Taking a Closer Look at Glaucoma
Online Health Chat with Dr. Jonathan Eisengart
February 11, 2011
Cleveland_Clinic_Host: Glaucoma is a condition characterized by degeneration of the optic nerve (the vision nerve) and impaired eyesight, ranging from slight vision loss to total blindness. Most patients with glaucoma do not notice any symptoms until the disease is very advanced.
Dr. Jonathan Eisengart joined Cleveland Clinic Cole Eye Institute’s glaucoma staff in July 2009. He received his medical degree from The Ohio State University in Columbus, Ohio. Dr. Eisengart completed his residency in ophthalmology and his fellowship in glaucoma and anterior segment surgery at the University of Michigan, Kellogg Eye Center, in Ann Arbor, Michigan. His specialty interests include medical, laser, and surgical glaucoma management, including filtering surgery with antimetabolites, glaucoma tube shunts, cyclodestructive procedures, combined cataract and glaucoma surgery, and newer non-penetrating glaucoma surgery.
Cleveland Clinic’s Cole Eye Institute is ranked among the top 10 ophthalmology programs in the country by U.S.News & World Report, making us the top-ranked program in Ohio. We are among an elite group of dedicated, comprehensive eye institutes. Our fully integrated model helps us provide patients with quick and easy access to specialty and subspecialty care for a wide spectrum of eye conditions – from the routine to the complex. Cole Eye Institute has extended its quality ophthalmic care to several locations throughout Northeast Ohio, allowing patient access to ophthalmologists closer to their homes.
To make an appointment with Dr. Eisengart or any of the other specialists at the Cole Eye Institute, please call 216.444.2020 or call toll-free at 800.223.2273, ext. 42020. You can also visit us online at www.clevelandclinic.org/eye.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Jonathan Eisengart, M.D. We are thrilled to have him here today for this chat. Let’s begin with the questions.
saelzcr: From my visual field test, the doctor said my vision loss is around 8 percent. Is that considered moderate field loss?
Dr__Jonathan_Eisengart: That is "moderate" vision loss. We are learning that even a little visual field loss means there is significant loss of optic nerve tissue (estimated to be 30 percent to 50 percent). In general, I grade glaucoma as "moderate" at the earliest signs of visual field changes. If there is glaucoma with no visual field loss, I grade it as "early" or "pre-perimetric." (Perimetric refers to the visual field test.)
deb777: I was recently diagnosed with glaucoma, but had no symptoms. Should I be concerned about losing my vision in the future? Does glaucoma cause blindness?
Dr__Jonathan_Eisengart: Most glaucoma can be successfully treated, and vision loss can be prevented. The most important thing you can do is keep your appointments with your eye doctor and use your eye drops as prescribed.
jerry: I have glaucoma. When I wake up at night, I cannot see (for a few seconds). Everything is blurred, and I also feel pain in my eyes. After blinking a few times, then I can see. What happens? Why?
Dr__Jonathan_Eisengart: Although this could be dry eye, it could also be a sign of a more serious problem. I would advise you to see your eye doctor promptly.
brilliant: I’ve been told that the opening of my optic nerve is larger than the vessels going through it. I was told that this could be a normal variant; and after further testing, I was told I did not have glaucoma. What do you think about this explanation?
Dr__Jonathan_Eisengart: A large optic nerve can definitely mimic the appearance of glaucoma, but simply be a "normal variant." It is relatively common for someone with a large optic nerve to be labeled as a "glaucoma suspect," and followed over time to ensure there is no glaucoma. It is important to note, however, that a large optic nerve is - by itself - a risk factor for glaucoma. Depending on your age and other risk factors, regular follow-up may be scheduled to ensure there is no glaucoma.
imfine: Regarding growth factor and new blood vessels – if this is happening in your eye, what are the chances this is happening elsewhere in your body? I ask because my teenage daughter had new blood vessels form in her lungs that were discovered during lung surgery. If this happens, what can you do to prevent the body’s signals to grow new vessels?
Dr__Jonathan_Eisengart: New blood vessels growing in the eye almost always mean there is not enough blood flow to the eye (usually from diabetes, a blocked blood vessel in the retina, or a blocked carotid artery). Rarely, new blood vessel growth in the eye can be from inflammation or, very rarely, from a tumor in the eye. I'm not aware of any connection between new blood vessel growth in the lungs and in the eye. There are medications that can prevent, and reverse, new blood vessel growth. At the moment, I am aware only of their use in the body to treat cancer and in the eye to cause abnormal blood vessels to go away. Whether these are appropriate requires discussion with your doctor.
smoothsailing: What is the increased risk of cataract surgery with pseudoexfoliation? If the diagnosed glaucoma is suspect baseline-tested with no progression after eight years, is it reasonable to assume you have a congenital large cup?
Dr__Jonathan_Eisengart: Pseudoexfoliation causes the zonules (fibers that support that natural lens in your eye) to be weak. Also, eyes with pseudoexfoliation often dilate poorly. Although these factors may make cataract surgery a bit more risky, an experienced cataract surgeon can still produce a very good outcome the vast majority of the time.
If you have a large cup and no progression for eight years, it is much less likely you have glaucoma. However, large cups are by themselves a risk factor for glaucoma. For my patients with large cups and no other evidence of glaucoma, I examine their eyes once per year.
grassisgreen: What is the function of pressure in the eye? If you reduce pressure, is there some function that will be lost?
Dr__Jonathan_Eisengart: Eye pressure keeps your eye "inflated," meaning stable and round. Additionally, the internal fluid brings nutrients to the vital structures inside your eye. Too little eye pressure (often less than 5mmHg) can cause serious problems with vision. It is very rare to have eye pressure too low, unless there has been serious eye disease, surgery, or injury.
history: What is normal eye pressure? Can the optic nerve be regenerated?
Dr__Jonathan_Eisengart: Average eye pressure is 9 to 21 mmHg. Glaucoma can occur even when the eye pressure is "normal." The optic nerve cannot be regenerated, which is why it is so important to treat glaucoma early and aggressively.
saelzcr: What would you consider to be a good eye pressure to maintain if you are on medications for glaucoma?
Dr__Jonathan_Eisengart: In general, we want at least a 30 percent to 40 percent reduction from the pressure before you began drops. This can vary depending on your stage of disease, age, and general health.
MattJam: When should a person consider having glaucoma implant surgery?
Dr__Jonathan_Eisengart: Surgery for glaucoma is typically reserved for people whose glaucoma has become difficult to control with medications and laser. Typically, the first-line procedure is called a "trabeculectomy," a surgery in which a new drainage flap is created in the eye to allow fluid to leave the eye and enter the tissues surrounding the eyeball. However, if trabeculectomy is likely to fail (ie if there is ongoing inflammation or scarring from previous surgery,), or if it has been tried and failed, then often a glaucoma drainage implant will be tried.
saelzcr: How successful is glaucoma surgery in stopping the disease? How risky is it?
Dr__Jonathan_Eisengart: Glaucoma surgery can be quite successful in lowering eye pressure (as high as 90 percent success at five years). However, it does entail significantly greater risk than cataract surgery. I strongly believe the risks and benefits must be carefully weighed, and only people who have a high risk of vision loss from glaucoma should have glaucoma filtering surgery.
JayM: I have a family history of glaucoma. Are there any other risk factors I should be aware of? Is there anything I can do to prevent glaucoma from developing?
Dr__Jonathan_Eisengart: If you have a first-degree relative with glaucoma (parent, sibling, or child,) then your risk of developing glaucoma is about 10 percent. If you have multiple family members with glaucoma, your risk may be higher. Although there is no action you can take to reduce your risk of developing high eye pressure, or glaucoma, regular eye exams will help ensure that if you develop glaucoma, it is caught early when it is most successfully treatable.
Mel767: Does high blood pressure cause glaucoma or increase the risk? Does it affect existing glaucoma?
Dr__Jonathan_Eisengart: There is no definite consensus in the medical literature whether high blood pressure can increase the risk of glaucoma. However, increasing evidence suggests that the glaucomatous optic nerve damage may be related to poor or abnormal blood flow in the optic nerve. Given that high blood pressure does affect small blood vessels and blood flow, it is reasonable to assume that high blood pressure is a risk factor for glaucoma. High blood pressure itself, however, does not directly raise eye pressure.
KelBell: I am taking corticosteroids for an adrenal problem. What is the likelihood I will develop glaucoma? I've heard that these types of medications can increase the risk.
Dr__Jonathan_Eisengart: Corticosteroids can raise eye pressure. If you’re taking just enough to replace your normal levels of steroids, the risk is probably low. If you're taking higher doses, there is an increased risk of raising your eye pressure. It is definitely worth having an eye exam to check your eye pressure and optic nerves.
JayM: With a history of glaucoma in my family, how often should I see an ophthalmologist to be tested for it? What it the test for glaucoma?
Dr__Jonathan_Eisengart: You should follow a normal regimen of eye exams, but starting when you are about 15 years younger than when your relative developed glaucoma, you should have yearly exams. A screening exam for glaucoma is a full eye exam - with special attention to eye pressure and an optic nerve exam. If suspicious findings are noted, additional testing - such as peripheral vision testing and optic nerve scans - can be performed.
doubletrouble: My sister has glaucoma and my father also had it. I have no sign of it to date (74 years old). What are my odds of developing it? My pressure is usually 13 to 15.
Dr__Jonathan_Eisengart: Your odds are probably low, but I still recommend an annual eye exam.
Carrie50: My husband was recently diagnosed with glaucoma, but he had no symptoms. How is a person supposed to know if they have or are developing glaucoma?
Dr__Jonathan_Eisengart: This is a great question. It is correct that glaucoma has no symptoms until vision loss has already occurred. This is why regular screening eye exams are so important. Exams should be done every two to three years in your 40s and every one to three years in your 50s. If you have risk factors for glaucoma, such as a family history, eye trauma, diabetes, extreme nearsightedness, or are African-American, a screening exam earlier and more often may be advisable.
saelzcr: I was diagnosed with glaucoma 20 years ago, and my doctor has been treating it with daily eye drops - Tarlatan® and Be topic-S®. When I was diagnosed, I had already lost about 5 percent of my vision. He says it's around 8 percent to 10 percent now. He says my eye pressure is being controlled by the eye drops. Is he is treating it conservatively. I am 58 years old and am wondering if this is the best approach, or should I have more aggressive treatment.
Dr__Jonathan_Eisengart: This is a difficult question to answer since I don’t have all the information I need to make an informed opinion. When treating glaucoma, I set a “target pressure” based on age, severity of glaucoma, starting pressure, and corneal thickness. The target pressure is the pressure at which I believe the glaucoma will not get worse. At every visit thereafter, I see if we are achieving the target pressure and whether the glaucoma is stable. The “target pressure” may change over time as we learn more about how your glaucoma is behaving.
quickquick: I have pressure but no glaucoma. I am using saline currently. If one eye shows borderline optic nerve changes and the other eye does not, must the second eye be treated?
Dr__Jonathan_Eisengart: This is a good question, and a good discussion to have with your doctor. Not all eyes with high pressure need treatment to lower the pressure. The decision to treat high pressure without glaucoma is based on your preference and your risk for developing glaucoma. High eye pressure is more likely to cause glaucoma damage if you are older, have thin corneas, have a larger optic nerve cup, or some specific changes on your visual field test.
photogramaph: My ophthalmologist has tried six different drops for my glaucoma (around 26 readings). I have a bad eye irritation reaction to all. (Azopt® worked for two years). He's recommended laser surgery and I'm wondering how side effects might be for me since I don't take medications well. Is there a connection with lisinopril and glaucoma? I've been on them for 20+ years. How does type 2 diabetes affect laser surgery?
Dr__Jonathan_Eisengart: If you've had redness, swelling, and irritation from "all" eye drops, you may have an allergy to the preservative in the drops, called BAK. Some preservative-free drops are available. I think laser is a good option when you haven't been able to take multiple different eye drops. Diabetes should not affect the success of laser surgery for glaucoma.
carny: What do you do if you cannot endure the acid HCl drop treatment used to lower internal pressure - “levobunolol” - your eye lids burn? Is the severity of myopic condition a relation to internal eye pressure?
Dr__Jonathan_Eisengart: The HCl (hydrochloric acid) in eye drops is to adjust the pH of the medication, to prevent it from being too acid or too basic. If an eye drop is burning your eyes too much, it may be worth trying an alternative. Although myopia doesn't raise your eye pressure, it probably is a risk factor for developing glaucoma.
AMiller: Is there a correlation between lisinopril and glaucoma?
Dr__Jonathan_Eisengart: No. The only point I would say is that glaucoma may be related to optic nerve blood flow, and it is important that your blood pressure not get too low. For patients with glaucoma, blood pressure medications that are dosed once per day should typically be taken in the morning to prevent the blood pressure from going too low at night (low blood pressure may contribute to glaucoma nerve damage.).
saelzcr: My pressure was 23 before I started the eye drops. Now the pressure is usually around 17. I worry I am not being aggressive enough by just taking medications. I take Betopic® and Xslatan®. Are there other medications that would be better at controlling glaucoma.
Dr__Jonathan_Eisengart: If you have specific questions regarding your management, I would suggest you please call and schedule an appointment with Cole Eye Institute or another glaucoma specialist. We cannot give you accurate answers to your disease management questions without a thorough exam of your eyes.
saelzcr: You mentioned controlling glaucoma with medications and laser before recommending surgery. I'm being treated with medications only. Could you further explain what the laser treatment is? My doctor has not mentioned this as a possibility.
Dr__Jonathan_Eisengart: Laser can be applied to the eyes internal drainage meshwork (called the trabecular meshwork) to help lower pressure. It is a quick, outpatient procedure that typically causes little discomfort. It is not a cure, and the effect wears off after several years, although the laser likely can be done again. Laser is usually as effective as one glaucoma medication. Argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT) are the medical terms for the laser. SLT is newer and can be repeated; ALT is older and can be done only once. Both are equally safe and effective.
glasses: Can vision be restored in the areas where laser is used?
Dr__Jonathan_Eisengart: If laser has caused a retinal scar, then vision cannot be restored in that area. It is extremely rare for glaucoma laser to cause any vision loss. Retinal laser, like for diabetic retinal swelling, may quite infrequently cause areas of vision loss.
AMiller: Is laser surgery a long-term solution to glaucoma?
Dr__Jonathan_Eisengart: Laser is rarely a long-term a solution, as its effects usually last one to five years. However, it probably can be repeated, although the effect may be less with each subsequent treatment.
AMiller: Is it possible for laser surgery to help me with glaucoma if I am unable to use the drops that are required after surgery due to allergies?
Dr__Jonathan_Eisengart: Yes. Laser surgery may reduce your need for eye drops.
saelzcr: I have the start of cataracts and – in the in future - am considering multifocal lens implants, in addition to cataract removal. I do have glaucoma. Could I still be a candidate for this type of surgery, even with glaucoma?
Dr__Jonathan_Eisengart: This is an excellent question, and not easy to answer. If you have early glaucoma with no visual field loss, I think a multifocal lens is a reasonable option. Be aware, though, that a multifocal lens will probably make your visual field test look worse, which can make it more difficult to accurately follow your glaucoma over time. If you have moderate or advanced glaucoma, I think the loss of contrast sensitivity from the multifocal lens may be a problem for you.
Another option is an accommodating lens implant. This is another type of lens implant that can help correct distance and near vision, but is not a multifocal and doesn’t adversely affect contrast sensitivity.
tardis: If I change my mind about the type of replacement lens after cataract surgery, can it be replaced? Can some of the symptoms of cataracts be corrected with eyeglasses?
Dr__Jonathan_Eisengart: It is definitely possible to replace a lens implant safely, but it involves additional surgery. Furthermore, the risks of lens replacement surgery may be higher than with the original cataract surgery. Glasses can help some of the blur from cataracts, but do not help glare or that sensation of “smoky” or “filmy” vision.
david: After cataract surgery, is there a lens that can be used for both close and distant vision?
Dr__Jonathan_Eisengart: There are several types of lens implants, each with their own advantages and disadvantages. The extra cost of the lens implant and professional services are not covered by your insurance. An additional, no-cost option that works well for many patients is called monovision, in which normal lens implants are used to make one eye have better distance vision, and the other have better intermediate/near vision. However, none of these are implanted after cataract surgery, only during the procedure.
pleasantlake: When is cataract surgery not recommended? For example, if you have cataracts in one eye only and 30 percent vision in other eye.
Dr__Jonathan_Eisengart: Cataract surgery can be performed on the good eye even in people who have only one seeing eye. Obviously, you want to make sure your cataract surgeon is experienced and reliable. There are two cases when I do not recommend cataract surgery: 1) the eye has some other problem so that cataract surgery wouldn’t help it see any better – such as severe, end-stage glaucoma - or 2) your cataract is not bothering you and you are satisfied with your vision.
chrissy: Do both eyes generally progress at same rate, regarding the timing of cataract surgery.
Dr__Jonathan_Eisengart: Cataract surgery should be done when your cataracts are causing you problems, like difficulty reading, driving, or watching TV. Also, it is reasonable to have surgery if you are simply quite unhappy with the quality of your vision. Cataracts do not necessarily progress at the same rate, and it is not too uncommon to have surgery in one eye and not the other.
jarhead: I had cataract surgery (both eyes) in 2007. When I come in from the outdoors, I have difficulty seeing for several minutes. Is this common?
Dr__Jonathan_Eisengart: That symptom may not be related to your cataract surgery. Although there is likely nothing to worry about, it is worth having you eyes examined.
carparts: Can you continue to wear contact lenses after cataract surgery?
OOO333: If I’m dissatisfied with the result of my cataract surgery in one eye, can the surgery be done again?
Dr__Jonathan_Eisengart: Some problems with cataract surgery can be repaired. If would advise a second opinion.
saelzcr: If I have the start of cataracts along with glaucoma, can I still have cataract surgery, without worsening the glaucoma. And if and when I have cataract surgery, should I consider surgery for the glaucoma at the same time.
Dr__Jonathan_Eisengart: People with glaucoma can most definitely have cataract surgery. In fact, cataract surgery may lower your pressure. The decision to combine cataract and glaucoma surgery depends on your stage of disease, your eye pressure, how many medications you're on, and how well those medications are working for you.
AMiller: Is there any way to reduce the eye pressure without medication or surgery?
Dr__Jonathan_Eisengart: Laser, as mentioned. Also, regular, aerobic exercise may lower eye pressure.
hemmedin: I’ve read that exercise works as well or better than pills to control glaucoma, please comment. If so, what kind of exercises?
Dr__Jonathan_Eisengart: I don't think it works better than medications, but regular aerobic exercise probably does help to lower eye pressure. It also improves your cardiovascular health (and your health in general), which is beneficial for your eyes and your glaucoma.
come_on: What is pigmentary glaucoma?
Dr__Jonathan_Eisengart: The backside of your iris has dark brown or black pigment cells. (Even blue eyes are black in the back.) In pigmentary glaucoma, these cells get "rubbed off" and end up clogging the internal drainage meshwork and raising eye pressure. It is usually treated like regular glaucoma, but – occasionally - laser is used to potentially reduce the release of pigment. (This is controversial.)
JHK: Have you heard of airplane pressures being a cause for glaucoma?
Dr__Jonathan_Eisengart: No, riding on an airplane, even frequently, does not contribute to glaucoma.
Cleveland_Clinic_Host: I'm sorry to say that our time with Jonathan Eisengart, M.D., is now over. Thank you again Dr. Eisengart for taking the time to answer our questions about glaucoma.
Dr__Jonathan_Eisengart: Thank you all for joining this glaucoma chat. I enjoyed answering your questions and hope that the responses were beneficial to you.
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