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.

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.

Thank you for submitting this interesting question. Let's divide this question into two parts. First, the most recent large study looking at the risk of alcohol consumption and the diagnosis of glaucoma were published in 2007 from Harvard Medical School. The study examined 80,486 female nurses followed from 1980 to 1986 as part of the prospective, longitudinal Nurse's Health Study, and 42,251 male healthcare professionals who were followed from 1986 to 2002. The final conclusion of this study was that the amount of alcohol consumed by an individual did not influence the risk of being diagnosed with glaucoma.

This brings up a second different question however, and that is whether or not alcohol consumption has an impact on intraocular pressure. The answer to that question is yes. Alcohol consumption can lower intraocular pressure for a short time; however, it should never be used as a method of treating glaucoma or increased intraocular pressure. This is important for patients with glaucoma or patients that are currently being followed because the eye doctor is concerned that the patient may develop glaucoma in the future (i.e. a ‘glaucoma suspect’). Patients in these categories should not consume alcohol prior to their doctor's visit as this may falsely lower their intraocular pressure and make monitoring or diagnosing glaucoma more difficult.

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).

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 question. There have been several studies that have shown an association between sleep apnea and the presence of glaucoma. Many ophthalmologists are beginning to routinely ask their patients whether or not they have ever been diagnosed with sleep apnea when asking about the patient’s past medical history. While we recognize that there is likely a correlation between sleep apnea and glaucoma we currently do not know the underlying reason behind the association. Some believe that sleep apnea causes a decrease in the amount oxygen being carried in the blood to the optic nerve. Others feel that it may be related to the use of the continuous positive airway pressure (CPAP) machine for treatment, as CPAP use has been correlated with increasing intraocular pressure. Other theories also exist. Currently very little is known regarding the cause and effect relationship between these two diseases; however, most ophthalmologists do agree that there is a correlation between them. A lot of studies are currently being done in this field and hopefully we will know more in the future.

I am unaware of any protein that can revive the optic nerve, but if you can send me the specific name of the protein, I will research it further. In general, patients with glaucoma should know that currently there are no prescription medications, natural therapies, vitamins, supplements, or alternative therapies that have been proven by controlled scientific studies in humans to be of benefit in protecting the optic nerve or reversing damage to the optic nerve caused by glaucoma. The only prescription medication currently on the market that is known to lower intraocular pressure and is also being studied as a potential “neuroprotective” agent (i.e. protects the optic nerve from damage caused by increased intraocular pressure) is brimonidine (trade name Alphagan). The original studies were promising in animal models of glaucoma; however, further studies are needed to prove this effect in humans.

Multiple medicines are being studied as possible "neuroprotective agents,", but to date there has been no conclusive evidence that any of these medications work in humans. There is a great deal of research in the field of "“neuroprotection" and I believe we will eventually find some promising new drugs in this area to help our patients, but we just are not there yet. I would caution you to research any supplements, vitamins, natural therapies, or alternative therapies carefully. These therapies are not regulated by the FDA and therefore the claims made regarding what they can dotheir efficacy does not have to be proven scientifically. Unfortunately, this can lead to false or misleading claims. That is not to say that supplements, vitamins, natural therapies, or alternative therapies cannot have beneficial effects;, the manufacturer should simply provide good controlled scientific evidence for the claims that they make. In addition, continue to have an ongoing conversation with your eye doctor regarding new developments in the field of "“neuroprotection"” research that may be of benefit to you.

The simple answer is yes. Even if you are using eye drops, you can go blind in the future if the intraocular pressure is not reduced enough to prevent further loss of vision. Without having examined your eyes previously, it is difficult to predict what will occur to your eyes in the future. There are a lot of different types of glaucoma and they can progress at different rates. Once a thorough eye exam has been completed, your eye doctor will likely set a target or goal intraocular pressure. To achieve this goal, there are essentially three different tools that he or she can use to treat your glaucoma. As glaucoma specialists, we use eye drops, laser treatments, and surgical methods to lower the intraocular pressure. We then follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves after the new treatment is started. If there is evidence of glaucoma progression, then more drops, more laser treatments, or more surgery will be necessary to lower the eye pressure even more. In the majority of patients, it is possible to lower the pressure enough to stop or dramatically slow the loss of vision; but this may take multiple surgeries, lasers, or medicines (and likely a combination of these three). In some cases, we cannot stop the progression of the glaucoma and our patients do eventually go blind, but this is the minority of patients. If you are concerned that your glaucoma is progressing, it is also ok fine to ask for a second opinion from an ophthalmologist that has completed a glaucoma fellowship.

In addition, this may simply be a case of miscommunication. It is important to understand what definition of “blindness” your eye doctor is using. Often when patients hear an eye doctor use the words “blindness” they think about the eye not being able to see even very bright lights. However, your doctor may simply be saying that you are “legally blind.” This may have an impact on disability or insurance claims. The definition of legal blindness includes both acuity (how small are the letters that you can see) and your visual field (how much peripheral vision do you have). Some patients with advanced glaucoma have excellent visual acuity (20/20 vision) but have very small visual fields (10 degrees or less) and are considered legally blind. I encourage you to have a discussion about this with your eye doctor to clarify what he meant. If it is necessary do not hesitate to ask for a second opinion from another glaucoma specialist.