I am now 66 years old and have had eye exams every two to three years since my late 40s. I was just recently diagnosed with Fuchs’ dystrophy and the doctor wants me to start taking TravatanZ. Should I get a second opinion and why wasn't this diagnosed earlier? [ 08/12/11 ]
Thank you for your question. Unfortunately without having completed a full exam and without having reviewed your medical history, it is nearly impossible for me to give accurate advice in this case. Fuchs' dystrophy is a disease of the cornea that shows up later in life (66 is a very likely time for you or your eye doctor to start noticing the signs and symptoms of this disease). Fuchs' dystrophy is a disease in which the innermost layer of the cornea, which consists of endothelial cells, is slowly lost. The job of those endothelial cells is to act like a “sump pump.” It takes water out of the cornea and pumps it back into the eye. If the cornea loses the ability to pump that water out, it can become swollen. This will cause changes in vision and can cause some discomfort. The question is why the doctor prescribed Travatan Z (a prostaglandin analog). I would have to assume that you also have signs of glaucoma because Travatan Z is not (to my knowledge) standard of care for Fuchs' dystrophy. If you have glaucoma and you need to treat the glaucoma, a prostaglandin analog such as Travatan is reasonable; most doctors simply recommend avoiding carbonic anhydrase inhibitors. If you are concerned, do not hesitate to get a second opinion from a glaucoma specialist. Also, do not hesitate to have an open dialog with your eye doctor and ask them why they have chosen to treat you with Travatan. I wish you the best of luck.
I am writing this question on behalf of my father, who cannot drive because he has vision in only one eye. He has had operations for retinal detachment in both the eyes and for cataract surgery. Have there been any recent developments in the field of glaucoma? Is there research or interesting developments regarding nerve cell stimulation or regeneration? [ 08/11/11 ]
Thank you for your question. I am sorry that your father is having such difficulty. I know that no longer being able to drive is quite difficult for many people because they often feel they have lost some independence. However, if your father's vision is dramatically impaired, he may well be a danger to himself or others if he gets behind the wheel.
There is new research on retinal stimulating chips and stem cell therapy for optic nerve and retinal cell regeneration. At this time, the results are not quite to the point that someone that is considered legally blind could drive again. Given that this research is likely to be several years or even decades away from benefitting people like your father, I think the best thing that I can offer you is a referral to a low-vision specialist. Often our low-vision partners have technologies such as telescopes, CCTVs, special lights, and other things that can help our “legally blind” patients regain some independence and get back to doing things that they enjoy. I highly recommend that you discuss getting a low-vision consult/recommendation from your eye doctor. I wish the best of luck to you and your father.
My wife has experienced a slow reduction in her vision after the birth of our baby. The doctor said that optic neuritis has turned into optic atrophy. Is there any medicine for this condition? [ 07/17/11 ]
Thank you for your question. Unfortunately, I am afraid that I will not likely be able to provide you with much advice in this situation. Without knowing the full history, the results of tests and previous eye examinations, the reasons for the optic neuritis, and your wife’s past medical history, it is nearly impossible to provide any recommendations or predictions. If the optic neuritis was caused by multiple sclerosis (MS), it would be possible to start medications that would help slow the number of recurrent MS events. Otherwise, the role of medications at this point is likely very minimal. Once optic atrophy has occurred, this is possibly a sign of irreversible damage to the optic nerve. That being said, this is outside of my area of expertise as I am a glaucoma specialist. I would suggest that you discuss this problem with your eye doctor and get a referral to a neuro-ophthalmologist for a complete evaluation and further recommendations.
My eye pressure is 27 millimeters of mercury if I do not use the timolol 0.5% eye drops. What is the difference between timolol and Timoptol? The latter is thre times more expensive. [ 07/13/11 ]
Thank you for your question. Timolol 0.5% and Timoptol 0.5% are glaucoma medications in the “beta-blocker” category. Both actually have timolol maleate as the active ingredient. Timoptol may be more expensive because it is a brand name or because you are using a gel-forming/long-acting preparation. Timolol is the generic form. As long as they both use timolol maleate 0.5% as the active ingredient, the effectiveness should be equivalent. If you are having difficulty paying for the medication, please tell your doctor, who can probably write you a prescription for timolol maleate 0.5% twice daily. In the United States, this can be purchased for approximately $4 per bottle at drug stores that have the $4 dollar generic medication list. If you have further questions, do not hesitate to ask your eye doctor or the pharmacist for advice. I am sure that they would be happy to assist you further.
I use Alphagan P for which the recommended dosage is three times daily. I read that it was probably fine to use this medication two times daily, and that the third dose was probably not doing too much. Is there evidence to support this? [ 06/11/11 ]
Thank you for your question. Theoretically, three times per day might be a bit better, but I agree the third dose is likely not doing much. To my knowledge, there is no conclusive evidence from a randomized controlled trial that shows three times per day dosing is significantly more effective than two times per day. A good meta-analysis (a pooled analysis of several different randomized controlled trials) showed that alpha receptor agonists (brimonidine, Alphagan, Alphagan P, etc.) are slightly less effective as beta-blockers or prostaglandin analogs at lowering pressure alone. For this reason, alpha receptor agonists are rarely a first line therapy alone, and often are used on conjunction with other medications. Many of these other medications can only be dosed twice daily (such as beta blockers), so some eye doctors simply tell patients to take Alphagan P two times per day if it is used in combination with another medication, to minimize the confusion in taking too many different eye drops at different frequencies. Once you have more than a couple of drops to keep track of, and if they are dosed more than a couple times per day, the ability of patients to remember to take them appropriately decreases significantly. For that reason, simplifying the regimen by using combination drops, or using all drops only once or twice a day, is helpful. I am sorry that I could not be more precise, but until a study looks at this specific question, I have to rely more on my clinical experience and my knowledge of patient adherence with medical regimens than with pure scientific facts. I wish the best of luck to you.
The retina in my right eye detached in October of 2007, and I subsequently had surgery. I have little vision now, because the silicon oil was not cleared due to low eye pressure. The silicon oil also damaged my cornea. Will I recover my vision? [ 06/09/11 ]
Thank you for your question. Unfortunately, without having completed a thorough exam or reviewing your complex history, it is difficult for me to give you an accurate answer. First, I am a glaucoma specialist, and it sounds like the two major problems that may have caused a decrease in your vision are either cornea or retina related. It is probably best to ask either a cornea or retina specialist these questions as well.
First, the cause of the retinal detachment may determine some of the underlying problem. If it was from a retinal tear, high myopia (high negative prescription), or an unknown cause, this is quite different than an end-stage diabetic retinopathy with tractional retinal detachment. If the retinal detachment was a “macula-off” retinal detachment (meaning that the fovea, the region of the macula where the very sharpest central vision is processed, was detached), there is often permanent vision loss. If the detachment was “macula-on” there may be other reasons for the decreased vision.
The silicone oil will stay in the eye until the retina surgeon removes it. The eye pressure does nothing to clear it out and it will never pass through the natural drainage system of the eye. If there is still silicone oil in the eye, this can decrease the vision by itself and it will not improve until the oil is removed. Note, in some cases the oil cannot be removed without causing the retina to re-detach, so often eye doctors do not plan on ever removing the oil. Finally, silicone oil can directly damage the cornea, and often the only way to fix this is perform a corneal transplant. I suggest that you discuss this with your eye doctors, and if you are not already in the care of a retina and cornea specialist, that you get second opinions as necessary. I wish you the best of luck.
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.