, which is an option. No one can predict with great accuracy whether you will have an angle-closure attack in your lifetime. The risk likely becomes greater as you get older, because your lens (I am assuming you have not had cataract surgery) will also thicken, making the angle even more narrow. I would recommend that you make a follow-up appointment with your ophthalmologist and discuss the risks, benefits, and alternatives of the procedure again before making your final decision.

Thanks for your question. I’m sorry to her about these symptoms and I don’t think that you should have to tolerate them. So I would say that instead of wearing corrective lenses to clear up your vision, your doctor will focus on finding a medication regimen that you can tolerate and is effective. It is also possible that you could have successful repeat laser for your glaucoma. Based on what you have told me, there are still some other medications that you could try. The other issue is whether dry eye exacerbated by your glaucoma drops is what is causing the blurry vision. If you are not already using artificial tears, I would recommend talking to your doctor about using them, and also ensure that any other underlying issues that could be causing irritation of the ocular surface, such as blepharitis or chronic inflammation of the eyelids, are addressed. Lastly, there are also preservative-free formulations of many glaucoma eye drops available and sometimes this can make a big difference in a patient’s tolerance of any eye drop. Please bring this information to your eye doctor and he can discuss the options with you in more detail.

Thanks for your question. There are side effects related to Travatan, which is a prostaglandin analogue. These include redness and irritation, which generally improves over time. In the long term, there can be increased pigmentation around the eyelids. There are also changes to the eye color that can occur, especially in hazel-eyed people. I can list even more side effects, but these are some of the more common ones. I certainly would monitor any side effects that you believe may be related to Travatan and discuss them with your ophthalmologist. There are always other eye drops with less (or different) side effect profiles. Sometimes there is a period of trial and error to figure out the most effective medication with the least amount of side effects.

Thanks for your question. Yes, while it is true that laser iridotomy can have side effects, let me first start out by saying that overall it is a fairly low-risk procedure. As you know from reading medication labels, many side effects will be listed but it is hard to tell which ones are most common. I usually advise my patients about the following issues, although this is not an exhaustive list.

There can be an eye pressure spike after the procedure, but I usually treat this in the clinic and have my patients wait 30-60 minutes after the procedure so we can check for this. I also tell my patients that the eye is like a camera, with the pupil acting as the aperture. After the laser you will have an extra “aperture” so theoretically stray light can enter the eye and cause halos, double or blurred vision, and glare. I generally place these holes superiorly, as long as the eyelid completely covers the hole created in the iris. Others will place the iridotomy at the 3 or 9 o’clock positions. There is also the side effect of inflammation, which is why I ask my patients to use a short (one week) course of topical steroids (or non-steroidal anti-inflammatory eye drops if they are very sensitive to topical steroids). Of course, there are other side effects that you will come across if you read a great deal, but overall I would say that if you have narrow angles (and a family history of narrow-angle glaucoma resulting in blindness) the benefit would outweigh these risks.

Ultimately, it might be helpful for you to bring the information presented above to your eye doctor and have a thorough conversation with him/her about the laser iridotomy procedure, so that you can feel that all of your questions are adequately answered.

Thanks for your question. Given that your son is six years old, he may be at the age at which soon he will be able to hold still and tolerate an eye pressure measurement in the clinic. But each child is different, so if he is not yet able to tolerate this in the clinic, then yes, he would need to have anesthesia for the pressure check. A frightened child who is squeezing his eyelids shut will not yield an accurate measurement and will render it meaningless. Many pediatric glaucoma specialists do have experience in measuring eye pressure in young children and are able to put them at ease. There are home tonometry units available now; however, given that your son is nearing an age for which in-office measurements should be possible, I would discuss this option with your ophthalmologist.

Thanks for your question. Many researchers, including myself, are working on regenerating optic nerve cells. This area of research is very exciting and moving quickly. However, even once the optic nerve cells are regenerated, they have to link up with the correct cells in both the eye and the brain. The optic nerve cells transmit a great deal of visual information and replacing them will not be as simple as injecting the replacement optic nerve cells into the eye. I do not think it is an impossible task, but it is a long-term project.