Are younger patients on glaucoma medications at a higher risk for detached retina?
Q: I have read that younger patients on glaucoma medications, such as miotic drops, are at a higher risk for detached retina. If this is so, what can be done to prevent the detached retina?
A: Age is not a factor in retinal detachment from using miotic drops. The predisposing condition is myopia. Patients with myopia are more likely to have peripheral retinal problems which can lead to retinal detachment, the most important of these is lattice degeneration, which is more common the greater the myopia.
Person with pigment dispersion syndrome and pigmentary glaucoma are more likely to have lattice degeneration. The reason for this remains unknown, but theyre maybe a genetic factor.
Younger persons with glaucoma are much more likely (as high as 80%)to be myopes than are older persons, in whom aging appears to contribute to the development of glaucoma. This is probably the reason for the mistaken impression that younger persons are at higher risk for detached retina. All persons beginning miotic therapy, and especially those with pigmentary glaucoma, should have a peripheral retinal examination or retinal tears before stating the drops.
A: Intraocular pressure works differently in different individuals, and there is not one pressure level that works for everyone. When your doctor conducts a comprehensive eye examination, it is likely that s/he is identifying a target pressure measurement that s/he believes would be "normal" for your specific condition, meaning it would hopefully prevent further optic nerve damage from occurring if you could stabilize your pressure at this target level. It would be very appropriate for you to ask your treating doctor what this target number is so that you can interpret and understand how your eyes are doing each time you visit the doctor for an eye exam. To put intraocular pressure measurements in perspective, the national average pressure measurement in the U.S. is between 14 and 16, and normal population pressures up to 21 may be within normal range. There are also many other personal characteristics and genetic issues, such as race, family history and corneal thinness just to name a few, that must be considered when a doctor reviews your examination results and determines whether your present condition can be damaging to your optic nerve. We encourage you to ask questions and communicate regularly with your doctor so that you can be an active and knowing participant in your treatment plan. If you continue to have questions about the right course of treatment for your glaucoma, consider seeking a second or even third opinion from another doctor.
Computers and Glaucoma
Q: I have glaucoma and work with a computer a great deal for my job? Does excessive computer work effect glaucoma? Are there computer aids to assist individuals with glaucoma?
A: Excessive computer work has no know provn effect on glaucoma. However, many people working with computers often complain of symptoms such as blurred vision, headaches or glare. One of the causes has been attributed to dry eyes. It appears that individuals, while looking at there terminals, forget to blink! Blinking keeps the eye moist, so try to remain yourself to blink. As an additional aid, there are antiglare screens, which can be purchased to fit over most computer terminals.
Surgery vs. Medication
Q: I have received two different opinions about glaucoma treatment one favoring an operation and the other favoring the use of medicine as much as possible due to the complications of surgery and I am interested in your opinion. If medication keeps the glaucoma in control, but the side effects are awful or make your quality of life not very pleasant, is an operation a better option? Will there eventually be a medicine or operation for glaucoma that will not have all the side effects? What should a person look for in a good eye doctor as far as treating glaucoma for life? The future just looks a little bleak if you have glaucoma, especially if you get it when you are under the age of fifty.
A: Open angle glaucoma with onset under the age of 50 is usually pigmentary glaucoma or juvenile open-angle glaucoma. Angle-closure glaucoma with onset under the age of 50 is usually caused by plateau iris. It can certainly be psychologically devastating to the patient to receive a diagnosis of glaucoma, but with appropriate treatment and timely intervention, a lifetime of continued functional vision is certainly possible. As with all chronic diseases, one should look for a physician in whom one has confidence and to whom one can relate.
It is certainly not unusual to receive differing opinions about the treatment of glaucoma. Most of us who are glaucoma specialists today probably would have been theologians in the 12th century. There are two important trends in the approach to treatment, which have developed over the past several years that should be taken into account.
Surgical intervention was formerly done as a last resort. It was fraught with complications and the success rate was not all that high. In the past decade, the use of anti-metabolites, such as 5-fluorouracil and mytomycin-C, in conjunction with glaucoma filtration surgery, has markedly increased the rate of success. At the same time, tighter would closure and post-laser suture lysis to titrate intraocular pressure has significantly reduced the complication of a flat anterior chamber, which used to be quite common. In essence, glaucoma surgery is safer and more effective than ever before. Routine trabeculectomy for uncomplicated open-angle glaucoma when performed as an initial surgical procedure in a patient who has not had previous intraocular surgery is a highly effective procedure. The chance of complications or surgical failure increases with previous intraocular surgery, complicated glaucoma, reoperations for glaucoma, and high myopia.
Quality of life is an important fact in the treatment of any chronic disease. Particularly if you have many years left to live, it is important to make a decision as to whether you want to spend those years with side effects, which make you miserable. You should first consider whether there is a way to eliminate the side effects of the medications you are presently taking. For instance, if you are taking pilocarpine eye drops which cause blurred vision and induced myopia, you could consider pilocarpine ocuserts which are extremely well tolerated by younger patients. Simple nasolacrimal occlusion can reduce or eliminate side effects of beta-blockers. If you are taking an oral carbonic anhydrase inhibitor, such as Diamox or Neptazane, you might ask your ophthalmologist about dorzolamide (Trusopt), a recently released topical carbonic anhydrase inhibitor. If none of this is effective and you are still suffering from intolerable side effects, or if your glaucoma is uncontrolled, then surgery is not an unreasonable option.
I have heard that marijuana can be used to treat glaucoma. What is the current medical and legal opinion on this?
A: Marijuana definitely does lower although pressure. Unfortunately, although many derivatives of marijuana have been tasted over the last 15 years, none has been both sufficiently effective and sufficiently free of side effects to bring to market. There is an eye drop created from THC, or tetrahydrocannabinol, the active ingredient, available in Jamaica, West Indies. In the United States, marijuana is available for patients with glaucoma who have had all other measures fail to control pressure. However, only a few patients are receiving government-provided marijuana cigarettes and a great deal of paperwork is necessary to get permission to receive them.
I have cataracts, can my glaucoma be treated and how?
Q: I have cataracts, can my glaucoma be treated and how?
A: Cataracts and glaucoma are two separate problems. Cataracts can be cured by having them removed with a relatively benign surgical procedure. Commonly, however a combined procedure can be performed at the time of cataract extraction, thereby, hopefully getting the glaucoma under control. Remember, the glaucoma is not cured, just controlled.
Can an ophthalmologist who does not specialize in glaucoma treat a glaucoma patient effectively?
A: Yes, however, the glaucoma patient needs to be educated and be sure they are routinely having their pressure monitored. Tests including visual fields, gonioscopy (checking the angle of the eye) and ophthalmoscopy (looking at the optic nerve in the back of the eye) should be performed. The patient needs to know that in the event of problem with intraocular pressure control or rapid deterioration of vision, they should see a glaucoma specialist.
What services are available for exams if you have no coverage, are out of a job, and are not on Medicare / Medicaid?
A: Hospital clinics: The Department of Social Services located in hospital clinics will help individuals arrange budget payments for services rendered. Studies: Ophthalmologocal studies are often advertised in publications and on radio and television. Invariably, participation in these studies does not require payment.
Do some people with glaucoma produce too much fluid and also have a drainage problem?
Q: Glaucoma means that the fluid in the eye does not drain properly or that too much fluid is produced. Do some people with glaucoma produce too much fluid and also have a drainage problem or can it only be one or the other of these problems? Can a doctor tell if patient only has one problem or two? Can having both problems mean that the patient will not respond easily to medications? You may not have any definite information on this question, but anything would be helpful to understanding glaucoma a little bit more.
A: Fluid is constantly produced within the eye by a small gland called the ciliary body. This clear fluid, known as aqueous humor, supplies the internal structures of the eye with nutrients and oxygen. The fluid then exits the eye through the drainage angle, which is called the trabecular meshwork. Increased resistance within the trabecular meshwork decreases the rate of flow across it and causes a build up of fluid within the eye, resulting in elevated eye pressure. This is invariably a result of poor drainage function, rather than an increase in aqueous humor production by the ciliary body.
Essentially, elevated eye pressure in glaucoma occurs because the rate of fluid production exceeds the eye's ability to drain it. The degree of this resistance to outflow varies from individual to individual. This situation is analogous to your kitchen sink. The faucet is always on and water goes down the drain. Imagine that you pour coffee grinds into the sink. What happens? The water level slowly rises and then overflows. In the eye, the fluid can't overflow, so the pressure goes up. Glaucoma medications lower intraocular pressure by either decreasing fluid production (turning down the faucet) or increasing fluid outflow from the eye (improving the function of the drain).--J.M.L.
Differing responses by different people to different eye drops
Q: Can you explain why some people with glaucoma and high pressure will respond to as little as one eye drop when another person with a lower pressure needs to take three or four drops? Does this mean that the person who has to take multiple drops has more serious glaucoma or does it mean that their body fights the effects of the eye drops?
A: The extent or seriousness of glaucoma damage to the eye cannot not be judged by the intraocular pressure alone or the number of glaucoma medications required to control it, but rather should be defined by the amount of damage to the optic nerve and visual field. This is an important point. Glaucoma is a disease characterized by progressive injury to the nerve; this results in loss of vision which can be detected on a visual field test. The response to antiglaucoma medications varies among individuals. Some individuals respond nicely to a single agent; others may require multiple medications to control their disease and prevent further vision damage. The desired or "target" intraocular pressure is chosen by the treating physician and based upon the extent of the glaucoma damage, the intraocular pressure at which the damage occurred, and other factors.--J.M.L.
Does your age determine the loss of vision?
Q: If a person gets glaucoma under the age of 50, does this mean they have more of a chance of losing some or all of their vision versus a person who gets glaucoma in their 60's or 70's? I keep reading about how fortunate a person is to get glaucoma late in life instead of around age 50. This is quite disturbing for a person who gets glaucoma at 50.
A: Not necessarily. It is the kind of glaucoma, not the age of the patient, that determines the potential for loss of vision. This is why we emphasize the importance of glaucoma testing for early detection of the disease. The earlier a patient begins treatment the more able we are to prevent vision loss regardless of the age of the patient.
Q: After months of trying to control pressure in my left eye with various combinations of drops and pills, a trabeculectomy was performed after which I was diagnosed with malignant glaucoma. Several steps of treatment have resulted in successfully controlling the pressure now. I have searched for information on malignant glaucoma but can find nothing. Can you tell me something about this condition?
A: Malignant glaucoma is also known as "aqueous misdirection" and presents the greatest diagnostic and treatment challenge of any of the angle-closure glaucomas. In aqueous misdirection, aqueous (the fluid in the eye) is secreted into the vitreous (a gel-like substance that fills the center region of the eye), building up the pressure in the vitreous, and pushing the lens forward into the trabecular meshwork (area that the fluid drains through) to cause angle-closure glaucoma which does not respond to iridotomy (a surgical procedure) and can lead to an angle-closure glaucoma attack. Aqueous misdirection is difficult to understand, not always easy to diagnose, and difficult to treat successfully. Patients with this condition need argon laser peripheral iridoplasty (another kind of surgical procedure) to break the attack and then definitive treatment for whatever mechanism is causing the aqueous misdirection after the iridoplasty. Unfortunately,we don't know at this time what causes this condition or why it is hard to locate. Congratulations on your successful treatment!
My wife has had progressive glaucoma for over 10 years. We've been to a retinologist, a glaucoma specialist, a neuro-ophthalmologist, and lastly to the Bascom Palmer Eye Institute.
Q: My wife has had progressive glaucoma for over 10 years. We've been to a retinologist, a glaucoma specialist, a neuro-ophthalmologist, and lastly to the Bascom Palmer Eye Institute. The last doctor said he sees about one glaucoma patient a month for whom he cannot do anything. Her pressure is controlled to between 10 and 12 and he felt surgery to lower the pressure is too risky. If the pressure were to be lowered and reach as low as 5, she would lose all vision. She is taking Timoptic, Phospholine, Iopidine, and Trusopt for her eye. She also takes Capoten, Norvasc, Provachol and baby aspirin, although she has never had a heart attack. Repeated visual field tests have shown progressive deterioration. The optic nerve is damaged. The opinion is that something more than glaucoma is at work. Perhaps lack of circulation to the brain and optic nerve. She has also been diagnosed with Alzheimer's, which also has progressed since its start about 4 years ago. Are there any suggestions or hope you can give us?
A: As the numerous ocular subspecialists you have seen in the past have probably told you, we know that there are two general types of glaucoma: pressure dependent and pressure independent (associated with a vascular, neurodegenerative, or ill-defined mechanism). Your wife sounds like she has a pressure independent glaucoma and may not benefit from any further reduction in intraocular pressure. I would, however, recommend that she be seen by her internist to exclude the possibility that she is overmedicated with systemic antihypertensive medications. This can produce systemic hypotension and reduce blood flow to the brain and optic nerve, particularly at night. In addition, reproducible and progressive visual field defects have been described in patients with Alzheimer's disease which may be a confounding factor. New developments in glaucoma research are focused on "neuroprotective agents" and we hope one day to be able to offer our patients medications which do more than simply control intraocular pressure.
What is the difference between cataracts and glaucoma?
A: The optical system of the eye allows us to see. When light enters the eye, it is focused by the lens onto the retina, which perceives the image, much in the same way a camera lens focuses light onto the film torecord a picture. As we age, the normally clear lens begins to thicken and gradually becomes discolored. This condition is called a cataract. This results in a loss of vision, and occurs at different rates in different individuals. Vision loss in glaucoma occurs because of damage to the optic nerve, which connects the eye to the brain. Because of its similarity to the nerve cells (called neurons) of the brain, once it is injured it cannot be repaired. The loss of nerve cells is irreversible.
Cataracts and glaucoma may occur together in the same person. For most people, these two disease processes are separate and distinct and may progress at different rates. It is important to remember that a cataract is a reversible form of vision loss and that glaucoma is not. Permanent loss of vision from glaucoma, however, can be prevented in most people by early detection and careful follow-up examinations to detect early signs that the eye is being damaged, followed by appropriate, timely intervention should these signs develop.
I'm worried my doctor will have to change my drops now that I have cataracts. Is this necessary?
A: For most patients, the slow development of a cataract will not require their physician to alter the management of their glaucoma. There are some exceptions to this, however. The group of medications called miotics, which includes pilocarpine and carbachol (most of these medications have bottles with green caps) often result in a smaller pupil in addition to lowering the intraocular pressure. When the pupil is small, less light enters the eye. As the cataract worsens, a smaller pupil permits even less light to enter the eye. This may upon occasion cause your doctor to substitute another agent for the miotic drop.
IOP - Is it possible to have a high pressure and no glaucoma signs or should I look for another opinion?
Q: During a recent eye exam, I was told that my IOP was 22, the doctor said that while this is a high pressure, there were no signs of glaucoma damage and that I should return in a year for a regular check-up. I am 66 with adult onset diabetes and am concerned because I have read that diabetes can lead to glaucoma and blindness. Since I enjoy an active life and read quite extensively, I am concerned that my age is leading to a do nothing because of old age diagnosis that some of my friends have recently received for eye and other health problems. My diabetes has been diet-controlled for quite some time, I have no other major health problems, and there is no known history of glaucoma in my family. Is it possible to have a high pressure and no glaucoma signs or should I look for another opinion? A: In a nutshell, it does not sound as if you need either treatment or a second opinion at this point in time, and that you should be able to look forward to a long and happy visual life with little likelihood of your going blind from glaucoma as long as you have appropriate observation and treatment if and when the latter ever becomes necessary. The number 22 as a demarcation of abnormal IOP was arrived at back in the 1950's when statistical studies were performed of populations in an attempt to determine the average pressure. Because the average IOP was about 15 mmHg to 16 mmHg, a cutoff point was defined above which approximately only 2.5% of the population would fall. For practical purposes, considering what we know about glaucoma today, this is basically only a mathematical and arbitrary number.
The term 'ocular hypertension' arose as a working definition to describe people who had IOP of 22 mmHg or more and no detectable optic nerve or visual field damage. The rate at which people with ocular hypertension convert, or develop glaucoma, is on the order of 1% per year. Therefore, most people with elevated pressure will never develop glaucomatous damage and of those who do, a much smaller number will actually become blind. The higher the pressure, the more risk there is.
We also now realize that IOP is just one risk factor for the development of glaucoma, others being cardiovascular problems, insufficient blood flow to the eye, inherited or acquired structural weakness of the optic nerve support structures, and other, as yet undiscovered factors. People with greater amounts of these other risk factors can have glaucomatous damage develop at lower pressures. Not all patients with glaucoma have a high pressure, and it is becoming more and more evident that a large number of people can develop glaucoma at normal IOP. Therefore, pressure is not the only factor, and periodic examination of the optic nerve head and assessment of visual field status are also a part of preventive care in glaucoma. An association between primary open-angle glaucoma and diabetes, although often conjectured, has never been proven. What can develop as a result of diabetes is neovascular glaucoma, which may occur in patients with diabetic retinopathy. However, this is a small proportion of both patients with glaucoma and patients with diabetes
What is Normal Tension Glaucoma? Is there any treatment to prevent blindness from Normal Tension Glaucoma?
A: Normal Tension Glaucoma (formerly called low-tension glaucoma) refers to open-angle glaucoma in which damage develops in normal range of intraocular pressure (21 millimeters of mercury or less). Once considered rare, it is becoming increasingly recognizes. Recent research implicates an insufficient blood supply to the eye as a major cause of glaucomatous damage occurring at normal pressures. Thus, it appears that there are two major means by which optic nerve damage from glaucoma may occur: a direct pressure effect on the nerve cells, and an indirect effect of peripheral vascular disease. The former mechanism is more easily susceptible to treatment witth pressure-lowering medications, while the latter is more resistant. Although intraocular pressure is a factor to some defree in all patients with glaucoma, and lowering it remains a mainstay of treatment. Recent advances suggest that drugs to increase the blood supply to the eye, such as calcium channel blockers, help to stabilize the visual loss field and reduce the progression of visual loss from normal-tension glaucoma. It is important to note that screening for glaucoma by checking intraocular pressure alone is insufficient to detect normal-tension glaucoma. A thorough glaucoma screening involves assessment of the optic nerve by an experienced examiner and a visual filed to detect scotomas (blind spots). Current research involves devising rapid visual field tests which can be used on a population screening basis.
What is a Glaucoma Suspect? Anxiety
Q: I have been diagnosed with low tension open angle glaucoma and have been using Travatan for one year. I recently changed doctors and was diagnosed a glaucoma suspect and not requiring treatment at this time. This discrepancy has caused a great deal of confusion as to my treatment options. What would you recommend as a course of action and or questions I could ask the Doctor in order to determine what action I should take. Is there any research that suggest that an anxiety disorder may contribute to an increase in IOP?
A: Anxiety - unlikely to affect open angle glaucoma. "Glaucoma suspect" is a term used to classify individuals without clear evidence of glaucoma but are "suspicious". Early in the course of the disease the diagnosis may be difficult to make, and some physicians prefer to wait for a clear diagnosis prior to instituting therapy. A third opinion, from a member of the American Glaucoma Society, would seem prudent.
Pressure and Pain
Q: I was recently diagnosed with vitreous detachment. I understand why I have flotaters in my vision but I do not understand why I experience a feeling of pressure and slight discomfort in that eye.
A: Other than floaters, vitreous detachment should not be associated with pain or pressure sensation. Repeat examination should be peformed if these symptoms persist.
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