Questions & Answers

It is not entirely clear what “trigger points” the article you read is referring to, and this is not a commonly recognized concept. Generally, the cause of increasing eye pressure in glaucoma, either with or following glaucoma surgery, is increasing resistance to aqueous humor outflow. Since your eye makes the watery aqueous humor on a continuous basis, increasing resistance to outflow will cause it to build up in the eye and increase the pressure. In an eye without glaucoma surgery, this increased resistance generally occurs in the angle of the eye, where the iris is connected to the wall of the eye. In an eye that has had glaucoma surgery, such as a filter, or trabeculectomy, increased resistance most likely is occurring within the filter itself, due to gradual formation of scar tissue. Pupil changes can occasionally be seen following glaucoma surgery, and an alteration in the pupil response to light can result from the glaucoma damage to the optic nerve. Changes within muscles of the eye generally do not cause changes in eye pressure, unless contraction of the ciliary muscle is produced by an eye drop called pilocarpine, an old and now uncommonly used medication.

Selective Laser Trabeculoplasty (SLT) is a laser treatment that results in increased outflow of aqueous humor through the drainage channel (trabecular meshwork) of the eye. The laser energy is directly applied to the angle structures of the eye. Posterior vitreous detachment (PVD) can result from anterior segment laser surgery, most commonly laser capsulotomy. It is very rare to have PVD related to SLT—the scientific literature does not report the occurrence of PVD linked to SLT.

Regarding the risk of removal of epiretinal membranes in patients with glaucoma, there is increased risk of glaucoma progression and vision loss associated with any intraocular surgery—whether it is glaucoma surgery, cataract surgery, or retinal surgery.

Vitrectomy carries with it the risk of undergoing local anesthesia with a retrobulbar block, as well as increased intraocular pressure intraoperatively as the surgery does require a period of elevated eye pressure, and the risk of postoperative elevated eye pressure, especially if gas tamponade is needed with the vitrectomy. Moreover, postoperative steroids are needed, and these may cause a secondary steroid-induced elevation of eye pressure.

Factors that influence the decision to proceed with vitrectomy and membrane peel for epiretinal membranes concerning glaucoma include the severity of your glaucoma, whether or not your visual field defects are close to fixation, the severity of the epiretinal membrane and its effect on your quality of vision, the experience of the retinal surgeon, etc. Many patients with glaucoma and epiretinal membranes undergo successful treatment with surgery; however, their care must be carefully coordinated between specialists. If your eye doctors are not both on board with the plan for surgery, a second opinion from both a glaucoma specialist and retinal specialist who work together (perhaps at an academic center) is advisable.

There is not a cause and effect relationship between cerebral vasculitis and juvenile glaucoma. Juvenile glaucoma typically affects patients at a young age (teens) and is managed similarly to open-angle glaucoma with reduction of the intraocular pressure. Juvenile glaucoma often has a genetic component, but can occur sporadically.

Sneezing is associated with the Valsalva reflex, which results in transient increases in eye pressure. However, these small increases are usually not significant and do not result in glaucoma.

Most of the time, the reason that glaucoma is listed as a contraindication for a particular drug is due to the ability of that drug to produce dilation of the pupil and precipitate an acute-angle closure glaucoma attack. However, this is unlikely to occur if the patient does not have a narrow anterior chamber angle (the angle between the iris and the trabecular meshwork) to begin with. In the United States, the majority of glaucoma patients have open-angle glaucoma, and are not at increased risk of acute angle-closure glaucoma. You should choose your treatment for the ADHD based on the drug that you feel will be most effective for the patient, and, if glaucoma is listed as a contraindication, contact the physician treating your patient’s glaucoma and make sure that this drug will be safe. Most likely, this will be on the basis of whether or not the patient has a narrow angle. The other consideration here is the potential for drug interaction. The majority of patients being treated for glaucoma will be receiving one or more of the following classes of medications: prostaglandin analogs, beta blockers, alpha agonists, or carbonic anhydrase inhibitors. You should ask your patient what glaucoma drugs he is using and see if the particular ADHD medication you would like to use has the potential to interact with them. Again, you should contact your patient’s ophthalmologist if you need any specific clarifications.

Primary open-angle glaucoma typically affects both eyes, but may be asymmetric, meaning that one eye is affected more than another. Unilateral glaucoma is a diagnosis of exclusion. In patients who present with glaucomatous damage to one eye, treatment of that eye is necessary to prevent further damage. Evaluation of other causes of optic neuropathy is also necessary, and it is important for your doctor to closely follow both eyes.

The bluish ring around the cornea may be what is referred to as arcus senilis. This condition results from the accumulation of cholesterol and other lipids in the peripheral cornea, and is more common with increasing age. The presence of arcus senilis in a young person may signal an underlying problem with lipid and cholesterol metabolism. Your husband’s eye doctor can provide you with an accurate diagnosis.

Increased intraocular pressure and a positive family history are associated with an increased risk of developing visual damage from glaucoma. If you have ocular hypertension without evidence of optic nerve damage, in which case treatment to reduce the eye pressure decreases your risk of developing glaucoma by 50% over the next 5 years. On the other hand, you may have increased eye pressure and signs of glaucoma damage seen with visual field testing or optic nerve analysis. In this case, reduction of eye pressure by 20-30% is successful in halting progression of glaucoma.

Optometrists are trained in glaucoma diagnosis and management. The typical evaluation for glaucoma should include a thorough ocular history, measurement of intraocular pressure, complete eye examination, gonioscopy, visual field testing, color vision testing, and optic nerve analysis with photography or special testing such as optical coherence tomography (OCT). If you are concerned about your eye care, a second opinion is never discouraged.