Questions & Answers

That is an excellent question. Unfortunately, the data on this subject is not consistent throughout the literature. There are multiple randomized studies currently looking at the effect of exercise on intraocular pressure. What we are finding is that it may depend on the type of exercise, the overall fitness of the patient, or other factors that we do not yet understand.

In general, eye pressure can be transiently increased by any exercise or activity that induces a “Valsalva.” The Valsalva maneuver, as defined by Wikipedia, "is performed by forcible exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervous control of the heart, or to "clear" the ears and sinuses (that is, to equalize pressure between them) when ambient pressure changes, as in diving or aviation." Holding your breath and bearing down to pick up a heavy object (heavy weight lifting) or even playing an instrument, such as the trumpet, are both methods of causing a Valsalva maneuver as well, and can transiently increase eye pressure. In addition, there is some evidence that certain yoga positions may also increase pressure inside the eye. Inverted positions that place the eyes below the heart for an extended period of time have the greatest potential for increasing the pressure inside the eye.

While some studies have shown an association with increased intraocular pressure and exercise, there are new studies showing that aerobic exercise may actually decrease intraocular pressure transiently. Overall, I do not believe that studies on exercise and intraocular pressure are consistent enough to draw many conclusions or provide a definitive recommendation. In general, as physicians, we would all recommend our patients follow an exercise regiment for your general health. Avoiding prolonged heavy weight lifting or inverted yoga positions may be reasonable until we have definitive studies to examine their long term effects. I encourage you to consult with your eye doctor and your primary care doctor to determine an appropriate exercise regiment for you.

No studies have shown that the use of Lexapro in addition to Alphagan cause any side effects with the eyes specifically.

You should be aware that both of these medications can have central nervous system side effects. Alphagan is an alpha receptor agonist and can be absorbed by the body to cause some side effects related to the central nervous system. Lexapro is a selective serotonin reuptake inhibitor primarily used to treat depression and/or anxiety. By its nature, it also acts on the central nervous system and can have side effects. The combination of these two drugs has not been studied in a controlled trial; however, because both have side effects that can be related to the central nervous system, it is possible that their use together could have additive effects. In doing some research, I found the following recommendations useful from the drugs.com website concerning this combination of medications:

Topically administered alpha-2 adrenergic receptor agonists such as brimonidine (Alphagan) are systemically absorbed, with the potential for producing rare but clinically significant systemic effects. Although the interaction has not been specifically studied, the possibility of an additive or potentiating effect with central nervous system (CNS) depressants such as alcohol, barbiturates, opiates, anxiolytics, sedatives, and anesthetics should be considered. Additive hypotensive effects (i.e. low blood pressure) and orthostasis (i.e. low blood pressure when standing up) may also occur, particularly during initial dosing and/or parenteral administration of the CNS agent. Patients prescribed brimonidine ophthalmic solution with other agents that can cause CNS depression should be made aware of the possibility of additive CNS effects (e.g., drowsiness, dizziness, lightheadedness, confusion) and counseled to avoid activities requiring mental alertness until they know how these agents affect them. Patients should also be advised to avoid rising abruptly from a sitting or recumbent (lying down) position and to notify their doctor if they experience dizziness, lightheadedness, syncope (i.e. fainting or feeling faint), orthostasis (i.e. lightheadedness or feeling faint when you stand up), or tachycardia (i.e. a fast heart rate).

Your physician can provide you with more details if you have follow-up questions or concerns.

Thank you for submitting your question. Congratulations on completing your Ironman Triathlon; , that is quite an accomplishment. I am sorry to hear that you have been having health problems since then. I did quite a bit of research trying to find a link between celiac disease and open- angle glaucoma. To date there are no definitive studies that link the two diseases; however, that does not necessarily mean that they are not related. I do not believe the celiac disease is directly related to the glaucoma; however, often celiac disease is treated by the use of oral steroids to calm the inflammatory component in the bowels and quiet the immune system. If you are taking steroids to treat your celiac disease, it is possible that you have a secondary glaucoma called "steroid- response glaucoma." Steroid response glaucoma is quite common. We primarily see steroid response glaucoma when patients take steroid eye drops after surgery or to treat a condition called uveitis; however, it is possible to get steroid response glaucoma from oral steroids or steroid creams. If you are taking any steroids, you should let your eye doctor know. In addition, because you are relatively young, I would also look for other secondary causes of glaucoma. Have you ever had trauma to the eyes (gotten black eyes as a kid or when playing sports)? This could lead to angle- recession glaucoma, and it can occur decades after the trauma. Otherwise, I have not been able to find any definitive connections between celiac disease, nodular hepatic hyperplasia, gallbladder problems and glaucoma.

Thank you for your question. Unfortunately, I do not know what your doctor means by a "non-penetrating" glaucoma surgery. The two classic glaucoma surgeries are a trabeculectomy and the implantation of a glaucoma shunt tube (like a Baerveldt or Ahmed shunt). The trabeculectomy procedure creates a trap door through which the fluid can escape and lower the pressure. By my definition, this would be a penetrating procedure. The implantation of a glaucoma shunt tube (such as a Baerveldt shunt tube) places a tube inside of the eye. The fluid drains down that tube to a plate that is placed on top of the eye. Again, the tube penetrates into the eye, so I would consider this a penetrating surgery. There are some newer surgical techniques being used, including the EXPRESS shunt, canaloplasty, trabectome surgery, the SOLX gold shunt, and a few others, but I would consider most of these to be penetrating surgeries for various reasons. If you can give me the name of the exact "non-penetrating" glaucoma surgery they are planning, I can give you my opinion on that procedure compared to the Baerveldt glaucoma implant.

That is an excellent question, thank you for submitting it. Interestingly, before 1980 we defined glaucoma primarily based on intraocular pressure. During the 1980s, we began to realize the importance of visual field defects in the diagnosis of glaucoma, so between 1980 and the mid 1990s we felt that visual field defects in addition to increased intraocular pressure were needed to be present to diagnose someone with glaucoma. Currently, the American Academy of Ophthalmology Preferred Practice Guidelines on the diagnosis and treatment of glaucoma does not even use intraocular pressure as a defining characteristic. As we have been able to study this disease more, we understand that glaucoma is 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 this does not define the disease. 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."

Our goal as eye doctors is to identify glaucoma before you, as a patient, ever notice any changes. Your eye doctor will need to do several tests, including checking your intraocular pressure, vision, visual fields, and theand the appearance of the optic nerves. At that point,, and then the eye doctor will make a decision on whether or not they think you have glaucoma. Only after having all of these pieces of information can the disease be accurately diagnosed.

"White halos" can be caused by several different changes that occur in the eye, including open- angle glaucoma, closed- angle glaucoma, changes in the cornea, cataracts, and a few others. In addition, halos around lights can also be seen by everyone when the humidity in the air is quite high. Halos are created when the light coming into the eye is scattered instead of being focused on the retina. When we think of halos associated with glaucoma, we classically think of "rainbow colored halos" that can occur with an episode of angle closureclosed-angle glaucoma. During an episode of angle closureclosed-angle glaucoma the eye pressure is very high. The fluid inside of the eye (aqueous humor) usually keeps the eye blown up like a water balloon. Unfortunately, during times when the eye pressure is very high, that fluid is pushed into the cornea. Usually the back layer of cells on the cornea act like a sump pump to draw the water back out of the cornea and deposit it back inside the eye. When the eye pressure is too high, these cells cannot keep up and the cornea gets cloudy and thick because of the aqueous humor being pushed into it. This cloudiness and thickening then causes the light to be scattered as it passes through the cornea and the result can be "rainbow colored" halos.

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.

Let me first say that without having examined your eyes personally, it is nearly impossible for me to tell what is going on. I suggest that you see an ophthalmologist that has completed a glaucoma fellowship. They will be the most likely to give you an accurate description of what has been going on. Let me try to break down some of what you are discussing into smaller parts. First, if you had a laser peripheral iridotomy, the ophthalmologist likely felt that you either had episodes of angle-closure glaucoma or you had narrow angles. The laser peripheral iridotomy is meant to be a "safety valve" of sorts that helps prevent an angle-closure attack. In general, this laser should not raise or lower the pressure; it simply allows the fluid in the eye to travel a different pathway to the drainage system. If your pressure is staying in the 30s, then you likely have some variety of glaucoma. Second, do not know what the yellow mass over the right eye was just after the procedure. I would ask your ophthalmologist what it was. Without having seen the yellow mass I could not begin to guess what it was. This is not typical of a laser peripheral iridotomy.

Third, the flashes of light that occur when you blink may be one of several things. This may simply be the onset of a posterior vitreal detachment (a normal process of the vitreous condensing and pulling away from the retina). You should have a dilated exam by an eye doctor to make sure that this is what is causing the flashes of light. The second possibility is that light is passing through the hole created in the iris. This can occur because of light being reflected off the tears when you blink. It is also possible that when you blink, your eye is opening a bit larger than usual (overshooting) and allowing light through the peripheral iridotomy. This can cause the flashes of light you notice (especially if they are near your feet). This is a known side effect of the laser peripheral iridotomy. I would discuss the flashes of light with your doctor as soon as possible to rule out the possibility of something more serious like a retinal detachment. I am sorry that I could not give you a more complete answer, but without having examined your eyes personally it is impossible to give an accurate description to you. I suggest that you see an ophthalmologist that is a glaucoma specialist and have this conversation with them after they have examined your eyes. They should be in a better position to answer some of these questions.