I had a laser procedure performed on my left eye after my doctor noticed changes in my visual field test. He said it would help lower my eye pressure. The procedure was painful and my pressure was not checked afterwards. I went home and had to keep my eye closed because of the pain and discomfort. Two days later, I called and he said I had some inflammation, so he prescribed Durazol. My symptoms got worse. It turns out that my pressure was 68 and probably had been for a few days. I have now gone to a glaucoma specialist who says that 95% of my optic nerve has been destroyed. I had a trabeculectomy, but the pressure keeps going up. The doctor says I still have effects of the inflammation from laser surgery. My guess from the comments made by three other doctors is that the laser power was too high and that I had sustained high pressure, which has caused most of my problems. Could all of this have been caused by laser power that was too high? How do they know what power to use? [ 09/19/12 ]
Thank you for your question. First, let me say that I am incredibly sorry that you have gone through all of this. Without having examined your eyes personally and without reviewing the results of past exams, tests, and procedure notes (including the laser settings used), it is nearly impossible for me to give a completely accurate answer. I don't know if it was related to the laser alone, the use of the steroid eye drops (Durezol), or a combination of both. Laser treatments, either selective laser trabeculoplasty (SLT) or argon laser trabeculoplasty (ALT), are both commonly used as treatments for glaucoma.
The appropriate power that needs to be used varies for each patient, and is mostly related to the amount of pigment in the trabecular meshwork (i.e., the drainage system) of the eye. The more pigment in the trabecular meshwork, typically the less power is needed. When eye doctors perform SLT they typically start at a relatively low power and increase it until they see tiny bubbles form at the trabecular meshwork after about 50% of the laser spots are created. When performing ALT, doctors should see a blanching of the trabecular meshwork to know that they have used enough power. Again, you start at a lower power and work up until you see the blanching so that you know that you are not over-treating.
Laser surgery is relatively well tolerated; however, it is a surgery. Before any surgery, your eye doctor should discuss the risks, benefits, and alternatives before you agree to have any procedure performed in the office or in the operating room. There is a small risk that the laser procedure can cause an increase in the eye pressure and that is always something I discuss with my patients. I have my patients wait approximately 20-30 minutes after the procedure and I check the pressure before they leave to make sure that it has remained stable. If the pressure goes up immediately, this can often be reversed in the office with a couple of additional pressure lowering drops and in most people the elevated pressure does not last long. It is very common to have a slight headache after the laser procedure, and patients may not feel like doing much that evening, but extreme pain is unusual. There is often a small amount of inflammation that occurs in the eye after the procedure, and it is not uncommon that doctors prescribe an anti-inflammatory eye drop for approximately one week. Unfortunately, I am not sure if you will ever really know why the pressure went up. Hopefully your eye doctor can get the pressure under control and work to preserve as much vision as possible.
I am a 74-year-old female, and at times I have forgotten the exact time that I put the first drop of Combigan in my eyes, which my doctor recommended that I use only twice each day. If I accidentally used the drops less than 12 hours apart, was that harmful to my eyes? [ 09/07/12 ]
No, it is not harmful if you have spaced it less than 12 hours apart. But, like any medication, the dosing is designed to maximize its effectiveness, based on how long it lasts in your system. Of course, each patient is unique and different, so I would not worry too much about the scenario that you described. It is more important that you are using the medication consistently. If you can remember to space it 12 hours apart, that is ideal, but again, it is more critical that you take both doses in a given day.
I am 55 years old and my dad had glaucoma. During my last visit to the ophthalmologist, my pressure was 22. My field test showed 'some' changes compared to the previous test. The doctor put me on timolol (one drop before bed). My main problem is glare and I can't get used to it. I never had this problem prior to the eye medications. Should I stop the eye drops? I'm being referred to a glaucoma specialist for follow up. I've never been formally diagnosed with glaucoma yet and would like to know what to do in the meantime. The glare is so annoying and I feel like I can't focus. [ 09/07/12 ]
Thank you for your question. I would first call and speak with the prescribing ophthalmologist and discuss with him/her whether it is appropriate to stop timolol; however, it is unusual to have glare symptoms from this medication. You could ask your doctor about using the medication only in one eye, and test out if it really is causing you to have the problems with glare. Sometimes patients notice problems coincidentally when they change their routine, and the glare may be caused by a different issue altogether. Certainly this is an important issue to discuss with your ophthalmologist and glaucoma specialist, and please do not make changes to your medication regimen until you talk with your eye doctor(s).
An optometrist suggested that I should go to an ophthalmologist since he was concerned about the possibility of glaucoma. Now, a year later, I've finally made an appointment with an ophthalmologist. Apart from the eye pressure that I'm starting to feel, there is a light yellow excretion. Is this a symptom of glaucoma? Every morning when I wake up, my eyelashes are "glued" together. If so, what can I do? My eyes are also tearing, as if I'm crying all the time. [ 09/07/12 ]
Thank you for your question. I am glad that you are seeing an ophthalmologist soon to help answer your questions. I am unclear about the light yellow excretion. If you are referring to discharge, that sometimes does build up overnight. First, it is important that you determine the cause of the excretion when you meet with the ophthalmologist and ask him/her if the following would be helpful to manage the discharge:
There are steps that I have provided to my patients to improve the condition of their eyelids and manage the discharge. The process is called “lid hygiene”—I think of it like flossing your teeth—and it is a step that one should take in the morning and at night, if possible. Sometimes my patients just start once a day, while they are in the shower, for example. They can take a warm towel and place it on their eyelids, to liquefy the secretions that the glands of their eyelids are excreting. Then, they take a cotton swab, dip it in warm water, and gently clean along the eyelid margin (both the bottom and the top eyelids). Some of my patients use a 1:1 mixture of warm water and baby shampoo. There are also over the counter products (look for “lid scrubs) but I think these simple steps explained above may help you.
I was diagnosed with Posner-Schlossman syndrome in January 2012. In a routine test, the eye pressure in both eyes was measured as 40 and 45. Two days later, the pressure was measured at 17 and 21 without any medication. Since that time, I have been applying Combigan eye drops two times daily. My field vision tests were normal but the CD ratios are high (0.8) in both eyes. What are the chances of successfully controlling my glaucoma and protecting my vision? [ 07/09/12 ]
Thank you for your question and I am sorry that you are going through all of this. The eye doctor's goal is to identify glaucoma before you, as a patient, ever notice any changes. While it sounds as though your visual fields are full, the optic nerves may have early damage from the glaucoma (hence the increased cup to disc ratio). Therefore it is important to get the pressure lower so that further optic nerve damage and vision loss does not occur in the future. Eye doctors use three different methods to decrease the pressure:
- medicated use medicated eye drops (such as Combigan)
- laser treatments
- surgical methods to lower the 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 to the treatment and ensure that you stay at your goal intraocular pressure. If the pressure is not reduced enough or your doctor ever notices advancement in your glaucoma, he or she will add more medications or use laser or surgery to help lower the intraocular pressure further.
If someone is diagnosed with glaucoma very early, the goal is to begin treatment and hopefully prevent the person from ever noticing any changes in vision. Unfortunately, doctors cannot predict if or at what rate a patient will lose vision because of the glaucoma. In some cases, despite the best efforts, doctors cannot stop the progression of the glaucoma and patients do eventually go blind, but this is the minority of patients. It will be important that you continue to visit your glaucoma specialist regularly, follow their advice, and maintain your eye pressure at the appropriate goal for the best chance of maintaining vision throughout the rest of your life. I wish you the best of luck.
I was born with cataracts, which were removed (along with my lenses), leaving me with decent vision. I was then diagnosed with glaucoma at age 7. When I was 15, I had a trabeculectomy in my right eye, and then a tube implant in the same eye at age 19. I’m 33 years old now. I also recently had a cornea transplant in the right eye because it decompensated. Somewhere amidst those glaucoma surgeries (10+ years ago) I lost functional vision/acuity in my right eye although the tube has kept the pressure low. My left eye has been fairly stable with eye drops until recently, but the pressure is creeping up and I may require surgery in that eye. I’m obviously nervous to lose functional vision in that eye following surgery, and would like to know the impact that modern tube surgery has on vision. What should I should I expect? Also, when medications are changed, how long should it take for the new medication to start lowering pressure? [ 07/07/12 ]
Thank you for your question. I am sorry that you are having so many problems with your eyes. It sounds as though you have quite a complex history. Unfortunately, given the complex nature of your problem, the fact that I have not examined your eyes, or the fact that I have not seen any of the test results from previous exams, it will be nearly impossible for me to give a completely accurate assessment; however, I can give you some general thoughts. These are questions that you should directly ask your surgeon prior to your glaucoma surgery.
First, ask about the impact of modern tube surgery on vision. Any time eye doctors discuss surgery, they should talk about the risks, benefits, and alternatives to each surgery that is recommended. In the case of glaucoma tube surgery, they discuss things like the risks of bleeding, infection, pain, the pressure not being low enough (requiring further surgery or medications), the pressure being too low (requiring further surgery or medications), decrease in vision, or loss of the eye. While these are some of the risks, this is not meant to be inclusive because each case is different. While these side effects can occur, the more serious complications, such as vision loss, happen in a minority of patients. Most patients notice only minimal changes (if any) in vision. If vision does change, the vision loss can occur immediately after surgery because of the stress the surgery places on the eye. In addition, simply inserting a tube into the eye can cause the cornea to change its refraction slightly; therefore, a glasses prescription may be needed (or it may need to be changed) to obtain the best visual acuity. Finally, some patients can notice some double vision because the glaucoma tube implant is near the muscles of the eye.
In your particular case I do not think this will be a problem given the poor vision in your left eye. Some vision loss may also happen later in life. Often a glaucoma tube, if placed into the anterior chamber, can cause cornea decompensation and the need for a cornea transplant. These would be the primary reasons for a change in vision after the glaucoma tube is implanted. Again, overall, most people do not notice much change in vision, but it is something that you should discuss with your doctor.
Finally, you asked about the length of time it takes for glaucoma medications to take effect. In most cases you can tell if a medication is working within a few days; however, there are a few medications, such as prostaglandin analogs, that may take a few weeks to have their full effect. I hope this helps and I wish you the best of luck.
I’m 49 years old and nearly three years ago I was told that I have advanced glaucoma in my left eye. I have pretty much tried all classes of eye drops for glaucoma, including some combination drugs, without sufficient eye pressure reduction. A laser procedure was tried but there was no significant effect at all. I eventually received a trabeculectomy in October 2010, which initially decreased the eye pressure to 13-14; however, the readings went back up to 18-20 a few months after the surgery, so the doctor tried Lumigan and Brimonidine. The eye pressure was kept around 18, but starting earlier this year the irritation and redness of my left eye got worse and increased over time. [ 07/05/12 ]
My ophthalmologist finally told me to stop all eye drops and prescribed oral methazolamide. I have not started on the pills yet as I'm very nervous about all the potential side effects. Is there data concerning the percentage of patients that experience severe side effects from this drug? What are the long-term health effects from taking methazolamide?
I am sorry to hear about your intolerance of eye drops and your glaucoma. Methazolamide is certainly an option, and for glaucoma patients who do not desire to have surgery (which is still an option for you), eye doctors sometimes offer them long-term methazolamide treatment, if it is tolerated.
As you know, many medications have side effects, and when you read the package insert of any medication, the list of side effects can be quite daunting. Methazolamide is typically better tolerated than the other oral medication in the same class, called acetazolamide. Some common side effects of this class of medication (carbonic anhydrase inhibitors) are: nausea, loss of appetite, change in taste, diarrhea, frequent urination, dizziness, and tiredness. These often improve with time. Other side effects that are more worrisome include blood in the urine, numbness or tingling of hands/feet, painful urination, sudden decrease in amount of urine, and ringing of the ears. There are also other rare side effects that are more serious, including a very serious (but also very rare) allergic reaction or decreased blood cell production.
I cannot give you a strict percentage of patients who have these side effects, but I can tell you that as long as you and your doctor monitor any changes after you begin therapy, the drug can always be stopped if you are experiencing intolerable side effects.
As for your question about long-term health effects, unfortunately that has not been well-studied; however, many of these side effects can be monitored and are related to the dose you are taking. One option for you is to start with a low dose (discuss with your ophthalmologist first) and then increase the dose upwards if the eye pressure is not low enough and you can tolerate the medication.
I am a glaucoma patient who had trabeculectomy surgery on both eyes. I later developed a cataract, which was removed. I was using Xalatan and Cosopt eye drops before the cataract surgery, and would like to know if I can still continue these medications? [ 11/13/11 ]
That is a great question. The answer often depends on the doctor doing the surgery. If possible, I will often times have my patients stop their prostaglandin analog (Xalatan, Travatan, Lumigan, or generic) a few days prior to cataract surgery because of a slight increased risk of swelling in the retina (called cystoid macular edema) after cataract surgery when you are on those medications.
Often the choice of whether or not to restart the medication after surgery is dependent on what the pressure in the eye is after cataract surgery. There has been some interesting new data that shows there is an approximate 2 mmHg drop in intraocular pressure that lasts for about two years after cataract surgery (there is not a full understanding of why this happens, but many researchers are currently looking into it). If the pressure has dropped sufficiently after the cataract surgery, it may not be necessary to restart the prostaglandin analog (Xalatan in your case) unless the pressure goes up again above your goal intraocular pressure. In other cases, even if there is a small drop in pressure, it may not be low enough to achieve your goal intraocular pressure, so the doctor will likely restart all of the glaucoma medications after a certain time period after surgery. Again, this is all dependent on the doctor's preferences and how your eye responds to the cataract surgery. Keep your regularly scheduled appointments and the doctor will monitor your pressure and make adjustments to your glaucoma medications accordingly. I wish you the best of luck