Science & Research
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.
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.
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Last Review: 04/28/13