Science & Research

Thank you for your questions. Because I have not examined your daughter's eye or seen the results of the test myself it is very difficult to give fully accurate advice in this complex case. I will take the information that you have given but will have to make some general assumptions to fill in the remainder. Let's take each of your questions individually:

• Do you think it is acceptable to wait 6 weeks for the eye clinic appointment?

  Given that your daughter is considered a glaucoma suspect and the pressures are only mildly elevated at this time, 6 weeks is not an unreasonable wait. There are patients with pressures that remain above 21 for nearly their entire life and never progress to glaucoma. We often describe them as "ocular hypertensives."

• What kind of ophthalmologist should we go to?

  Keep your appointment with your pediatric neuro-ophthalmologist. After they have seen your daughter they will be able to make a more clear recommendation as to whether or not a glaucoma specialist is needed. It sounds as though your daughter has need of a pediatric specialist, possibly a neuro-opthalmology specialist, and possibly a glaucoma specialist. Starting with a pediatric-neuro-ophthalmologist is an excellent beginning and they will be able to assess whether or not she needs to see a glaucoma specialist. Because you are in a University Hospital setting, the pediatric-neuro-ophthalmologist probably has a glaucoma specialist partner that can easily be consulted. I do suggest that you try to use a single practice for your sub-speciality care and not see a pediatric specialist in one practice, a neuro-ophthalmologist in another practice, and a glaucoma specialist in a third practice. It is better for patient continuity and care to have all of the specialty care in one practice, if possible.

• Our new appointment is with a pediatric neuro-ophthalmologist. Should we see a glaucoma doctor?

  See the answer above.

• The new doctor ordered a full spectrum visual field test. What other tests should they order?

  This is difficult to determine because I did not personally examine the visual field test results and I did not examine your daughter's eyes. In general, if I am concerned about glaucoma I would typically like to see the visual fields, gonioscopy, central corneal thickness, stereo disc photos (for baseline comparison in the future), and possibly an OCT of the optic nerve head and a couple of other general exam findings. Again, this all may change if the visual field and the optic nerves look relatively healthy and the only issue is slightly increased pressure. Let the neuro-ophthalmologist examine her first and they will have a better idea of which tests to order.

• Can my daughter go on roller coasters, play sports, swim, hike, or fly in an airplane without treatment? Is that safe?

  This is an interesting question. In our patients with pigment dispersion syndrome and pigmentary glaucoma, we do know that they can have increased pigment dispersion with exercise and this can lead to occasional bouts of elevated eye pressure. While your daughter's angle appears to be relatively wide open, it might not be a bad idea to restrict her intense exercise for a couple of weeks until she sees the specialist. This being said, roller coasters are fine if they do not jar her head around. Mild exercise with sports/swimming/hiking is fine (and encouraged considering her age, height, and current weight). Flying should also be fine.

• My daughter is 5’3” and very over weight (170 pounds). Could her weight have an impact on her eye problems?

  First, at the age of 13, a girl that is 5'3'' and 170 pounds is likely considered morbidly obese. This has ramifications on her health way beyond just her eyes. She is at risk for early diabetes, hypertension, heart trouble, and a lot of other health problems. As her parent, it is important for you to provide guidance. I highly recommend that you find a pediatrician that can help you plan a good diet and exercise routine to help your daughter lose some weight and become healthier overall. As for her eyes specifically, this is nearly impossible to determine without examining her eyes myself. Young women that are obese can have certain eye problems that are also accompanied by headaches and swelling of the optic nerves; however, by what you have told me about her exam, this does not appear to be the case. Again, overall, making a lifestyle modification that includes a better diet and an exercise program is the best advice for her long-term health.

Thank you for your question. This is something that many of our readers inquire about. Essentially, your question relates to the long-term effectiveness of drops. This simplest and most straight forward answer is that every patient with glaucoma progresses at a different rate and patients often react to medications differently over time. Unfortunately, neither I nor any other glaucoma specialist can predict how long a certain treatment will continue to work in an individual patient. In many of our patients, a drop will continue to work for their entire life; however, we also have many patients that have used a drop for years and have done well, but suddenly the drop no longer maintains their intraocular pressure at the target level. The exact reason for this is not always clear, and researchers are exploring why this happens.

Glaucoma is a progressive disease, and it may just be that the resistance to the flow of aqueous through the trabecular meshwork continues to get worse over time. It is possible that one drop may be adequate initially, but as the glaucoma progresses, it eventually becomes insufficient. It is also possible that the body may begin to respond less well to the same medication over time. More research is required to find the exact mechanism(s). Continue to use your eye drops as prescribed by your eye doctor and visit him/her routinely. Your doctor will examine your eyes and watch for any signs of progression. If there is any evidence that the current treatment regimen is not working, they will change it quickly and hopefully prevent any further damage to your eyes.

Yes it should be safe to continue to use the eye drops after they have been scanned. Please continue to use them as prescribed by your eye doctor.

Thank you for your question. Glaucoma is classically defined as a stereotypical pattern of damage to the optic nerve and certain layers of the retina. In addition, in patients with glaucoma, there are also corresponding visual field defects that are consistent with the damage to the optic nerve. Often patients may have an eye exam and all of the classic findings associated with glaucoma may not be present, but something on the exam may cause the eye doctor to become concerned that there are signs that the eye could develop glaucoma in the future. This may be a family history of glaucoma, an early defect in the visual field, something curious that they see on the optic nerve during the exam, or other findings. If this is the case, the doctor may tell you that you are a “glaucoma suspect” or that you have “pre-glaucoma.” This means that they do not yet believe you have glaucoma, but that you should be watched closely for the development of glaucoma 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, OCT, and the appearance of the optic nerves to see if there is any evidence of glaucoma that presents in the future.

As for preventing you from progressing to glaucoma, that is a more difficult question to answer. In a patient that will eventually go from being a glaucoma suspect to having clinically diagnosed glaucoma, it is possible, but not absolutely proven, that lowering the intraocular pressure may slow that progression. This can be achieved by starting a pressure lowering drop in a patient labeled as a “glaucoma suspect.” However, there are some patients that may remain glaucoma suspects for their entire life and never progress to clinically defined glaucoma. Knowing which patients will progress and which patients will not progress is impossible. The problem is that some of our glaucoma drops have side effects, and starting drops without clinically defined glaucoma puts a patient at risk for experiencing those side effects when it may not be necessary. You would need to discuss the risks, benefits and alternatives of choosing this course with your doctor and then determine whether or not you are willing to risk the side effects of the medicine even though you may not need them.

Thank you for your question. The answer to both questions is absolutely. First, most drugs that we use have a relatively short half life, meaning that they only work for a short amount of time (usually several hours to one day). This is the reason that you have to put drops like Travatan in each day, and the reason we have to put drops like timolol and brimonidine in multiple times during the day. If you skip using the drop one night, your pressure absolutely can, and likely will, be increased the next day. The second part of your question relates to the long-term effectiveness of drops. In many of our patients, a drop will continue to work for their entire life; however, we also have many patients that have used a drop for years and have done well, but suddenly the eye drop no longer maintains their intraocular pressure at our target. The exact reason for this is not always clear, and people are doing research to look into this. Glaucoma is a progressive disease, and it may just be that the resistance to the flow of aqueous through the trabecular meshwork continues to get worse over time. It is possible that one drop may be adequate initially, but as the glaucoma progresses, it eventually becomes insufficient. It is also possible that the body may begin to respond less well to the same medication over time. More research needs to be done to find the exact mechanism, but the simple answer to your question is that it is not unusual for an eye drop that has worked for some time in a patient to become insufficient at maintaining our goal intraocular pressure later in life.

Thank you for your question. Without having examined your mother or having seen the results of her previous exam tests, it is nearly impossible for me to predict what course her disease or vision will take. To my knowledge, there are no approved intraocular injections for the treatment of open-angle glaucoma. Occasionally, we will inject medications around the eye after a trabeculectomy to help the trabeculectomy function, but the injection does not go into the eye. The medications that we typically inject into the eye are anti-VEGF agents (Lucentis or Avastin, for example) for the treatment of neovascularization, which may be caused from diabetes, macular degeneration, or after a vessel occlusion in the eye. The second medication that can be injected into the eye is steroid, and this is to treat inflammation. With pressures of 40-50 I would suggest asking her doctor if she has neovascular glaucoma. If this is the case, my question would then be why is the neovascularization present? For example, does your mother have diabetes or has there been a vascular occlusion of the eye. Without knowing more and examining her myself, I could not give you an accurate recommendation. What I can tell you is that if your mother has advanced glaucoma that has progressed to the stage that she is only seeing some light and images with difficulty, a pressure of 30 is still too high and at that pressure, she will likely continue to lose vision. Unfortunately, if the vision loss is caused by glaucoma it is most likely permanent. I suggest you speak with your eye doctor to understand why the course of treatment has been taken and what the goal pressure is for your mother. You can also ask for a second opinion from an ophthalmologist that has completed a glaucoma fellowship and is comfortable treating advanced complicated problems.

The second part of the question is again difficult to answer without having actually seen the “blood mark” myself. It is very possible that this is simply a subconjunctival hemorrhage. The eye is similar to a baseball wrapped in plastic wrap. The leather of the baseball is similar to the sclera. The plastic wrap is similar to the conjunctiva. A subconjunctival hemorrhage is simply a small blood vessel that has broken between the conjunctiva and the sclera that has allowed the blood to collect. It is almost always completely benign and will likely resolve over several weeks (longer if your mother takes blood thinners). To be safe, I suggest you have the spot examined by an eye doctor for confirmation.

Thank you for your question. Let’s take the last part of your question and answer it first. Cat Scratch Disease is caused by getting scratched by a cat and that scratch then allows the penetration of bacteria known as Bartonella henselae into the body. This infection can involve the eyes and result in what we call neuroretinitis. This is a swelling and inflammation of the optic nerve and the retina. However, this swelling is different from the enlarged optic nerve cup that is a sign of glaucoma. An eye doctor should not be confused by the appearance of these two very different presentations, so I would say that this is not likely related to your kittens.

As for the asymmetric cupping between the right and left eyes, this is another matter. I think you should be followed closely by a glaucoma specialist to watch for the development of glaucoma. It sounds as though your doctors have done a good job by completing a visual field exam, taking the intraocular pressure, and looking at the optic nerves. I would suggest making sure that you have baseline stereo optic nerve photos completed as well. It may be possible that the enlarged cupping may be related to the previous retinal detachment. In the area of the detachment, there may be some old scaring and thinning of the retina. Because one of the layers of the retina, the retinal nerve fiber layer, comes together to create the optic nerve and optic cup, a thinning of the retina related to your old retinal detachment may be the cause of the enlarged cupping. If this is the case, it will likely remain stable. However, in some patients, previous eye surgery can put you at a slightly increased risk of developing glaucoma in the future, so I think that you should be watched closely. Your eye doctor should continue to monitor your visual fields and intraocular pressure, and continue to do dilated exams to look for changes in your optic nerve.

Yes, you are correct; Cosopt is a combination of timolol maleate 0.5% and dorzolamide HCL 2%. Using each drop individually may in fact be cheaper depending on where you get the medications and what insurance company you are currently using. In most cases, you can get timolol for 4 dollars at many of the national chain pharmacies. Recently, however, Cosopt has become available as a generic medication. This being the case, it may now be cheaper to buy the single bottle of generic Cosopt instead of a bottle each of timolol and dorzolamide. Check with your local pharmacist and they can assist you making that comparison.