Monday Night Chat Highlights
July 23, 2001

Norma Devine, Editor

On Monday, July 23, 2001, Dr. Jeff Henderer, a glaucoma specialist at Wills, paid a visit to the Monday night chat room. 

Dr. Jeff Henderer:  Hello, everyone!

Monitor:   Welcome, Dr. Jeff.  As usual, we have glaucoma patients from quite a few states:   New York, Minnesota, Mississippi, Virginia,  Florida, Maryland, Washington -- and one patient from New Brunswick, Canada. 

Dr. Jeff Henderer:  How is everyone?  Any questions?

P:  Yes.  Doctor Jeff, does a rough cornea cause distortion similar to macular problems?  How long does it take for the roughness to clear up?

Dr. Jeff Henderer:  That depends on the cause.  What is causing yours?

P:  After I had a trabeculectomy in April,  I had hypotony.  The macula looks fine now and the intraocular pressure is all right at 10 mm Hg.     

Dr. Jeff Henderer:  Well, it is possible the cornea is still folded a bit from the hypotony.  That can take a while to clear, but it usually does.

P:  What do you think of the new Proview eye pressure monitor? 

Dr. Jeff Henderer:  Proview is the phosphene tonometer?  I didn't know it by any other name than the phosphene tonometer.  I understand it is pretty good.  Not perfect, but pretty good.

P:  What are some of your favorite new tools for office use, such as the HRT?

Dr. Jeff Henderer:  I like the HRT.  I am not sure what it does for me as a diagnostic tool yet.  It may be best at follow-up, looking for disc change.

P:  I have an appointment tomorrow with my eye doctor.  How are the new glaucoma eye drops doing?  Alphagan makes me sleepy and Xalatan irritates my eyes.  

Dr. Jeff Henderer:  The new glaucoma eye drops, Travatan and Lumigan, are very similar to Xalatan.  They both have similar side effects.  I have had some patients who have done well on one of the new ones who had no effect from Xalatan, and I have had others who had no added benefit.

P:  Lumigan does not make me tired at all.

P:  I am tired without any of the drops.

P:  Maybe I need some drops to get a good night's sleep 8-).

Dr. Jeff Henderer:  I have not heard of Lumigan making people tired either, but I have heard Xalatan blamed for almost everything, so it might be possible.  Not that I am convinced of all these side effects, but each patient is a new experience.

P:  I believe my normal-tension glaucoma is a secondary glaucoma, as there is none in my family. 

Dr. Jeff Henderer:  In my experience, secondary glaucomas really have high eye pressure. 

P:   I think it is a  result of low blood pressure and circulatory problems.  I'm getting my circulatory system and low blood pressure checked out in a month.

Dr. Jeff Henderer:  That is an excellent point.  Low blood pressure has consistently been related to glaucoma, while high blood pressure is related to high eye pressure.

P:  But I have low blood pressure and very high eye pressures.

Dr. Jeff Henderer:  There are always examples of the other way but, in general, what I said  seems to be fairly true.

Monitor:  Isn't normal-tension glaucoma unusual in people in their forties?

Dr. Jeff Henderer:  It's unusual, but not unheard of.

P:  Speaking of low blood pressure, I'm being treated for high blood pressure.  If it drops too low, I understand IOP can rise. How low is too low?

Dr. Jeff Henderer:  I don't know about IOP rising if the blood pressure goes low.  I think less than 100 systolic is low.  Some data suggest that drops in blood pressure at night can be associated with glaucoma and with ischemic optic neuropathy, so I like to have people take the blood pressure medication in the morning, if possible.  It's not a big deal if you don't, but given the choice, that would be mine.

P:  Is systolic the top number?  I can't keep them straight.

Dr. Jeff Henderer:  Yes, systolic is the top number.  Diastolic is the bottom number.

P:  Have you heard of optometrists diagnosing people as glaucoma suspects and not referring them to an ophthalmologist or a glaucoma specialist?

Dr. Jeff Henderer:  No, I haven't.  But then I wouldn't, because they wouldn't end up in my office.  O.D.'s in some states can treat glaucoma patients, but I have no idea how many states.

P:  My ophthalmologist wasn't sure if I had glaucoma or not.  My pressures were in the low 20's,  but he wasn't sure if the cupping was from my high myopia or from the pressure, so he sent me to a glaucoma specialist, whose diagnosis was glaucoma suspect. 

Dr. Jeff Henderer:  I agree with that.

P:  What is an "O.D.?"

Dr. Jeff Henderer:  A doctor of optometry.

P:  What is a "D.O.?"

Dr. Jeff Henderer:  D.O.'s are doctors of osteopathy.

P:  My doctor is a D.O.  How do D.O.'s get to take care of eye problems?

Dr. Jeff Henderer:  D.O.'s can take any residency, just like M.D.'s.  They are very capable doctors.  

P:  My original diagnosis as a "suspect" was about six years ago, and the glaucoma specialist saw definite progression.  So here I am with two trabs.

Dr. Jeff Henderer:  Guess there was progression of nerve or field damage.

P:  I reacted to practically all the drops, and Xalatan wasn't lowering the pressure as low as he would have liked.  It was 17 mm Hg.

Dr. Jeff Henderer:  Okay.  Then key is to lower pressure:  medication, laser, surgery, whatever.  Just lower the pressure.

P:  Yes, my IOPs are now 10 mm Hg. OD (right) and 6 mm Hg. OS (left).

Dr. Jeff Henderer:   Remember,  not all people need pressures that low to remain stable. 

P:  But have there been any cases where the effects of trabeculectomies have made vision worse than progression would have caused?  Pardon the ignorance from a newbie.

Dr. Jeff Henderer:  YES, YES, YES!  Dr. Spaeth likes to say that more people have gone blind from treatment than from the disease. It is tricky stuff.

P:  I was diagnosed by my optometrist, but he referred me to Wills Eye Hospital.  I saw Dr. Courtland Schmidt, who sent the report back to my optometrist, for drug medication, etc.  So far, so good.  I will probably see Dr. Schmidt once a year.  Do you think a D.O. can treat a glaucoma patient, including visual field testing, until the pressure increases or the visual field test shows damage, etc?  My optometrist had no problem referring me to Wills Eye Hospital and Dr. Schmidt.

Dr. Jeff Henderer:  Yes, that can work very well. I agree with that plan.

P:  I'm going crazy with the distortion in my right eye from the trab I had in April.  The trab in the left eye last November went just fine. 

Dr. Jeff Henderer:  That is why surgery is not to be undertaken lightly!

P:   But sometimes you have no options.

Dr. Jeff Henderer:  Agreed.  If you need it, you need it. 

P:  I sure didn't undertake mine lightly.  My doc had to wait about six months before I was convinced it had to happen.

P:  After my two trabs, the better eye returned to normal much faster than the bad one.

P:  Likewise for me.  

P:  I'm frustrated because the one I've had the most trouble with was the better eye.  Now it's not the better eye.

Monitor:  Dr. Jeff, is it typical after trabeculectomies for the better eye to return to normal faster than the poorer eye? 

Dr. Jeff Henderer:  That depends.  It can be either way.

P:  What do you think of the connection between sleep apnea and normal-tension glaucoma?  

Dr. Jeff Henderer:  It is certainly a risk factor that I would modify.

P:  What do you think about taking ginkgo biloba?

Dr. Jeff Henderer:  Ginkgo has some real science behind it.  It seems to work for Alzheimer's and maybe for glaucoma, too, by helping blood flow.  It should not be taken if you are already on blood thinners like aspirin.

Dr. Jeff Henderer:  Okay, guys, the baby calls!  I had better go.  Good night.

Monitor:  Thank you.  We appreciate your help a great deal.  Please come again soon. 

End of highlights for July 23, 2001.

On July 25, Dr. Wilson discussed "Non-Penetrating Glaucoma Surgery" in the Chat room. Click here for highlights of that meeting.

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