Questions & Answers

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.

I am sorry to hear that you now have to make this decision. Unfortunately, I am not likely to be of any help in this particular situation (i.e., I cannot make this decision for you). Given your situation and the fact that there have been some changes in the exam, I agree that continuing to see your doctor every 6 months is not the appropriate thing to do. I often give my patients the exact same options that you have been given. Unfortunately, no one except you can make the decision as to what route is best for you. When I tell patients that we are making a change I always discuss the risks, benefits, and alternatives of starting a new therapy. First your doctor needs to discuss what medication he would consider starting you on. If it is a prostaglandin, then he will likely discuss the fact that it can make your eyes red, and it can change the color of the eyes or the color of the skin around the eyes, etc. If he were to choose a beta blocker, he would likely discuss the fact that you could have symptoms of feeling lightheaded or have a drop in your blood pressure. Also, he would need to know if you have asthma or any other pulmonary issues, etc.

The benefit of starting therapy is that the intraocular pressure will likely be lowered. Lowering eye pressure is the only way we have of preventing further vision loss if you do in fact have glaucoma instead of borderline eye pressure. The alternative is to do nothing and continue to examine the eye for changes. The real question is whether you want to start taking medications now and risk possible side effects from the medicine even though you don't necessarily have a diagnosis of glaucoma, or would you rather wait until we can definitively say that you have glaucoma before starting treatment. That is something that only you can decide. I have some patients that say that they would rather know they are trying to do something to prevent any loss of vision even though they may not have glaucoma. Others say that they want to avoid using medications as long as possible and want more definitive proof that they have glaucoma before using drops.

Taking either route is fine, and that is why the doctor gave you the two choices. If the doctor felt strongly that you needed to start medications, he/she would not have given you the choice of staying off medications but having more frequent exams. There is really no correct or incorrect answer, you simply have to decide which would make you feel better. Best of luck with making this decision and I encourage you to discuss the risks, benefits and alternatives with your eye doctor.

That is an excellent question, thank you for submitting it. First, let us define "primary glaucoma" as either open-angle glaucoma or angle-closure glaucoma. In each of these cases, there is no other reason found for the glaucoma or increased intraocular pressure, and the glaucoma itself is defined as the reason for increased pressure. Anytime that we can define a reason for the increased pressure we call it "secondary glaucoma."

Probably the most common "secondary glaucoma" is the prolonged use of steroids (steroid-induced glaucoma). It is most common if topical steroids, such as prednisolone acetate, are used. However, systemic steroid use, such as oral prednisone, can also cause an increase in eye pressure in some patients. Severe diabetic retinopathy and central retinal vein occlusion can cause a lack of blood flow to the eye. When the lack of blood flow gets severe enough, the eye attempts to develop new blood vessels to get more oxygen rich blood to the eye; however, these blood vessels can cause problems in the eye. Often, they cause a closure of the natural drainage system of the eye and the eye pressure increases. This is called neovascular glaucoma. Uveitis, or inflammation in the eye, can also cause a closure of the drainage system in the eye. This is known as uveitic glaucoma. Finally blunt trauma to the eye can cause damage to the drainage system of the eye. When the drainage system is damaged in a certain way, we call it angle recession. In some people, this can eventually lead to angle-recession glaucoma.

Above I have listed several of the known secondary glaucomas. Eye pressure can also be transiently increased by a Valsalva maneuver. 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 or even playing an instrument, such as the trumpet, are both methods of causing a Valsalva maneuver and can transiently increase eye pressure.

Thank you for your question. From your description, I believe that the majority of your problem is likely related to dry eyes. Typically the vision loss that occurs with glaucoma is slowly progressive in nature and very few people notice moment to moment fluctuations in vision. The job of the eyelids is to protect the eye, and also spreads the natural tears over the surface of the eye when you blink. This is likely the reason that your vision clears when you blink. You are spreading a new fresh layer of tears over the cornea. The question is whether or not the dryness is related to a low level of natural tear production or something else. The dryness may in fact be related to or exacerbated by the Xalatan eye drops. You have gotten a very nice response with the use of Xalatan (a drop of eye pressure from 21 to 14 is excellent). Rarely would we ever stop someone from using Xalatan for this reason, we would simply add artificial tears to your daily regimen. Your doctor can do a test to determine how well you produce tears. This is called a Shirmer's test. If needed, he may start you on some artificial tears or make other recommendations.

Thank you for your question. Please ask your doctor to confirm this, but I would assume that these are the measurements of the intraocular pressure in your right and left eye (or left and right eye). The eye is similar to a water balloon. There is a small amount of fluid that is made by the eye that keeps the eye inflated, but there is also a drain that constantly allows some of that fluid to leave the eye and be re-absorbed by the body (note: the fluid that is made and leaves the inside of the eye is not the same as the substance that makes tears; rather it is a different fluid called aqueous humor). If the eye makes too much fluid or not enough fluid is allowed to drain out of the eye, the pressure will increase inside the eye. We measure pressure in units called "millimeters of mercury" (mmHg), so it sounds as though your eye pressure is 67 mmHg and 27 mmHg. If this is the case, you likely have glaucoma and need to be evaluated and treated. A pressure of 67 mmHg will eventually lead to blindness if not treated quickly. Your eyes should be examined by an eye doctor who has expertise in evaluating someone for glaucoma.

Thank you for submitting it this excellent question. Unfortunately, it is impossible to predict how long each of these medications will continue to work in your specific case. Every patient is different. We know that some medications tend to work better than others, but even this is never guaranteed. I have some patients that have been using a single medication for over 20 years and it works well for them. I have other patients that have tried to use the very same medicine but it either did not work at all, or only worked for a little while. There is no way to predict how long medications will continue to work in an individual patient. This is why it is very important that you continue to see your eye doctor for regularly scheduled visits. The doctor will check the eye pressure to make sure the medication is still working well and that your intraocular pressure is being maintained at the appropriate level.

Thank you for your question. This is actually something that I am asked quite frequently by my patients and their families. Unfortunately, even though we have made tremendous advances in research and the treatment of glaucoma, eye transplants or optic nerve transplants are not possible at this time. The most promising research in this area is stem cell research. There are several people exploring stem cell research to determine whether the stem cells can be used to help fix the optic nerve, but these studies are in their earliest stages. The use of stem cells to treat a damaged optic nerve is likely decades away. For now, our only treatment for glaucoma is to lower eye pressure by using drops, laser, and surgical methods.