Science & Research
Seven years ago, I had closed-angle glaucoma and iridotomy laser surgery. Last year, I had cataract surgery and two YAG surgeries. Recently, optic nerve scans and measurements of cup ratio indicated progressive optic nerve damage, and the doctor told me that he was quite concerned. My eye pressure reading was eight, and I would like to know if I have glaucoma. Also, I have silicone plugs that were place in my tear ducts to treat dry eyes. [ 05/26/11 ]
Thank you for your question. Without having examined your eyes myself or having seen the results of the tests and exams, it is nearly impossible for me to give you an accurate assessment. If you have had laser peripheral iridotomies (LPIs) for angle-closure glaucoma in the past, it is important to determine whether or not you are a patient with chronic angle-closure (i.e., is the angle slowly closing off despite having LPIs in each eye). Your doctor should complete a gonioscopy to determine if the angle is beginning to close off. If this is the case, it is possible for the pressure to elevate, and for you to have continued progression of the optic nerve damage. I would say that simply using an optic nerve scan is not sufficient enough to determine whether or not you are having disease progression. Those tests often have some error associated with them, and you can get a false elevation of the cup to disc ratio. Your doctor is doing the right thing by also checking your visual field. If there is progression on the visual field test as well, then there is likely a bit more cause for concern. In addition, I think it is important to get stereo disc photos (although some say that this is controversial). One of the best ways to tell if there have been changes in the optic nerve is to have an old photo of the nerve compared with the appearance of the optic nerve during the office exam. Often, you can tell if there have been changes by comparing the two. Finally, given that your eye pressure is eight (and assuming that the pressure is not fluctuating and the corneas are of normal thickness), it would be highly unlikely that your glaucoma would be progressing. If the pressure is consistently low but the doctor feels that the glaucoma is progressing, I would recommend a diurnal curve (checking the pressure throughout the day every hour or two). There may be periods during the day that the pressure is spiking. Unfortunately, I cannot tell you whether or not you have glaucoma without examining you; however, if you are concerned, it is always acceptable to have a second opinion completed by a fellowship-trained glaucoma specialist. Lastly, the silicone plugs for dry eyes will not play a role in determining whether or not your glaucoma is advancing.
I had a glaucoma implant one week ago, and my eye is still swollen. Can you please tell me if that is normal. [ 05/25/11 ]
Thank you for your question. It is not unusual for your eyelids and tissue surrounding the eye to be a bit swollen after the surgery. If the swelling is simply from the retractor put between the eye lids during the surgery, I would expect that to go away within a week or two. However, there may be a bit of “fullness” in the area of the implant for the rest of your life. This is more noticeable in patients that are thin or have very little fat around their eyes. The glaucoma implant sits on top of the eye (between the muscles of the eye) directly behind the eyelid. Further, once the drain begins working, the fluid from the eye will travel along the tube and be released over the plate of the glaucoma implant and create a “bleb” before it is reabsorbed by the body. Both the plate and the bleb will take up space and you may notice some fullness of the eyelid directly in front of them. This fullness of the lid rarely causes any functional problems and often goes unnoticed even by family and friends that have known you for quite some time. If you are concerned about it, do not hesitate to discuss this with your doctor. I wish you the best of luck with your recovery.
I have been told I have "flakes" in the back of my right eye, which prevent the drainage of aqueous fluid, and thereby cause the eye pressure to rise. The pressure in my left eye is 12, and in the right eye it is 24. I’m currently using Azopt, which causes eye discomfort. What kind of glaucoma is this, and what causes these flakes? My doctor said there was “flaking off of the core," and that I have a cataract. I was not aware that one could have glaucoma in only one eye. I was told to use the eye drops twice daily, but sometimes they cause eye irritation, and I do not put the drops in during the evening. I have a friend who was diagnosed with glaucoma, and decided to stop the eye drops. She is now using a compounded form of vitamin C and DMSO, and suggested that I try that treatment regimen, but it seems a bit radical to me. [ 05/24/11 ]
Thank you for your question. Unfortunately, without having examined your eyes myself or having seen the results of tests completed or notes taken in the clinic, it is nearly impossible for me to provide an accurate diagnosis related to the “flakes” in your eye. The description that you are giving for having “flakes” in the eye is most likely consistent with pseudoexfoliative glaucoma; however, I do not know what your doctor means by the fact that they are coming off of the “core.” The “core” is often a part of the vitreous (or gel) in the back of the eye and there are no “flakes” that ever come from that region. The only flakes seen in the vitreous core are from asteroid hyalosis, and that does not cause glaucoma. Pseudoexfoliative glaucoma is primarily seen in patients of Scandanavian descent, but also has a high prevalence in some African tribes, Saudi Arabians, and people from other areas. It is relatively rare but (but not impossible) for African Americans and Eskimos to have pseudoexfoliative glaucoma.
Pseudoexfoliative glaucoma occurs when pseudoexfoliative material (the “flakes” your doctor likely described) become deposited on the inside of the eye and clog the drainage system. This pseudoexfoliative material actually comes from the basement membrane of cells within the body. In fact, it is widely believed that the pseudoexfoliative material is actually deposited in many different areas of the body (heart, lungs, etc.); however, is really only causes a significant problem in the eyes because it clogs the drainage system. Further, it is not unusual for pseudoexfoliative glaucoma to be found in only one eye. Primary open-angle glaucoma (a different form of this eye disease), usually affects both eyes. Typically, pseudoexfoliative glaucoma this can be a difficult form of glaucoma to treat, so continued care by a glaucoma specialist is a must.
I understand that some drops do cause irritation in the eye (carbonic anhydrase inhibitors, such as Azopt, do sting quite a bit); however, it is important to use the drops exactly as prescribed or they are not effective in keeping the pressure down. If the drop is causing that much pain, tell your doctor and he/she can switch you to another drop with fewer side effects (less stinging). Further, stopping your medications to use DMSO and vitamin C is a very bad idea. There are no randomized, controlled clinical studies that show DMSO in combination with vitamin C lowers the intraocular pressure. If your friend has glaucoma and has stopped her drops to use this combination, I fear that her pressure will go back up and she will likely begin to lose vision. There are a lot of alternative medicines that simply do not work. However, because they are not regulated by the FDA, the makers of the alternative medications can make claims about their mediations that are simply false or misleading without threat of any repercussions. I urge you to listen to your glaucoma specialist for treatment recommendations, and if you are not comfortable with his/her recommendations, I suggest you get a second opinion from a fellowship-trained glaucoma specialist.
How long will it take for a noticeable drop in eye pressure to occur after starting glaucoma medications? I go back to the doctor for further testing very soon, and I am wondering if my pressure will be lower now that I have been taking the eye drops for around nine days. Does it take longer for eye pressure to decrease if the pressure readings were initially very high? [ 05/23/11 ]
Thank you for your question. There are a few different answers to your question depending on the exact drop that you are using. Some of the drops work immediately (you can see a lowering effect within hours), and some take longer (often people say that a full six weeks may be necessary to see the full benefit, but the majority of the effectiveness can be seen within a few days). If your pressure was extremely high, one full week of using eye drops should inform your doctor whether or not the medication will work in getting the pressure low enough, or if additional medications will be required. If you are taking all of the eye drops prescribed and the pressure is still not reduced enough, further laser or surgical intervention may be necessary.
You also asked whether or not having extremely high eye pressure means that it will take longer for the pressure to come down. That is a slightly more difficult question to answer without knowing more about the type of glaucoma you have, examining your eyes myself, and seeing the results of various tests. Your eye constantly makes fluid (aqueous humor) that keeps the eye blown up like a water balloon. However, in glaucoma, the pressure in the eye is often too high and it needs to be lower. I tell my patients that the eye is a bit like a sink that has a dripping faucet. The water continues to drip into the sink and then it runs out the drain at the bottom. When you have glaucoma, it is similar to having a clog in the drain and the sink backs up (i.e., the pressure builds up). The medications used to treat glaucoma essentially do two different things. Either they turn the dripping faucet down (we call this aqueous suppression) or they allow more water to flow out of the eye by a couple of different methods (the traditional pathway and the uveoscleral pathway). In some regards, the efficacy of using the medications often depends on how much of the drain is continuing to function. If the drain is completely closed off, turning the faucet down will still not be helpful enough because a small amount of fluid being made will still cause the sink to overflow (i.e., the pressure in the eye to go up). Essentially, when one medication alone does not work (does not turn the faucet down enough or does not open the drain enough), doctors will add medications that work on different parts of the eye to have a effect greater than just one drug. Often, when the initial eye pressure is higher, one medication alone will not be sufficient to bring the pressure down to your doctor's goals. I wish you the best of luck.
My 7 year old has uveitis that is associated with juvenile idiopathic arthritis (JIA). She was diagnosed 5 years ago, and has been using steroid eye drops, Timoptol, oral steroids, methotrexate and Humira. The inflammation is finally under control, but my ophthalmologist has said that even though we are starting to come off steroids (she's a steroid responder) her pressure may not return to normal, and they may need to insert a “drain.” My daughter was in the doctor’s office, so I couldn't ask too many questions. Can you please answer the questions below? [ 05/06/11 ]
First, let me say that I am sorry that you and your child are going through while she is so young. I hope everything turns out well. Unfortunately, these cases can sometimes be quite difficult to manage, so routine follow-up with a pediatric glaucoma specialist will be of utmost importance. Given the fact that your daughter is so young and has so many years of life ahead of her, it is important to control the glaucoma as well as possible to preserve as much vision as possible. Let me try to answer your questions one at a time.
- Is it a complicated operation? The operation itself is really not technically difficult from the surgeon's standpoint as long as the eye anatomy is relatively normal. I typically tell my patients that it takes an hour to 90 minutes in most cases. Some surgeries are more complex than others, but for the most part, if your daughter's only problem is JIA and uveitic glaucoma, the surgery should not be technically difficult.
- Are there side effects? Absolutely. There is not a single medication or surgical procedure that does NOT have side effects. Any time we recommend a treatment or surgery, we discuss the risks, benefits, and alternatives of the treatment or surgery. Risks for the glaucoma drain or glaucoma valve include (but is not limited to) pain, bleeding, infection, double vision, pressure being too low after surgery which can cause some problems, pressure not being low enough after surgery, need for further surgery because the pressure is too low or too high, loss of vision, loss of the eye, or death (any surgery that involves anesthesia must include risk of death in the discussion even though it is incredibly low). Each of these risks is relatively low; however the risks are real. You need to have a full discussion with your eye doctor before agreeing to have the surgery. I suggest that you have your daughter step out of the room or make a separate appointment without your daughter to discuss the risks. In addition, you can also discuss alternative treatments or no treatments at all (although if the pressure is elevated that would likely mean loss of vision eventually). Again, you will need to have a full discussion with your doctor prior to the surgery.
- Where does the fluid from this drain go? I tell my patients that the eye is like a baseball (the sclera) wrapped in saran wrap (the conjunctiva). During the surgery, we cut a hole in the conjunctiva and attach a small plate with a tube to the sclera at the top of the eye between the muscles. The tube is then tunneled into the front of the eye and we cover that with some tissue. We then sew the conjunctiva back and it heals over. The fluid travels from inside the eye, down the tube (drain), and onto the plate and is released on top of the eye (but under the conjunctiva). The body then reabsorbs the fluid naturally and the pressure goes down.
- Will her eye look different after the surgery? Possibly. There is always a risk for the lid drooping slightly (ptosis) or being slightly fuller than the other side (there is a plate under the eyelid and on top of the eye). In addition, the tube is covered with a piece of tissue (either donor sclera or another material) and that tissue is white. You can often lift the lid and see that white piece of tissue covering the tube. Some doctors are now covering these with donor corneas. The advantage is that it is a clear piece of tissue and is less noticeable, but it does cost a bit more.
- Will her vision be affected? If the pressure is not reduced and there is evidence of glaucoma, then yes her vision will likely continue to decline. If you chose to do the drain, there is a possibility of having double vision because the plate sits between the two muscles and does take up some space. Otherwise, the drain itself does not usually cause changes in vision. As mentioned previously, this surgery can cause the pressure to be too low or not low enough. Too low and the vision can be changed (and possibly require further surgery). Too high and you are back to needing further surgery or drops to get the pressure down to the target
I hope this helps. I know this can be a difficult time. I suggest that you take time to have a long discussion with your eye doctor regarding your child's risks, benefits, and alternatives. There will be risks, but it is important to be informed going into the surgery. No surgery is perfect and there is always a chance that a single surgery or treatment will not be enough; however, in most cases eye doctors can eventually control the pressure. I wish the best of luck to both of you.
I used artificial tear drops once daily along with Travatan Z. I suffer from glaucoma in both eyes, and they are also both swollen. Why are my eyes swollen? Are there other eye drops that you would recommend? Also, do you know where I can get discounts for the artificial tears? [ 05/05/11 ]
Thank you for your question. The prostaglandin analog medications (Travatan, Lumigan and Xalatan) do have a variety of side effects. Determining whether or not the swelling is from the medication or another reason is likely very difficult (often our eyelids look more swollen as we age, so it could just be a natural part of aging). Without having examined your eyes before and after starting Travatan, it is impossible for me to give any recommendation. Further, I would need results of your previous tests, the results of new tests, and your chart history before making any recommendations on new eye drops. Unfortunately, I don't know of any places that have discounts for artificial tears, but you can ask your eye doctor if they have any samples.
For completeness, I have included the Travatan Z side effect profile from the insert with my lay explaination IN CAPITAL LETTERS. Note eyelid swelling is not listed as one of the common side effects.
The most common adverse reaction observed in controlled clinical studies with Travatan (travoprost ophthalmic solution) 0.004% and TravatanZ® (travoprost ophthalmic solution) 0.004% was ocular hyperemia (REDNESS OF THE EYES) which was reported in 30 to 50% of patients. Up to 3% of patients discontinued therapy due to conjunctival hyperemia (REDNESS OF THE EYES). Ocular adverse reactions reported at an incidence of 5 to 10% in these clinical studies included decreased visual acuity, eye discomfort, foreign body sensation (FEELING OF SAND, GRIT OR DIRT IN THE EYE), pain and pruritus (ITCHING).
Ocular adverse reactions reported at an incidence of 1 to 4% in clinical studies with Travatan® or TravatanZ® included abnormal vision, blepharitis (SIMILAR TO DANDRUFF OF THE EYELASHES), blurred vision, cataract, conjunctivitis, corneal staining, dry eye, iris discoloration (CHANGE IN THE COLOR OF THE EYE), keratitis (CHANGES IN THE CORNEA OF THE EYE), lid margin crusting (SIMILAR TO THE BLEPHARITIS), ocular inflammation, photophobia (SENSITIVITY TO LIGHT), subconjunctival hemorrhage (A BLOOD VESSEL BETWEEN THE CONJUNCTIVA AND SCLERA BREAKING AND BLEEDING A LITTLE) and tearing.
Nonocular adverse reactions reported at an incidence of 1 to 5% in these clinical studies were allergy, angina pectoris (CHEST PAIN), anxiety, arthritis, back pain, bradycardia (SLOW HEART RATE), bronchitis, chest pain, cold/flu syndrome, depression, dyspepsia (UPSET STOMACH), gastrointestinal disorder, headache, hypercholesterolemia (HIGH CHOLESTEROL), hypertension (HIGH BLOOD PRESSURE), hypotension (LOW BLOOD PRESSURE), infection, pain, prostate disorder, sinusitis, urinary incontinence and urinary tract infections.
As you can see, this is quite a list, and the reality is that Travatan does not cause all of these problems. The FDA is obligated to include any symptom that any patient has during the trial of the drug and list it as a side effect. If the patient was taking the medication during the trials and their child came home with a cold from daycare and passed it to their parents, the FDA would list cold/flu syndrome on the side effect list even though there was really no reason that the drug caused it. I suggest you ask you eye doctor if they believe the swelling is related to the medication or another reason. I wish you the best of luck.
I am 78-years-old and have the early stages of glaucoma. I have been taking Travatan for approximately 2 months and my eye doctor is pleased with the results so far. I have recently been prescribed the drug Vesicare from my primary care physician, and wonder if this drug will affect the glaucoma or conflict with the Travatan. [ 05/04/11 ]
Thank you for your question. I looked for interactions between Travatan and Vesicare on Drugs.com. They have a relatively comprehensive site for determining drug interactions, and the search did not find any. I recommend that you contact your pharmacy and ask them to also run an interaction check for these medications. Often pharmacists have access to larger data bases and may recognize interactions within their systems more quickly. I wish you the best of luck.
If the pressure in my right eye is holding around 24, and the optic nerve does not show any signs of glaucoma, are eye drops still recommended? I do have glaucoma in the left eye. [ 05/03/11 ]
Thank you for your question. Unfortunately, in this particular situation, it is impossible for me to tell if you have glaucoma or ocular hypertension in your right eye; however, given the fact that glaucoma often occurs in both eyes, you may simply be in the earliest stages and the doctors cannot detect any changes. Further, without having examined your eyes myself and having seen the results of previous tests, it would be difficult for me to give you an accurate answer. 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 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. Doctors often see patients with glaucoma that have never had increased intraocular pressure, and they are given the diagnosis of "normal-tension glaucoma."
Your eye doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future. Unfortunately, we cannot look into the future to find out if you will be one of the fortunate people with ocular hypertension that never develops glaucoma in the second eye, or if you will eventually develop this eye disease. I often give my patients two options. First, you can either start a medication now, or you can wait. Unfortunately, only you can make this decision.
When I tell patients that I am considering changing medications or recommending a new therapy, I always discuss the risks, benefits, and alternatives with them. First, your doctor needs to discuss what medication he would consider starting you on. If it is a prostaglandin, then he will likely discuss the fact that it can make your eyes red, change the color of the eyes or the color of the skin around the eyes, etc. If he were to choose a beta blocker, he would likely discuss the fact that you could have symptoms of feeling lightheaded or have a drop in your blood pressure. Also, he would need to know if you have asthma or any other pulmonary issues, etc.
The benefit of starting therapy is that the intraocular pressure will likely be lowered. Lowering eye pressure is the only way we have of possibly preventing or slowing the onset of glaucoma. The alternative is to do nothing and continue to examine the eye to see if it continues to progress to the point that you can be definitively diagnosed with glaucoma. The real question is whether you want to start taking medications now and risk possible side effects from the medicine, even though the doctors have not officially given you a diagnosis of glaucoma, or whether you would rather wait until they can definitively say that you have glaucoma before starting treatment. That is something that only you can decide. I have some patients that would rather know they are trying to do something to prevent any loss of vision even though they may not have glaucoma. Others say that they want to avoid using medications as long as possible and want more definitive proof that they have glaucoma before using drops. Either route is fine as long as you are comfortable with the choice. Best of luck with making this decision, and I encourage you to discuss the risks, benefits and alternatives with your eye doctor.
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Last Review: 04/28/13