My 13-year-old sister has uveitis, and last week they told us that she has uveitic glaucoma. The tests indicate that her optic nerve is healthy. The glaucoma specialist gave her eye drops and we need to go back next week. Right now her uveitis is under control, but her eye pressure is 28. If the pressure is still high next month, she will start new eye drops that may cause a uveitis flare. Will the glaucoma cause vision loss? We are terrified of this possibility. [ 03/26/11 ]
Thank you for your question. Unfortunately, without having examined your sister myself, learned more about her medical background (other possible diseases that she may have), reviewed her history and exam findings (including blood work) it is nearly impossible for me to provide an accurate assessment for your sister. Even with an accurate diagnosis to define why she has uveitis, this does not always help us predict whether or not she will lose vision from the glaucoma. Chronic inflammation in the eyes (iritis or uveitis) and use of steroids (the treatment for uveitis) are two well-known causes of what doctors call “secondary open-angle glaucoma.” This means that the glaucoma did not happen by itself but was related to another issue. If there was no other factor that caused the glaucoma, we would call that “primary open-angle glaucoma.” Secondary glaucomas such as uveitic glaucoma or steroid-induced glaucoma happen when the ability of aqueous fluid in the eye to get through the trabecular meshwork is decreased. This causes a buildup of fluid and pressure in the eye. Determining the exact cause is more difficult. Uveitis is a well-known cause of secondary glaucoma and may have caused your sister's problems. Steroid use for the treatment of the uveitis can also cause an increase in eye pressure, and in some people will also cause a secondary glaucoma.
While it sounds as though the optic nerve is healthy at this point, it is important to get the pressure lower so that optic nerve damage and vision loss does not occur. This can be accomplished by using eye drops (like she is currently using) or adding more drops in the future, if needed. The medication that they are considering is like a prostaglandin analog (Xalatan, Travatan, or Lumigan) and it can cause a rebound inflammation. If the doctors decide to use this drop, they will watch the severity of the uveitis very carefully to ensure that it is not making the uveitis worse. If the drops do not work, there are always surgical options to help lower the pressure and prevent vision loss as well. Unfortunately, we cannot predict the path that your sister will take, but you should know that we have a lot of different treatment options available to help her. It sounds as though her doctors have done an excellent job in recognizing both the uveitis, but also the increase in intraocular pressure. They have a good plan in place to try to decrease that pressure as well. If you or your family is concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist, if you are not already seeing one. I wish the best of luck to your sister and your family.
I have glaucoma and I have had laser surgery in both eyes. My right eye has lost all vision, and would like to know how to maintain the vision in my “good” eye. I appreciate your help. [ 03/25/11 ]
While every patient diagnosed with glaucoma is completely different, once you have been diagnosed, a plan for follow-up should be established. This can be either a plan to watch your eyes closely or to begin new treatments. All of this depends on how advanced the glaucoma is and how much damage has been done to the eyes. As an example, immediately after surgery, I may see my patients 1-2 times per week until they are stable. For those patients with advanced glaucoma (like yourself), and uncontrolled intraocular pressure, I may see them several times per month if we are making changes to their eye drops or we are considering surgery. Other patients that are glaucoma suspects, or patients with mild glaucoma that has been stable for several years with no changes in intraocular pressure, may be seen 1or 2 times per year. The goal of eye doctors is to identify glaucoma progression before you, as a patient, ever notice any further changes. Your eye doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves at different intervals to see if there is any evidence of glaucoma progression that presents in the future. The frequency of examinations will depend on how advanced the glaucoma is and how well you are responding to treatment. Taking all of your medications, not missing any drops and always going to the scheduled appointments with your eye doctor is the best thing that you can do. If you have questions or concerns, do not hesitate to start an open dialog with your eye doctor and ask why he/she has chosen the particular monitoring or treatment plan that was prescribed for you. If you are still concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist.
I have glaucoma and I take numerous eye drops daily (timolol, fluorometholone, and Alphagan-P). Should I be concerned about the long-term side effects that these medications may have on the liver, kidneys, lungs and heart? [ 03/24/11 ]
Every medication can have potential side effects; however, currently there are no studies that indicate any long-term negative side effects for the liver, kidneys, lungs or heart with any of these medications. The doctor that prescribed the medications should continue to ask you if you are noticing any side effects during each of your visits. The medications were manufactured with the assumption that once they were started, the patient would likely continue using them for years or even decades, so they inherently are created in an attempt to minimize the side effect profiles.
It is worthwhile discussing the proper installation of eye drops briefly however, as this not only increases the efficacy of the medication, but it also decreases the side effects. The most efficient method of instilling eye drops is to place a drop in the eye and then close the eyes. It is probably best to either recline or sit upright. The other thing that we often teach our patients is to place gentle pressure on the nose just next to the lower part of the eye. Ask your doctor to demonstrate this the next time you are at the office for a visit. This helps block the tear drainage system and does two things:
- First, the drug stays in contact with the cornea longer and allows more absorption into the eye.
- Second, it decreases the amount that drains into the nose and throat.
When the medication drains into the nose and throat it can be absorbed into the body, and the risk of side effects from the medication increases. Finally, we typically tell our patients to wait a full 5 minutes between drops or wait 5 minutes after the last drop before cleaning the eyelids. Most of the medication that will be absorbed into the eye will have done so within 5 minutes. Finally, I always recommend that my patients bring their eye drop bottle to the clinic so that I can watch them put in at least one drop, just to make sure they are doing it correctly. You would be amazed at the things that I have seen patients do. Doctors often take for granted that patients know how to instill drops and they simply should not. I highly recommend that you ask your eye doctor to watch you put in a drop to make sure that you are doing it correctly.
I’m 31 yrs. old and have been diagnosed with primary open-angle glaucoma. In ’07 my eye pressure was at 18 bilaterally, 20 bilaterally in ‘08 and it increased to 25 in ’09, but the optometrist didn’t give me drops or perform any follow-up tests. In Jan. of ’10, my pressure was at 36 in the right and 30 in the left. A visual field test revealed slight vision loss in both eyes, but more on the right. I was put on Travatan and referred to an ophthalmologist. The ophthalmologist added timolol in the right eye. My pressures have come down to 25 in both eyes. My Dr. has recommended laser surgery (ALT or SLT). I read online that some Drs. don’t even attempt trabeculoplasty on people younger than 60 because success rate is low. I also read that the surgery can cause more harm in younger people. I would like to know what your thoughts are. I’m curious if there is any research about trabeculoplasty success rates and complications in younger people. [ 03/18/11 ]
Thank you for your question. Answering your question may be slightly difficult as I have not personally examined your eye, reviewed your history, or seen the results of your previous tests. Given your young age, it would be slightly unusual (but not impossible) for you to have “run of the mill” open-angle glaucoma. Typically, open-angle glaucoma presents in much older individuals. I would be curious to know if you had a subset of open-angle glaucoma such as pigmentary glaucoma, pseudoexfoliation glaucoma, or another type altogether. In any case, you are correct, your course or response to treatment may not be similar to an elderly patient with glaucoma that received identical treatment. It likely also depends on many other factors including the amount of pigment in the trabecular meshwork, which can be seen using gonioscopy.
The information that you read online concerning glaucoma treatment in younger individuals (and provided to me as part of your question) is interesting, and I think there may be some truth to these observations. Unfortunately, I found it difficult to find studies in the literature fully supporting this notion. This may be a result of the fact that we do not have many “young” patients with glaucoma and we simply have not studied it closely enough. From my own personal experience, I agree that sometimes laser does not appear to work as well in younger patients. Given that, a search of the literature actually shows a few studies that state age is not a predictor of success or failure. Some of these studies had patients in their 30s. I think it is fair to say that studies on the subject are inconclusive.
So without definitive evidence in the current literature, it essentially comes down to the fact that you have to discuss the risks, benefits, and alternatives of having either laser or surgical intervention and then decide how you would like to treat your eyes. There are risks with every procedure, so please share all of the information that you have obtained with your eye doctor and have a thorough discussion. You will have to decide which treatment provides the best benefit with reasonable risks in your opinion. That is a decision that only you can make (and two different people with the same options may make different choices based on their willingness to assume certain risks). That is why you must sign an “informed consent” before any procedure is completed. It states that you have been given the risks, the potential benefits and understand that you have alternate choices.
I wish I could provide a more definitive answer, but unfortunately I don't think there is one. If there was definitive information showing that laser in young patients was contraindicated, your doctor would not have offered it as an alternative. I wish you the best of luck.
My wife has glaucoma, which is under control; however, she is now having problems with a tic in her left eye lid, which is driving her crazy. Is the tic related to the glaucoma? [ 03/17/11 ]
Thank you for your question. I have had a similar tic on occasion and it nearly drove me crazy too! Fortunately, this likely has nothing to do with the medications or the glaucoma. These are usually termed “myokymia” and last only a short time (although it can be several weeks). Often they occur when individuals are under increased stress, and it doesn't help that having the tic stresses you out more! The best advice is to ignore it and it will soon go away on its own. In addition, increasing exercise, increasing sleep, and decreasing caffeine or any other stimulants may help. To be safe, if it lasts more than a couple of weeks, you should probably stop by the eye doctor to just make sure it is this type of muscle twitch and not something related to other medical conditions. I know this can be aggravating, and I do wish you the best of luck.
Is there a relationship between blood pressure and eye pressure? I have no family history of glaucoma, so I would like to know why I have developed glaucoma. [ 03/16/11 ]
Thank you for your question. You bring up a point that many of my patients ask. Let's first take the case of high blood pressure. Unfortunately, the only real answer that I can give you is that I believe there is possibly a link between elevated blood pressure (hypertension) and elevated eye pressure, but the studies that have looked at this association have come up with various answers. Some support a link between the two and others do not find a link. Many of the studies were not designed the same and the outcomes were very difficult to interpret. I would say that because the data in the studies has been so inconclusive, I cannot give you an accurate answer. I think that more very well controlled studies, which are in progress, need to be completed before we will have a definitive answer. Regardless of the connection, it is always in your best interest to treat both hypertension and glaucoma.
While the association with hypertension (elevated blood pressure) is not as clear, I think there is more conclusive evidence to show that low blood pressure (hypotension) is associated with a very special type of glaucoma known as “normal-tension glaucoma.” In these patients, the intraocular pressure is not elevated but they still have signs of glaucoma. In some cases, it is believed that raising the blood pressure to a normal level may be of some benefit, and the eye doctor will then work with the primary care physician regarding ways to safely increase the blood pressure.
You should know that you can still get glaucoma even though no one in your family has had this eye disease before. In fact, a good number of my patients do not have family members with glaucoma. In the same respect, this is also good because it also means that if they have children, there is a good possibility that the children may not be affected. Just because something is “genetic” does not always mean that every person in the family will have the disease. It is often much more complex than that. I hope this helps, and I wish you the best of luck.
When I had glaucoma surgery several years ago, I suffered a severe problem, whereby my retina became ruffled and my vision became very impaired. Is this a common occurrence? I have had many further surgeries since that time, including one where my doctor sewed a piece of tissue on the bleb to stop the fluid from leaking out. The pressure is now holding at 14, but my vision is still impaired. [ 03/15/11 ]
Thank you for your question. I am sorry that you had these troubles. Without having examined your eyes, looked at your chart history, and known more about your post-operative recovery, it is very difficult for me to guess what happened inside your eye after the surgery. It sounds as though you had a trabeculectomy (filter) completed. Before any surgery, I always discuss the risks, benefits and alternatives of the surgery with the patient. In general, regardless of the surgery that you had, I always include infection, pain, bleeding, loss of vision, loss of the eye, intraocular pressure staying too high, intraocular pressure falling too low, need for further surgery, and death (due to anesthesia) among the risks. The chances of these happening to any individual are relatively low, but as I tell my patients: “If your risk of an adverse side effect is one in one million, that does not sound bad….unless it happens to you. Then, you don't care about the 999,999 people who did not have that side effect—you are not happy that it happened to you.” Risks and side effects are real and they are not usually the fault of the doctor that performed the surgery. It is simply part of the risk you take when operating on a very sensitive organ. In your case, it sounds as though the intraocular pressure dropped too low (one of the known risks) and the retina developed folds or choroidals. This causes a decrease in vision (another known side effect). It sounds as though the fluid was draining too quickly out of the eye and the trabeculectomy flap did not heal down as it usually does (you may not heal quickly). He likely put the tissue back over the trabeculectomy flap in order to slow the fluid from escaping to help stabilize the pressure. Again, this is all a guess from what you provided me. It sounds as though you had some side effects from the surgery, and while they may not be common, they are also not completely unexpected. It sounds as though your doctor recognized what was happening and used the appropriate intervention to bring the pressure back up. I hope this helps.
Xalacom brought my daughter's pressure down from 40 to 30, but no lower. We now also use Azopt, which has lowered the pressure to 16. Why do we need both types of drop to successfully reduce pressure and would like to know which drug is safer for long-term use. My daughter is only 2 years old and is aphakic due to congenital cataracts. [ 03/14/11 ]
Thank you for your question. Xalacom is a combination of the drugs timolol (a beta blocker) and latanoprost (a prostaglandin analog). Azopt is a carbonic anhydrase inhibitor. 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 that we give to patients 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). Timolol and Azopt essentially work as aqueous suppressants (turning down the faucet), but they may also cause the traditional drainage system to work slightly better as well. The latanoprost works by increasing the outflow through the uveoscleral pathway. Essentially, when one medication alone does not work (does not turn the faucet down enough or does not open the drain enough) the doctors will add medications that work on different parts of the eye to have an effect greater than just one drug. At this time, all three drugs appear to be well tolerated in children and may possibly be used the rest of her life if it keeps the pressure stable. We never say that drugs are “safe,” because every drug has side effects, but your doctors will be watching for those side effects, and if they become an issue, other treatment options will be given to you. I wish the best of luck to both you and your daughter.