Questions & Answers

That is an excellent question, thank you for submitting it. Glaucoma is classically defined as a stereotypical pattern of damage to the optic nerve and certain layers of the retina. Elevated intraocular pressure is a risk factor for glaucoma, but just because the pressure is elevated this does not mean you have glaucoma. Often people with elevated intraocular pressure alone, and no other signs of glaucoma, are given the diagnosis of ocular hypertension. Similarly, just because the intraocular pressure is normal, this does not mean that someone cannot have glaucoma. We often see patients with glaucoma that have never had increased intraocular pressure, and we call this "normal tension glaucoma." There are a lot of different types of glaucoma, and they can progress at different rates. It is difficult to predict what course glaucoma will take. Regardless of the type of glaucoma that you have, the only variable that we can change to slow or stop the progression of glaucoma is the intraocular pressure.

Once a thorough eye exam has been completed, as eye doctors we often set a target or goal intraocular pressure. To achieve this goal, there are essentially three different tools that we can use to treat glaucoma. We use eye medicated eye drops, laser treatments, and surgical methods to lower the intraocular pressure. The eye doctor will follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if the glaucoma progression has stopped. If the pressure is not reduced enough or the doctor ever notices advancement in the glaucoma, they will add more medications or use laser or surgery to help lower the intraocular pressure further.

I am sorry that your husband is having this difficulty, and I appreciate your concern. First, let me be clear. Having debilitating pain that keeps you in bed for half a day or a full day is not normal, and this is not typical for glaucoma patients. I strongly suggest that he be seen by a glaucoma specialist on one of the days that he is having the eye pain so that the glaucoma specialist can determine what is causing the pain. There are a variety of different problems that can cause pain around the eye that may or may not be related to increased intraocular pressure (such as migraines, sinus problems, etc). If the eye pressure is well controlled, then the doctor needs to look for other causes of the pain. When you describe a "flap" on the eye, I assume you mean that he has undergone a trabeculectomy surgery and has a trabeculectomy flap. It is important that the eye doctor examines the trabeculectomy bleb or filter to make sure it is working properly. Sometimes they are not working well enough and the pressure remains too high and additional therapy is needed. Other times, the trabeculectomy is overfiltering and the intraocular pressure is too low. This can also cause pain.

To answer the other part of your question, "can anything be done?" The answer is yes. First, do not hesitate to ask for a second opinion from a glaucoma specialist (an ophthalmologist that has completed a glaucoma fellowship). In regard to the cataract, it is possible that the cataract can be safely removed. In regard to the intraocular pressure, it is possible that additional mediations, laser surgery, or incisional surgery is needed to help reduce the pressure. I do agree that caution is needed in your husband's case though. When patients have already lost vision in one eye and have had a trabeculectomy in the other eye that sees well, I am often cautious regarding any further surgery in that eye (i.e. cataract surgery). The cataract can be removed when it becomes visually significant, but with the understanding that it can have deleterious effects on the trabeculectomy and it may cause the need for further glaucoma surgery in the future. Only a glaucoma specialist can determine whether or not cataract surgery or any other surgery is in the best interest of your husband. Best of luck to both of you.

Thank you for your question. The answer to this question is not as straight forward as you might originally think. First, vision loss from glaucoma can have a couple of different components. There is the degree of field loss (how far away from your central vision does the field loss start) and depth of field loss (how bad is the field loss....i.e. can you see objects even though they are fuzzy, or is it black). Your ability to function depends on both the amount of peripheral vision loss and the depth or density of the vision loss. You can have very mild peripheral vision loss and still be able to see objects in the periphery or you can have very dense vision loss where you can see no objects in the periphery. A visual field test (either an automated Humphrey visual field or Goldmann visual field) performed by your eye doctor can help determine the extent of the loss.

In addition, it depends on whether or not there is any loss in the right eye as well. Visual field loss on the sides (temporal visual field) is often more problematic because this area of vision is only created by one eye. The opposite is true of visual field loss toward the inside of the nose (nasal visual field) because the nasal visual fields are duplicated by the opposite eye. This is most easily demonstrated by putting your finger about a foot in front of your nose. Both eyes can see your finger. If you put your finger a foot from either shoulder, only the eye on that side can see the finger (your nose is in the way of the other eye). If you are bumping into things on your left side (the side where your glaucoma is mostly noted), then yes this could all be from your glaucoma. You should be aware that this portion of your vision is gone, and you need to be particularly aware when you are driving as you may not see things around you on the left side as well. Secondly, if you are bumping into things on your right side (opposite of where your glaucoma is worse) then you should look for another cause or determine if your right eye has also lost some vision. I hope this helps.

Thank you for your question. The first part of your question is easier to answer. Lifting heavy objects can cause an increase in eye pressure in some people. Anytime you perform a “Valsalva maneuver” (hold your breath and bear down to lift heavy objects, play trumpet, hold a yoga pose, etc.) the pressure in the eye can become elevated. The second part of your question is more difficult to answer because I have not examined your eyes. The answer is based primarily on how much damage has been done to the optic nerve because of the glaucoma. If you were my patient, I would find out how much you lift and try to reproduce this in the office. I would take your eye pressure while you are resting and then take the pressure again while you are lifting something heavy. If your pressure increases, we would have to determine whether or not it is elevated enough to be worrisome. I hope this helps.

That is an excellent question, thank you for submitting it. Glaucoma is classically defined as a stereotypical pattern of damage to the optic nerve and certain layers of the retina. Elevated intraocular pressure is a risk factor for glaucoma, but just because the pressure is elevated this does not mean you have glaucoma. Often people with elevated intraocular pressure alone, and no other signs of glaucoma, are given the diagnosis of ocular hypertension. Similarly, just because the intraocular pressure is normal, this does not mean that someone cannot have glaucoma. We often see patients with glaucoma that have never had increased intraocular pressure, and we call this "normal-tension glaucoma." With a family history of glaucoma, or any other risk factors for glaucoma, your eye doctor may give you the diagnosis of being a "glaucoma suspect." This means that they do not yet believe you have glaucoma, but that you should be watched closely for the development of this disease in the future. Our goal as eye doctors is to identify glaucoma before you, as a patient, ever notice any changes.

Your eye doctor will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future; however, these visits do not need to be on a monthly basis. Glaucoma progresses very slowly over time. I typically see my ocular hypertensive patients and my glaucoma suspect patients initially every 3-6 months, and if they are stable for quite some time, I may extend their visits to every 6-12 months, but every patient is different. If you have questions or concerns, do not hesitate to start an open dialog with your eye doctor and ask them to explain why they have chosen the particular monitoring plan that they have prescribed for you. If you are still concerned, it is always acceptable to ask for a second opinion from a glaucoma specialist.

Thank you for the interesting question. This is a topic that is debated around the water cooler and in rounds by many ophthalmologists, glaucoma specialists, and residents in training. There are very few studies that have actually looked at the effect of wearing a necktie on intraocular pressure. In 2003, one study showed that wearing a "tight" necktie for approximately 3 minutes caused the intraocular pressure to increase in both "normal" patients and patients that had been diagnosed with glaucoma. These researchers believed that the increase in intraocular pressure was caused by pressure being placed on the jugular veins, which restricted the blood flow out of the head. This likely led to an increase in the blood pressure in the head and an increased intraocular pressure. A second study completed in 2005 again showed that wearing a necktie caused an increase in intraocular pressure 3 minutes after tightening the tie, but that without loosening the tie, over the next 12 minutes the intraocular pressure actually decreased back to near the original level. From this study, many concluded that the initial tightening of the tie increased intraocular pressure, but that prolonged wearing of a necktie does not cause an increased risk in patients with glaucoma because the pressure equalized over time.

I think the only conclusion that I feel comfortable making from these studies is that a "tight" necktie can increase the intraocular pressure, but I do not know the long-term consequences. There is no evidence to suggest that it causes an increase in the rate of progression of glaucoma; however, no studies have specifically looked at this, so it might be possible. I typically recommend that a neck tie and buttoned up collared shirt should not be overly tight around the neck. In addition, I ask all of my patients to unbutton their collar and loosen their tie before I take their intraocular pressure so that the tightness of the necktie does not interfere with my reading of the intraocular pressure. Personally, I buy a shirt 1/2 size larger so that mine stays a little loose, but I always wear a tie when I am seeing my patients.

This is an excellent question. What you have experienced is not unusual. There is a great deal of evidence that suggests cataract surgery can lower intraocular pressure, and that some glaucoma patients may be able to reduce or stop their glaucoma medications for some time. The reason for the decrease in eye pressure after cataract surgery is not yet known, but there are several studies trying to find the answer. Some people have proposed that the cataract, which is the natural lens in the eye that has gotten cloudy may be at fault.

Over our lifetime, the natural lens in the eye continues to grow similar to an onion adding layers. As the lens gets bigger, it may crowd the drainage system in the eye causing the pressure to increase (like a sink backing up when the drain gets clogged). Removing the lens may allow the drainage system to expand again and begin to flow better. Other people have proposed that the inflammation caused after the surgery may in fact be of benefit and cause the drainage system to start working better.

Finally, some people feel that some of the techniques that we currently use to remove the cataract (i.e. phacoemulsification) may have steps that cause the drainage system to be cleaned and begin flowing better. The true answer is that we don't know; however, we do know it is a real phenomenon. There are some lucky patients (like my grandmother) who used glaucoma drops for years prior to cataract surgery and have never had to restart them again. However, on average, we tend to see the eye pressure staying lower for about 1-2 years, and then it often increases again over time. It is important that you continue to see your eye doctor for routine exams to check the intraocular pressure, vision, visual fields and optic nerves because we cannot predict who will need to restart their medications or when this need will occur. Best of luck, and I hope you are one of the lucky patients that get to stay off of your drops.

Thank you for the questions. Unfortunately, there is currently no "cure" for glaucoma. When I use the word "cure," I mean that the damage done to the optic nerve and the vision lost due to the damage at the optic nerve cannot be reversed. However, there are a lot of different types of glaucoma, and they can progress at different rates. It is difficult to predict what course glaucoma will take. The only variable that we can change to slow or stop the progression of glaucoma is the intraocular pressure. Once a thorough eye exam has been completed, as eye doctors we often set a target or goal intraocular pressure. To achieve this goal, there are essentially three different tools that we can use to treat glaucoma. We use eye drop medications, laser treatments, and surgical methods to lower the intraocular pressure. The eye doctor will follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see if the glaucoma progression has stopped. If the pressure is not reduced enough or the doctor ever notices advancement in the glaucoma, they will add more medications or use laser or conventional surgery to help lower the intraocular pressure further.

To answer the second part of your question, there are essentially five different types of drops that are primarily used to treat glaucoma. I will give you the type or class of medications that are used. There are many different companies that make each class of medication and there are too many brands to list (plus I do not specifically endorse any single brand over another). Feel free to ask your doctor which class of medicine(s) they have prescribed. The five different classes of medications include:

1. Prostaglandin Analogs: These medications work primarily by helping fluid exit the eye from a secondary, less common drainage pathway (i.e. the uveoscleral pathway).
   
2. Beta-Adrenergic Antagonists or Beta-Blockers: These medications work primarily by decreasing the amount of fluid made inside the eye.
   
3. Alpha Agonists: These medications work primarily by decreasing the amount of fluid made inside the eye, but they also help fluid exit the eye from the uveoscleral pathway.
   
4. Carbonic Anhydrase Inhibitors: These medications work primarily by decreasing the amount of fluid made inside the eye.
   
5. Parasympathomimetic or Miotics: These medications work primarily by helping the fluid exit through the main drainage system of the eye (i.e. the trabecular outflow pathway).