General Qs & As Reprinted from Our Newsletters

Do I have glaucoma?

Patients frequently ask their doctors the question “Do I have glaucoma?” To reply, I need to do a complete eye exam as well as visual field testing. Additional tests such as HRT (Heidelberg Retina Tomography) and OCT (Ocular Coherence Tomography) may help me answer. I often tell patients that to truly say one has glaucoma, we must document characteristic optic nerve head changes and/or visual field loss during the first exam or follow-up appointments. We must also see signs of worsening of the optic nerve or visual field over the follow-up period. It may take many years before changes are found.

 

My family member has glaucoma, what are my chances of getting it?

Although glaucoma tends to run in families, it does not affect all family members equally. Your overall risk increases with the more first degree relatives (parents, siblings) affected by glaucoma that you have. If you have family members with glaucoma, you should be screened regularly.

 

Do only elderly people get glaucoma?

No, not all glaucoma patients are elderly. In fact, 25 percent of patients are under 50 when they develop the disease.

 

I see very well and do not wear glasses. How can I have glaucoma?

Glaucoma affects the peripheral vision first, and only affects central vision very late in the disease, so it has no effect on your need to wear glasses.

 

I have glaucoma and was told my vision is not good enough for me to drive. What are the requirements to keep my driver’s license?

Patients with advanced glaucoma may not meet the legal requirements to drive. The current regulation is to maintain 20/50 or better vision in at least one eye and have at least 120 degrees of continuous visual field. Because glaucoma can affect peripheral vision, many patients with advanced glaucoma may have 20/50 or better vision but they do not have enough continuous visual field. In Ontario, physicians must report this by law. This may result in a suspension of your license.

 

Can I use medical marijuana to lower my eye pressure?

Researchers have found Cannabinoid receptors in human eyes. Cannabinoids are the active ingredient in marijuana and help to lower eye pressure. Their action is short lived so you would have to smoke marijuana constantly to have any long-term effect in lowering eye pressure. This would result in a constant “high” which would be unsafe. Also smoking marijuana has significant health risks including lung cancer. Using marijuana to treat glaucoma is not recommended.

 

Does wearing sunglasses help glaucoma?

A recent report suggests that certain wavelengths of light could be bad for the optic nerve. This hasn’t been proven yet but it would be wise to wear sunglasses and a hat on very bright days.

 

Does eye strain cause glaucoma?

No.

 

I have been diagnosed with glaucoma and understand that I should not lift weights, or do any exercise where my head is below my waist. What exercises can I do to maintain my strength in my arms and upper body?

Overall exercise can lower eye pressure, but avoid any activity that can raise the pressure around the face. This includes heavy weightlifting, certain yoga positions such as downward dog and headstands, and playing wind instruments.

I recommend talking to a personal trainer who can advise you on a program that mixes light weights with cardio to maintain both strength and fitness.

 

Studies have shown that sleeping with pillows elevated 20-30 degrees lowers IOP. Would this be a good thing for someone with visual field loss to try?

Sleeping with lots of pillows simply tilts the head forward bending the neck. This bending may not help with lowering eye pressure. It’s important to raise the head of the bed so your head is raised above your heart without bending your neck. This has been shown to lower eye pressure in some patients. Placing pillows under the mattress to raise the head of the bed by a few inches is one way to achieve this.

 

Will using steroid cream for a skin condition accelerate glaucoma’s progression?

All steroid medications can potentially cause eye pressure elevation and lead to the development or worsening of glaucoma. The most common steroid medication that causes eye pressure elevation is topical steroid eye drops instilled directly into the eye, followed by topical steroid creams applied around the eyelids, and by orally ingested steroids.

Inhaled steroids for lung conditions and steroid nasal sprays and creams applied to body parts are less likely to cause elevated eye pressure, but I recommend getting your eye pressure checked about 2 weeks after starting any steroid medication to see if it has an effect on you. Please note glaucoma patients are especially at risk of a pressure spike with steroid use.

 

Should I tell my family doctor and pharmacist that I have glaucoma?

Yes, let them know, so that they can advise you about possible effects on the eye of any prescribed medications and vice versa.

 

Can vision deteriorate despite treatment for glaucoma?

Yes, as part of the normal aging process, we lose cells in the optic nerve responsible for vision. Currently, there is very little that can be done about this change due to aging.

Patients with severe damage from glaucoma will be more aware of this progressive loss of vision. That’s why it’s essential to diagnose glaucoma early before damage occurs to the nerve cells.

 

I have been diagnosed with early stage glaucoma and need to start treatment. What do you recommend?

We usually start with a prostaglandin medication or a beta blocker. Side effects are generally minimal in healthy adults but can affect the eyes – red eyes, stinging, allergic reaction – or the body – headache, slow heart rate or gastrointestinal upset. The other option is laser treatment, but it may not work or its effect may not last, requiring eye drops in the future.

 

Why is the first-line treatment for glaucoma eye drops, rather than surgery?

Both eye drops and surgery are ways to control eye pressure. Surgery may have complications such as bleeding, infection and loss of vision. The recent Collaborative Initial Glaucoma Treatment Study (CIGTS) comparing early surgery to eye drops showed very little difference between the two groups in final outcomes for glaucoma control. But more side effects were noticed in the surgical group.

For early cases, we are looking at surgical techniques such as iStent, Xen, Infocus, and Hydrus as ways of controlling eye pressure with minimal eye trauma and better success for the patient without the use of eye medications.

 

I was recently diagnosed with moderate to severe glaucoma in my right eye and put on Lumigan, Cosopt and Alphagan. Despite only having had my pressure taken a couple of times, my doctor suggests immediate laser treatment followed by surgery if the laser doesn’t work. Is this normal?

If you have moderate to severe glaucoma, IOP control is very important. We usually recommend an eye pressure at least 50% below the untreated number and/or <15 mm Hg. Probably despite all the eye drops you are using, you are still not at target eye pressure and that is why the doctor is recommending laser treatment and/or surgery.

 

I was diagnosed with early stage glaucoma during a routine eye exam two years ago. Since then, I have noticed that my peripheral vision is not as sharp as it once was, and I keep bumping my head. Should I see an eye specialist?

I suggest your family doctor or optometrist refer you to an ophthalmologist for a full glaucoma assessment including an eye exam, optic nerve imaging and visual field testing. This will help make the correct diagnosis and determine the best way to lower intraocular pressure (IOP) – the only treatment for glaucoma.

 

I have had glaucoma for over 30 years. I have always stayed on my medications, had many laser and traditional surgeries, and kept my appointments. But after getting corneal transplants in my eyes over a year ago, I lost sight in my left eye. Doctors tell me that nothing that can be done. Please let me know what you think about this situation.

It is difficult to know from this question if the vison loss described is a consequence of the transplant surgery or the glaucoma or both. Unfortunately, loss of vision from glaucoma alone does occur even with the best treatments. Glaucoma is a progressive condition, treatment only slows the progression. There is no cure at this time.

 

Are there ways to increase ocular pressure?

No. Low eye pressure happens because the faucet of the eye turns off (ciliary body shut down). This can be from injury or post-operative inflammation. Usually it restarts over time. Eye inflammation can be controlled with a topical steroid eye drop. Topical atropine drops may also help.

 

I have received alarming emails warning that reading from mobile phones in the dark can cause serious vision problems including irreversible macular degeneration. Please comment.

This type of unsolicited chain email has no basis in scientific fact. No evidence links smart phone use to early onset macular degeneration, glaucoma or cataracts.

 

What are the possible treatments for closed angle glaucoma? Is cataract surgery one of them?

The mechanism of the glaucoma determines the best treatment. The main cause for angle closure is pupillary block where the lens and the iris are in contact so fluid cannot flow from behind the eye to the drain of the eye that is in front of the iris and lens.

In this case, treatments include eye drops to lower eye pressure, pilocarpine to constrict the pupil, laser or surgical iridotomy to open the angle and cataract surgery to remove the large lens.

Sometimes if the eye pressure is not controlled, conventional glaucoma surgery is used.

Recent studies from China have shown that cataract surgery is beneficial in managing closed angle glaucoma.

 

Could blurry vision and headaches be warning signs of glaucoma? I am 27 years old and spend a lot of time in front of the computer.

These could be signs of glaucoma but you are a bit young. Lengthy time spent on a computer can cause dry eyes and eye fatigue. I suggest you get a complete eye exam to rule out glaucoma or anything else that may be causing these symptoms.

 

I have been diagnosed with early stage glaucoma. Can you advise me if using a computer all day worsens the condition? What about stress?

Working on a computer all day will have no impact on the worsening of your glaucoma. No studies have shown that stress worsens glaucoma, but many ophthalmologists have found that eye pressure may be elevated during periods of stress. This may be due to poor compliance with eye drops use. The best way to minimize worsening of glaucoma is to use your drops and attend your regular follow-up appointments.

 

My wife has lost one eye to glaucoma and surgery on the other eye has left her with 10% vision. Would acupuncture help to improve the optic nerve and regulate the pressure?

Acupuncture has no benefit on eye pressure, although it may help alleviate stress and anxiety.

 

Does “loss of vision” mean blindness?

Loss of vision can range from mild vision blur to complete loss of sight meaning unable to see light or dark.

 

If someone has lost the rim in one eye, will this affect the other eye? What could be done to halt the deterioration?

The risk to the second eye depends on the eye pressure. If it is controlled, the risk is usually minimal. Monitoring the visual field test will determine if the second eye is getting worse. However, it is imperative to listen to your ophthalmologist, keep follow-up appointments and use the medications prescribed to control the eye pressure.

 

What is Ocular Hypertension? Does it need treatment?

Ocular Hypertension occurs when the eye’s pressure is elevated (greater than 22) but there is no damage to the optic nerve or visual field.

Many years ago, patients with eye pressure greater than 22 were treated for glaucoma.

The Ocular Hypertension Treatment Study concluded that not every patient with elevated eye pressure needed treatment. In the study, some patients worsened despite treatment and over 80% of untreated patients did not worsen.

The study found other risk factors that contributed to glaucoma and these factors combined with elevated eye pressure may indicate the need for treatment.

 

What is the difference between glaucoma and ocular hypertension?

Glaucoma refers specifically to high pressure causing damage to the optic nerve and/or peripheral vision. Ocular hypertension refers to high pressure which does not damage the nerve or vision. Most patients with ocular hypertension do not develop glaucoma.

 

Are there any new therapies?

Some new formulations of existing medications are now available including:

• Travatan Z with a different preservative
• Lumigan RC where a lower concentration of the drug provides the same IOP lowering effect
• Azarga which combines Timolol and Azopt in the same bottle

These various medications may either reduce eye drop side effects or reduce the frequency of eye drop use.

Surgically, new treatments include:

• the Express Shunt
• Canaloplasty
• Trabectome
• iStent

All these surgeries aim to lower intraocular pressure and reduce eye drop use.

 

What is low tension glaucoma?

Normal tension or low tension glaucoma is a condition where there is damage to the optic nerve and/or the visual field in the setting of normal eye pressure (<22). More than 50% of normal tension glaucoma patients don’t worsen even without treatment so it is okay to watch.

 

Can issues, such as blood pressure, weight, diet, and smoking affect my glaucoma?

There is more of an association of glaucoma worsening with low blood pressure than with high blood pressure. Certain blood pressure medications, such as diuretics (water pills) or calcium channel blockers have been associated with glaucoma worsening, but the data to support this is still limited.

Diet and weight loss do promote overall general well-being and obese people may have higher eye pressure readings.

Smoking has been shown to affect glaucoma surgical outcomes in a negative way and patients are encouraged not to smoke.

 

I have low normal blood pressure and low tension glaucoma. Recently, a blood vessel burst in the white of my good eye (only about 30% vision loss). The blood covered about half the eye (white part only). I was told by two doctors that there was nothing to worry about and that it would clear up in a couple of weeks. I had not suffered a blow to the eye; the blood appeared after I finished a strength training and aerobic workout. It took only three days for my eye to clear up. Should I be concerned?

You had a subconjunctival hemorrhage. This can happen with coughing or sneezing and is also associated with the use of blood thinners such as Aspirin or Coumadin. Most are of no concern, resolve in about a week, and have no effect on your glaucoma.

 

What is the time frame for the progression of vision loss in normal tension glaucoma when there was considerable nerve damage (~75%) at the time of diagnosis?

We can’t estimate time to vision loss. Each patient progresses at their own rate although it’s a good sign when there is no progression over the years. Treatment will help maintain vision and slow progressive vision loss in most cases. The Normal Tension Glaucoma Study shows a 30% lowering of eye pressure slows the worsening of glaucoma.

 

Are any other medical problems associated with glaucoma?

Raynauds syndrome and migraine are commonly associated with normal tension glaucoma as is low blood pressure and major blood loss.

 

What does a hemorrhage on my nerve mean?

In glaucoma, a small hemorrhage on the rim of the optic nerve indicates that eye pressure is too high for the nerve. Your eye specialist will usually recommend lowering your pressure to a safer level with eye drops, laser treatment or surgery.

 

Are there any possible causes for optic nerve damage other than glaucoma?

Other things can mimic glaucoma field loss. These include a “stroke” to the eye which can cause a similar visual field defect, previous eye trauma with damage to the retina, or, more rarely, a brain tumor.

 

I lost my peripheral vision due to a pituitary tumor which compressed my optic chiasm. The tumor was removed, but my peripheral vision has not returned.

Compression of the optic chiasm from a pituitary tumor can lead to loss of peripheral vision as retinal ganglion fibres that start in the eye travel down the optic nerve to the chiasm and then finally to the brain. After surgery to remove the tumor, there is less compression on the chiasm and ganglion fibres, so as long as the fibres haven’t been destroyed by the compression they may possibly recover to some extent and your peripheral vision may return but the process will take time.

 

If my blood pressure is high will my eye pressure be high?

Not necessarily. Although there is an indirect relationship between high blood pressure and glaucoma in older patients, patients under stress or who experience a sudden increase in blood pressure do not usually have high eye pressure.

 

The Canadian Medical Association recently published an article showing a higher incidence of inflammatory eye diseases – uveitis and scleritis – for users of osteoporosis drugs (oral bisphosphonates). Do these eye diseases worsen glaucoma?

Osteoporosis drugs have been linked with uveitis. Discontinuing osteoporosis drugs is usually the best management for uveitis.

The use of these medications does not directly cause glaucoma to develop or worsen. However, if someone develops uveitis, the treatment is topical or oral steroids. Long term use of steroid medications can cause eye pressure elevation and the development of glaucoma. This is less likely to occur if you are under the care of an eye specialist who monitors your condition.

 

Would applying a warm damp compress for 10 minutes a day reduce the IOP in the aqueous humour of my eyes?

No – there is no clinical evidence that a warm compress will reduce IOP either by reducing aqueous production or enhancing aqueous outflow.

 

I want to use baby shampoo to treat eye lash inflammation. Do I mix it with water or use it straight from the bottle?

The use of baby shampoo or eye make-up remover is for the treatment of Blepharitis – an inflammation of the eye lashes. Either use hot compresses for 5 minutes or lid scrubs (analogous to removing eye make-up). You can use them undiluted, but there may be less stinging and eye irritation when diluted.

I suggest trying just a drop on the finger first – if it is too irritating for the eye then dilute it with some water. No formula, just add enough water so it stays soapy but not irritating.

 

Why can’t the eye grow new nerve cells to replace the ones damaged by glaucoma?

The eye is made up of sophisticated nerve cells that are an extension of the brain and are incapable of regenerating when they are damaged. Currently, we are only able to regenerate certain neural cells in laboratory conditions. We are looking at medications that may help damaged cells survive longer or prevent the damage altogether.