Science & Research
Is there any significance in having asymmetrical intraocular eye pressures (12 in one eye and 19 in the other)? I was told that I have damage to my optic nerve, and every time I have my IOP checked, the technicians look worried. Last time, they ran several tests that are used in the diagnosis of glaucoma (a photograph of the inside of my eye and visual field testing). I have not been told that I have glaucoma, and I have not been prescribed eye drops. I am 38 years old and I can no longer drive at night because I cannot see well in the dark; the headlights seem to be way bigger and brighter than they should be. The sun also hurts my eyes when I go out in the daytime, and I periodically have a disturbance in my side vision where it feels like I am looking through water. It affects both eyes and lasts for 15 or 20 minutes. Last year the doctor just told me to come back in a year for another evaluation. I appreciate your input. [ 03/31/11 ]
Thank you for your question. This is a difficult case to make too many recommendations about because of how little information that you currently have. In addition, because I have not been able to examine your eyes personally, it is also difficult to give an accurate assessment. In general, you are correct to have concerns about the asymmetric pressure in your eyes. This is especially true if you have documented nerve damage. 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 it does not mean that 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, as in your case, this does not mean that someone cannot have glaucoma. We often see patients with glaucoma that have never had increased intraocular pressure, and we call this "normal tension glaucoma." With a family history of glaucoma, or any other risk factors for glaucoma, your eye doctor may give 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 this eye disease in the future. Our goal as eye doctors is to identify glaucoma before you, as a patient, ever notice any changes. Your eye doctor will likelyfollow 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.
In your case specifically, there are things that I would like to know. First, the eye pressure is usually relatively symmetric in both eyes. I would want to perform some very specific exams to determine why the pressure is different. The first thing that needs to be done is a thorough history to determine if you have ever had trauma to the eye. You need to have a gonioscopy completed (this is a very simple test that any glaucoma specialist can do) to look for any damage to the natural drainage system of the eye (especially the eye with elevated pressure). Next, I would make sure that the visual field, the OCT and the stereo disc photos are normal and do not show any signs of optic nerve damage. If there is any evidence of damage, I would suggest treating the eye and reducing the pressure to the same level as the other eye, if possible. In addition, I would want to know if you have been using any steroid drops, inhalers with steroids, or any medications that have steroids in them. This can lead to a secondary steroid-induced glaucoma.
In general, when a young person presents with glaucoma in a single eye (asymmetric glaucoma), you need to figure out why. It is difficult to determine whether the changes in vision are related to the asymmetric pressure. Often, glaucoma slowly takes vision, but it does not fluctuate noticeably over 15-30 minutes. I suggest that you be seen by an ophthalmologist that has completed a glaucoma fellowship for a second opinion and discuss all of the symptoms that you are having. If you do have glaucoma, this is not a routine case of primary open-angle glaucoma in all likelihood. If you do end up having a diagnosis of glaucoma, the doctors may also be able to tell you why. If your current eye doctor is not a glaucoma specialist, do not hesitate to ask for a second opinion. I wish you the best of luck.
I have glaucoma, and have been treated with eye injections and laser surgeries. My right eye has been completely blinded by the glaucoma and from complications associated with cataracts. I currently see very little through my left eye, and have been pronounced legally blind. I am also diabetic. My doctor inserted an implant in the left eye; however, a “film” grew over the eye and the doctor does not want to remove it. The vision in that eye is now cloudy. Does this treatment plan make sense? Is there any hope for me? [ 03/30/11 ]
Thank you for your question. Unfortunately, without having examined your eyes personally, knowing a bit more about your complicated history and seeing the results of previous exams and tests, it will be nearly impossible for me to provide an accurate recommendation. Diabetes is one of the leading causes of blindness and can be very difficult to treat. I am guessing that you have diabetes that was not well controlled at some point, which led to the new blood vessel growth in the eye and possibly the formation of cataracts.
When you state that your glaucoma has been treated with injections and laser surgery, that tells me that you do not just have primary open-angle glaucoma; it is more likely glaucoma related to the diabetes (also called neovascular glaucoma). When the diabetes is out of control, the eye creates new blood vessels to try and get oxygen to the eye. Those new blood vessels eventually grow into the front of the eye and they can block its natural drainage system. This can cause an increase in eye pressure (i.e., neovascular glaucoma). You should know that glaucoma is not typically treated by injections; however, the new blood vessel growth (a complication of diabetes) is treated by injections. This is such a complicated case that you would need a full eye exam to determine the appropriate treatment plan, and it may take a combination of doctors. If this is related to diabetic eye disease, I would make sure that you are seeing a retina specialist that can examine the retina and treat the diabetic complications as well as a glaucoma specialist that can treat the increases in eye pressure caused by diabetes. You are dealing with a very serious disease and if you do not get your diabetes and eye pressure under control, you will likely continue to lose vision and could easily become blind in both eyes. I am sorry that you are having all of these difficulties, and I know it can be scary. I wish you the best of luck.
I have secondary glaucoma due to cataract surgeries, and the doctors suspect that I also have Marfan syndrome. The glaucoma was diagnosed when I was 36, and I currently take Xalatan and bromonidine. I hope to continue driving and working, so I would like to know how long I can expect to maintain my vision. [ 03/29/11 ]
Thank you for your question; it sounds as though you have been through quite a bit at a relatively young age. There are a lot of different types of glaucoma, and they can progress at different rates. Some types of glaucoma, like angle-closure glaucoma,can progress quickly if the pressure isincredibly high, and vision loss can occur within days or weeks. Other types of glaucoma are quite slow and it may take months or years before there is any evidence of vision loss. It is difficult to predict what course your glaucoma will take; that is why it is important to seethe eye doctor regularly and not miss the appointments. Once a thorough eye exam has been completed,the eye doctor will often set a target or goal intraocular pressure. The only variable that doctors can change to slow or stop the progression of your glaucoma isthe intraocular pressure, and to achieve this goal, there are essentially three different tools available: medicated eye drops, laser treatments, and surgical methods. Your doctor has started you on two eye dropsand willfollow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how your eyes respond. If the pressure is not reduced enough or your doctor ever notices advancement in your glaucoma, they will add more medications or use laser or surgery to help lower the intraocular pressure further. In the majority of patients, it is possible to lower the pressure enough to stop or dramatically slow the loss of vision; however, this may take multiple surgeries, laser treatments, or medicines (and likely a combination of these three).
Given that you are quite young and likely have decades of life ahead of you, it will be important to maintain a close watch on the intraocular pressures for the rest of your life and keep them very well controlled. Unfortunately, any vision that is lost due to glaucoma cannot be regained, so this is something that you will be dealing with the remainder of your life, and it is important to aggressively lower the pressure now and not wait to see evidence of further damage. I wish you the best of luck.
I wanted to know if moderate alcohol consumption can, in any way, affect the longevity of a trabeculectomy. [ 03/28/11 ]
Thank you for your question. I have been asked many times whether or not alcohol consumption causes glaucoma, but never its effect on trabeculectomy longevity. Unfortunately, the short answer to your question is that after searching the literature, I could not find any studies that have addressed this subject. In general, when my patients ask about the connection between alcohol consumption and glaucoma, I tell them the following:
First, the most recent large study looking at the risk of alcohol consumption and the diagnosis of glaucoma were published in 2007 out of Harvard Medical School. The study examined 80,486 female nurses followed from 1980 to 1986 as part of the prospective, longitudinal Nurse's Health Study, and 42,251 male healthcare professionals who were followed from 1986 to 2002. The final conclusion of this study was that the amount of alcohol consumed by an individual did not influence the risk of being diagnosed with glaucoma.
This brings up a second different question however, and that is whether or not alcohol consumption has an impact on intraocular pressure. The answer to that question is yes. Alcohol consumption can lower intraocular pressure for a short time; however, it should never be used as a method of treating glaucoma or increased intraocular pressure. This is important for patients with glaucoma or patients that are currently being followed because the eye doctor is concerned that the patient may develop glaucoma in the future (i.e., a 'glaucoma suspect'). It is important that you do not consume alcohol prior to your doctor's visit as this may falsely lower your intraocular pressure and make monitoring or diagnosing glaucoma more difficult.
I am sorry that I could not answer your question directly, but to my knowledge, there are no studies that have ever addressed that specific issue. I hope that the other information is helpful.
I have advanced glaucoma in the right eye. Treatment has included many eye drops and laser surgery. There is a great deal of optic nerve damage and my doctor wants to do a trabeculectomy on my right eye. After researching this procedure, I am now afraid, and would like to know if there are any non-invasive treatment options. Thank you for your help. [ 03/27/11 ]
Thank you for your question. There are a lot of different types of glaucoma, and they can progress at different rates. Intraocular pressure is the only variable that we can change to either slow or stop the progression of your glaucoma. To achieve this goal, there are essentially three different tools that doctors can use. There are medicated eye drops, laser treatments, and surgical methods to lower the intraocular pressure. In most cases, it is often possible to lower the pressure enough to stop or dramatically slow the loss of vision; but this may take multiple surgeries, lasers, or medicines (and likely a combination of all three).
Once a thorough eye exam has been completed, eye doctors often set a target or goal intraocular pressure. Your doctor will follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how your eyes respond. If the pressure is not reduced enough or your doctor ever notices advancement in your glaucoma, they will add more medications (if they can) or use laser (one or more times) to help lower the intraocular pressure further. Unfortunately, sometimes medications and laser do not lower the pressure enough and surgical options are needed. Unfortunately, medications and laser are the only non-invasive treatment options that we have, and it appears that you have already maximized these options. You may not be at your target eye pressure or your glaucoma is still progressing, and in these cases, unfortunately, the only remaining options are surgical. Your doctor should discuss the risks, benefits and alternatives of each surgical option and why they think one specific surgery (trabeculectomy) is the best option for you. It sounds as though you have tried all other options and this has not lowered the pressure sufficiently. If the eye pressure is not lowered further, you may eventually lose vision in that right eye. It sounds as though surgery is the next best option for you; however, if you are concerned, it is always acceptable to ask for a second opinion. I wish you the best of luck; I know this is often a difficult time for patients.
My 13-year-old sister has uveitis, and last week they told us that she has uveitic glaucoma. The tests indicate that her optic nerve is healthy. The glaucoma specialist gave her eye drops and we need to go back next week. Right now her uveitis is under control, but her eye pressure is 28. If the pressure is still high next month, she will start new eye drops that may cause a uveitis flare. Will the glaucoma cause vision loss? We are terrified of this possibility. [ 03/26/11 ]
Thank you for your question. Unfortunately, without having examined your sister myself, learned more about her medical background (other possible diseases that she may have), reviewed her history and exam findings (including blood work) it is nearly impossible for me to provide an accurate assessment for your sister. Even with an accurate diagnosis to define why she has uveitis, this does not always help us predict whether or not she will lose vision from the glaucoma. Chronic inflammation in the eyes (iritis or uveitis) and use of steroids (the treatment for uveitis) are two well-known causes of what doctors call “secondary open-angle glaucoma.” This means that the glaucoma did not happen by itself but was related to another issue. If there was no other factor that caused the glaucoma, we would call that “primary open-angle glaucoma.” Secondary glaucomas such as uveitic glaucoma or steroid-induced glaucoma happen when the ability of aqueous fluid in the eye to get through the trabecular meshwork is decreased. This causes a buildup of fluid and pressure in the eye. Determining the exact cause is more difficult. Uveitis is a well-known cause of secondary glaucoma and may have caused your sister's problems. Steroid use for the treatment of the uveitis can also cause an increase in eye pressure, and in some people will also cause a secondary glaucoma.
While it sounds as though the optic nerve is healthy at this point, it is important to get the pressure lower so that optic nerve damage and vision loss does not occur. This can be accomplished by using eye drops (like she is currently using) or adding more drops in the future, if needed. The medication that they are considering is like a prostaglandin analog (Xalatan, Travatan, or Lumigan) and it can cause a rebound inflammation. If the doctors decide to use this drop, they will watch the severity of the uveitis very carefully to ensure that it is not making the uveitis worse. If the drops do not work, there are always surgical options to help lower the pressure and prevent vision loss as well. Unfortunately, we cannot predict the path that your sister will take, but you should know that we have a lot of different treatment options available to help her. It sounds as though her doctors have done an excellent job in recognizing both the uveitis, but also the increase in intraocular pressure. They have a good plan in place to try to decrease that pressure as well. If you or your family is concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist, if you are not already seeing one. I wish the best of luck to your sister and your family.
I have glaucoma and I have had laser surgery in both eyes. My right eye has lost all vision, and would like to know how to maintain the vision in my “good” eye. I appreciate your help. [ 03/25/11 ]
While every patient diagnosed with glaucoma 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 new treatments. 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 (like yourself), 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 1or 2 times per year. The goal of eye doctors is to identify glaucoma progression before you, as a patient, ever notice any further 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 progression 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. Taking all of your medications, not missing any drops and always going to the scheduled appointments with your eye doctor is the best thing that you can do. If you have questions or concerns, do not hesitate to start an open dialog with your eye doctor and ask why he/she has chosen the particular monitoring or treatment plan that was prescribed for you. If you are still concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist.
I have glaucoma and I take numerous eye drops daily (timolol, fluorometholone, and Alphagan-P). Should I be concerned about the long-term side effects that these medications may have on the liver, kidneys, lungs and heart? [ 03/24/11 ]
Every medication can have potential side effects; however, currently there are no studies that indicate any long-term negative side effects for the liver, kidneys, lungs or heart with any of these medications. The doctor that prescribed the medications should continue to ask you if you are noticing any side effects during each of your visits. The medications were manufactured with the assumption that once they were started, the patient would likely continue using them for years or even decades, so they inherently are created in an attempt to minimize the side effect profiles.
It is worthwhile discussing the proper installation of eye drops briefly however, as this not only increases 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. 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 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. Doctors often take for granted that patients know how to instill drops and they simply should not. I highly recommend that you ask your eye doctor to watch you put in a drop to make sure that you are doing it correctly.
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Last Review: 04/28/13