Science & Research

Thank you for your question. There are a many different types of glaucoma, and they can progress at different rates. If you were diagnosed at the age of 19, you likely have some form of congenital/juvenile glaucoma, angle-closure glaucoma, or secondary glaucoma and not primary open-angle glaucoma. Some types of glaucoma can progress quickly if the pressure is incredibly high and it can take vision within days or weeks. Other types of glaucoma are quite slow and it may take months or years before there is any evidence of vision loss. It is difficult to predict what course your glaucoma will take; however, if your pressure remains in the upper 30s to 40s range it should be treated aggressively to lower it as soon as possible. It is important to see your eye doctor regularly and not miss any appointments.

Once a thorough eye exam has been completed, eye doctors often set a target or goal intraocular pressure. The only variable that we can change to slow or stop the progression of your glaucoma is the intraocular pressure. To achieve this goal, there are essentially three different tools that we can use to treat glaucoma. We use eye medicated eye drops (like the Betoptic that you are using), laser treatments, and surgical methods to lower the intraocular pressure. Your doctor has prescribed Betoptic, and it is very important that you continue to use the eye drop daily as directed. He or she will likely follow the intraocular pressure, vision, visual fields, and the appearance of the optic nerves to see how your eyes are responding. If the pressure is not reduced enough on Betoptic alone or your doctor ever notices advancement in your glaucoma, they will add more medications or use laser or surgery to help lower the intraocular pressure further. 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, doctors cannot stop the progression of the glaucoma and patients do eventually go blind, but this is the minority of patients.

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." 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. 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 OK to ask for a second opinion from a glaucoma specialist.

Your blood pressure and cholesterol medications should not have a harmful effect on your eyes. In fact, one of the most commonly used oral medications for controlling blood pressure (beta-blockers) are the same type of medication that we use in drop form to lower eye pressure and treat glaucoma. In addition, there are studies that are currently ongoing that show cholesterol lowering medications (statins) and blood pressure medications may actually be beneficial for patients with certain types of glaucoma. These studies are all preliminary and must be repeated in larger studies, but overall these medications are in no way contraindicated in patients with glaucoma at this time.

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.