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.
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 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).
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
I am living in Japan and seeking SLT surgery to lower my eye pressure (it is between 18 - 20 mmHg). My ophthalmologist states that SLT can cause a sustained rise in eye pressure and does not think it is called for unless my visual field is noticeably worsening. All the literature that I am reading seems to indicate that it is a very safe procedure with few side effects. I received a second opinion from another doctor and was told the same thing. How common is a sustained rise in eye pressure as a result of SLT laser surgery? [ 11/11/11 ]
Thanks for your question. Of course it is difficult without examining you to tell if you should have SLT, but I can address your questions about eye pressure rises after SLT. While I certainly always warn patients of this risk when I talk with them about this procedure, it is generally infrequent, on the order of 3 - 5 percent, and it is not usually sustained. I have heard a few anecdotal cases of sustained eye pressure rises requiring surgery, but these situations are uncommon. There are also several maneuvers your ophthalmologist can do to minimize the risk of an eye pressure spike with SLT. I always give my patients a drop of apraclonidine (or brimonidine) before the procedure to reduce the risk of an eye pressure increase. I titrate the laser power so that I am using the minimum amount of energy to achieve an effect. I usually treat 360 degrees of the drainage system, but some ophthalmologists will only treat 180 degrees to minimize an eye pressure spike, although to my knowledge this has not been definitively shown to be of benefit. I also always have my patients wait 30 – 60 minutes after the procedure so that I can re-check the eye pressure. If there has been a spike, we control it with medications and then re-check the pressure again. Of course, one must weigh the risks and benefits of laser surgery, but I would say that overall SLT is a relatively safe procedure. I have not discussed all of the side effects of the procedure here, but you should have a conversation with your surgeon about the risks, benefits, and side effects before you proceed.
I have been using Xalatan for six months and my sleeping habits are not consistent. How important is it for me to take the drops before bedtime? Can I take them when I do not plan to sleep? I may go to bed at 8 p.m. one night and midnight or later the next night. What should I do? [ 11/09/11 ]
Thanks for your question. I think a lot of patients run into your dilemma. The reason that Xalatan is dosed at bedtime is because it begins working 3-4 hours after instillation, peaks at 8 -12 hours, and persists for 24 hours. Because we know that eye pressure is highest in the morning, taking the drop at bedtime puts you in a situation in which the drug is most likely to be peaking at the time when the eye pressure is also peaking. The most important thing is for you to be consistent about taking your drops, so if it is easiest for you to remember to put them in right before you go to bed, then that is what I would recommend. If, however, you know that you will not be going to bed until midnight or later, and you can remember to take the drops around 9 p.m., then it is reasonable to do schedule it then. Alternatively, if you go to bed at 8 p.m., I would not set an alarm clock to wake yourself up and take the drop at 10 in the evening! I hope this helped to answer your question.
I would like to find a glaucoma expert in Athens, Greece who can use a laser to treat narrowing of the cornea. Do you have any suggestions for how to find such a person? [ 09/24/11 ]
Thank you for your question. I assume that you mean that you would like someone to use a laser to treat you for narrowing of the drainage angle, and not the cornea. While I personally do not know any glaucoma specialists that are in Athens, Greece, I might suggest contacting the Athens University Department of Ophthalmology. The department may be able to recommend someone in the area for a consultation.