Chat Highlights
Managing Your Glaucoma
January 24, 2001

Norma Devine, Editor

On Wednesday, January 24, 2001, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Managing Your Glaucoma." 

Moderator:  Hello Dr. Wilson.  The topic tonight is  "Managing Your Glaucoma."  Do you recommend that patients keep track of office visits, intraocular pressure, visual field test results, etc.?

Dr. Wilson:  I have mixed  feelings about that.  I want the patients to be educated so they ask good questions and understand the problems the doctor faces.  And if your record gets lost, a replacement in your hands would be a godsend.  On the other hand, I don't want my patients dwelling on their illness all the time, being too compulsive about keeping track of all their visits, etc.  I told my mother to let me help her pick the best doctor and then trust the doctor to do what's right for her.

P:  You will need your own records if you ever have to deal with Social Security. You are not allowed to see any records they have.  

P:  It's very hard not to dwell on your illness when you hurt and feel lousy all the time

Dr. Wilson:   I agree,  but it doesn't help. 

Moderator:  I think in the beginning I was more prone to want to keep track, but 10 years later I do not keep track.  If the doctors says "stable,"  I say "great."

P:  About the only thing I could do at first was read everything on glaucoma that I could find. I guess it made me feel like I was doing SOMETHING.

P:   I know it's good to be informed, but it's also very frightening.

P:  The more I know, the more scared I get!  But I don't want to stop learning, because the bits I have learned have helped me make better decisions.

Dr. Wilson:  It's a double-edged sword.  That's why I have mixed feelings about it.

P:  I have a question about managing my glaucoma.  I'm 41 years old, was diagnosed with open-angle glaucoma when I was 18 years old, and had pressures in the high 40's.  My glaucoma has been under control, but now my pressures range between 21 and 28.  I have no vision loss to date.  Should I  feel lucky?    

Dr. Wilson:  Yes, you should feel very lucky.  

P:  You're one of the luckiest glaucoma patients I've heard of.

P:  You have had glaucoma under control for 20+ years?  I only wish!

P:  Count your blessings! 

P:  You are very lucky.  

P:  That's for sure.   I knew nothing about glaucoma until I learned I had the disease.  No one in my family had it.  Now I am having pressure spikes after over 20 years and I wonder why.   I'm so confused about pressure.  All those years my IOP was close to 20, but I had no damage!

P:  What do you mean, spikes? How high is your pressure now?

P:  My pressures range between 21 and 28.  

Dr. Wilson:  No, a spike occurs if your pressure is mostly in the 14 to 18 range, but moves up to 23 for a part of the day.

P:  Doctor, can you tell us more about pressure spikes?    

Dr. Wilson:   Research in 2000 showed that it is not just how low the IOP is kept, but also how steadily the IOP is kept low that is important. Therefore, medications should be spread evenly throughout the day, unless your doctor has identified a spike in your IOP and aims your medication at it.  It is possible to aim the peak action of a medication to hit when the diurnal curve of IOP is at its highest during the day.

P:   What harm do spikes cause?

Dr. Wilson:  Every spike kills a few ganglion cells.  After several years, that adds  up.    Therefore, a medical treatment plan you can live with is important.

P:  How would I know if I had a pressure spike?  

Dr. Wilson:  You wouldn't know.  

P:  Doctor, if spikes are so dangerous, why aren't diurnal curves done for every glaucoma patient right off the bat, and then regularly monitor for spikes?  I mean, every year or two?  

Dr. Wilson:  Most patients are not interested in sitting around all day for IOP tests. We usually do those that are suspect and those that are getting worse with what seems to be good intraocular pressures. 

Moderator:  I bet most would stick around all day if given the option.

P:  Anything to preserve one's sight.

P:  Is it true IOPs are usually higher in the mornings than later in the day?

Dr. Wilson:  A slight majority of patients seem to have their highest IOPs in the morning, but many have them in the afternoon.   It would be rare in the evenings or at night. For some people, the highest IOP is just before arising.

P:  Is the main managing of our glaucoma done by using drops?  Then we really need to monitor pressure throughout the day.  My last visit showed that the IOP in my good eye had jumped from 15 to 20.  So, that does not sound good for preventing damage.  All this is frightening. 

P:  I don't know how others manage their glaucoma.  But I write about it.  I learned to paint and play the piano.  You're never too old.   

P:  Dr. Rick,  my IOPs do spike and the difference between the right and left eye is sometimes 10 points.  I have pigmentary glaucoma, and I am using Xalatan at night and Alphagan three times a day.  I will have a visual field test in March.  My IOPs in December were 21 and 20; in January, 21 and 23.  What would be the next step in treatment?  Laser?  

Dr. Wilson:  Bob Ritch and I are among a large group of glaucoma specialists that prefer pilocarpine Ocuserts for pigmentary glaucoma. I have patients that have gone into remission from their glaucoma after being on pilocarpine for several years. A laser iridectomy can be helpful if pilocarpine is not tolerated. 

P:   Is there a more defined test for examining the optic nerve that my doctor should do?

Dr. Wilson:  Good observation through a dilated pupil is best, comparing what is seen to photographs taken in the past. Computerized imaging devices can be helpful, especially if your doctor is not an expert at looking at the optic nerve. 

P:  Is optic nerve damage very apparent from the typical exam by an ophthamologist?

Dr. Wilson:  If damage to the optic nerve is advanced, it is apparent; it is not so apparent in the early stages.

P:  You have probably answered this many times, but can you say which surgery is more effective, a tube shunt or a trabeculectomy?

Dr. Wilson:   The aqueous shunt has a higher success rate in getting IOPs into the upper teens.  The trabeculectomy does not have as high a success rate as the shunt, but can get IOPs lower.

P:  There is an explanation and diagram of shunts in the latest Gleams.

P:  If  you wear contact lenses, is there a reason to prefer a shunt over a trabeculectomy?  Or, if you have had trabs, is it advised not to use contacts?

Dr. Wilson:  Yes.  Very good questions.  Contact lens wear is an indication for a shunt instead of a trab. It is dangerous to wear contacts if you have a thin bleb.

P:  I wore contacts, but shunt surgery was never mentioned.  Now I can't wear contacts.  I wonder why they didn't give me an option? I guess you live and learn.

P:  What is the greatest risk from a shunt?

Dr. Wilson:  Infection is the greatest risk.  

P:   Does laser surgery affect the success of trabeculectomies, and why are lasers sometimes used before trabeculectomies?   

Dr. Wilson:  A laser is less invasive than surgery and less for the patient to go through. We do not use laser on everyone before surgery, just on patients we expect to do well with them.  Two studies suggest that laser trabeculoplasties somewhat decrease the success rate of  trabeculectomies. 

P:  What percent of laser surgeries have successful results?

Dr. Wilson:  That depends entirely upon how carefully the patients are chosen.  I can give you a group of 85-year olds with pseudoexfoliative glaucoma, and a one hundred percent success for three to five years.  I can also give you a young group with no pigment in their drains to absorb the laser energy, and a success rate of  zero to three percent.  

P:  If my pressure remains at around 11 (where it is now after my trab), will my blurry vision remain as long as the pressure is at that level?

Dr. Wilson:  Most people with IOPs of 11 do not have blurry vision from it.  If you are young and myopic, an IOP of 11 can cause blurry vision.  A thin sclera,  I have found out, is a real risk factor for low IOPs.

On January 31, Dr. Wilson discussed "Glaucoma and Stress" in the Chat room. Click here for highlights of that meeting.

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