General Glaucoma Discussion
Chat Highlights
November 7, 2001

Norma Devine, Editor

On Wednesday, November 7, 2001, Dr. Rick Wilson, a glaucoma specialist at Wills, held a general glaucoma discussion in the chat room.

Dr. Rick Wilson:  Sorry I'm late.  Any questions?

P:  Yes.  Are other patients who are using Alphagan eye drops bothered by suddenly falling asleep?

Dr. Rick Wilson:  Alphagan can cause lethargy, fatigue, etc.

P:  I notice fatigue, but not outright sleep.

P:  I get lethargic in mid-afternoon on Alphagan

Dr. Rick Wilson:  I had a hyperactive eight-year-old patient that I put on Alphagan.  It turned him from a hellion into to a tractable child who even took naps.  The parents were heartbroken when it didn't work and I had to operate.

P:  I've been on Xalatan about four years.  Lately, all my joints are hurting.  I'm 56-years old.  Could the drops cause the joint pain? 

Dr. Rick Wilson:  Yes.  Perhaps your doctor would let you switch to something else for two weeks to see if the joint pain persisted.

Moderator:  Should our heads be higher when we sleep than the rest of our bodies?  

Dr. Rick Wilson:  Sleeping with the head elevated does give a theoretical advantage.  Breathing problems during sleep have been related to normal-tension glaucoma (NTG).  

P:  How are breathing problems related to NTG?  

Dr. Rick Wilson:  Patients who stop breathing for short periods at night (sleep apnea) may have low oxygen levels and increased resistance to blood passage through the eye.  I need to look into that more.  

P:  Do NTG patients never go blind, once their IOPs are low?  

Dr. Rick Wilson:  A small percentage of patients with normal- tension glaucoma continue to get worse even if the IOP is low.  The progression is markedly slowed, but not stopped.  For those patients, circulation, autoimmune disease, or something else is far more of a problem than the IOP.  

Moderator:  What are some types of  autoimmune disease?   

Dr. Rick Wilson:  Lupus, scleroderma, Sjogren's syndrome, rheumatoid arthritis, etc.

P:  I have read that NTG patients are more apt to go blind than others, since IOP is likely a secondary cause, and the only real treatment today is IOP reduction  

Dr. Rick Wilson:  True, but very infrequent.  I can only think of about six patients that went totally blind while I was taking care of them over 21 years.  More certainly lost vision, often significantly, but I feel we are very good at preventing patients from symptomatically worsening.

P:  During sleep, does the position of a shunt on the outer, upper quadrant make a difference? 

Dr. Rick Wilson:  Not nearly as much if a shunt is in place.  

P:  If I don't have a shunt, do I have a plate?   

Dr. Rick Wilson:  No shunt, no plate.  A shunt has a tube that discharges onto a plate that keeps the scar tissue from closing off the end of the tube and gives the aqueous (watery fluid of the eye) a place to be absorbed.

P:  Does a Molteno shunt have more than one plate?  

Dr. Rick Wilson:  A Molteno may have one plate or two.  

P:  What do you consider when deciding whether to revise a bleb that is encapsulated or add another shunt?  Is one preferred over the other? 

Dr. Rick Wilson:  That depends upon whether there is a plate between the muscles above and out, and above and in.  If there is only one plate, a recent study said it is more effective to add a second plate than to revise the first.  If there are already two plates, I would revise one of them.

P:  What percent of glaucoma patients are able to do without medication entirely?  

Dr. Rick Wilson:  Usually only those with angle-closure glaucoma, inflammatory glaucoma, a few pigmentary glaucomas, and traumatic or steroid responsive glaucomas.  

P:  As a ballpark estimate, how long would it take for optic nerve damage to develop (assuming it does so) with an IOP of about 30 mm Hg?  

Dr. Rick Wilson:  That varies dramatically.  Some patients have no discernable damage after five to ten years; others having dramatic damage after one or two years.  Dr. Hans Goldmann used to say it took 15 years on average to go blind from untreated glaucoma.  Clearly, that is related to how high the IOP is.

Moderator:  If you are still on drops, have had many surgeries, still have a healthy-looking optic nerve and pressures in the teens are you considered cured?  

Dr. Rick Wilson:  Not if the surgery is controlling your IOP and the outflow is not normal on its own.

P:  It's said that with proper medication,  IOP reduction, and healthy life style, few people will actually lose their sight.  However, if sight is lost, does the patient end up seeing all black or still see shapes?  

Dr. Rick Wilson:  As one loses vision, the field gets smaller and smaller till only a central island and an area off to the temporal side remains.  Shapes and movement would be the next-to-the last thing to go before light.  Then there would be darkness.

P:  The trabeculectomy I have is 14 months old and is working really well.  The IOPs are staying at 11 and 12 mm Hg even with Pred Forte twice a day.  Is there anything I can do to take care of the trab so it will last forever?  

Dr. Rick Wilson:  Not that I know of. 

P:  I had to stop Xalatan and Alphagan.  I am now using Lumigan and only my left eye is itching and has dull pain now and then.  My doctor says I should keep using Lumigan if I can tolerate it.  What do you think?  

Dr. Rick Wilson:  Aches do seem to be related to Lumigan.  Ask if you can try Travatan, which is just as powerful and does not seem to produce the eye aches that some people get with Lumigan.  Xalatan has even fewer symptoms, but it is not clear if it is quite as strong as Travatan and Lumigan, although it is usually very close to being as strong.

P:  Lumigan makes my eyeballs feel thick, which seems to be different from the aches others describe.    

Dr. Rick Wilson:  It may be related. 

P:  Is it okay to use Alphagan after Lumigan in the evening? 

Dr. Rick Wilson:  The only reason to use any of the "-an" type meds in the evening is that the redness the medications cause in some eyes improves before the patients arise.

P:  Theoretically, is there any reason topical CAIs (carbonic anhydrase inhibitors), such as Azopt, would reduce IOP more in aphakic eyes than in phakic eyes?  

Dr. Rick Wilson:  Only if the cornea were more permeable to the drops by dryness, or the drop was able to get to the ciliary body where the drug works more readily in that patient.

P:  Does that mean CAIs don't just saturate receptors like beta blockers, and can therefore work better if more drug reaches the ciliary? 

Dr. Rick Wilson:  We are not completely sure how CAIs work, but the effect is dose- responsive up to a point, when all the carbonic anhydrase that can be blocked is blocked.

P:  Would a secular iridectomy make it easier to get to the ciliary?  

Dr. Rick Wilson:  It certainly might. 

Moderator:  Has the average age of patients you see gone down?  

Dr. Rick Wilson:  No, it has gone up.  As our population ages, the prevalence of glaucoma increases in much more than a linear fashion.

Monitor:  Dr. Rick, will you be in New Orleans at the Academy meeting next week?  

Dr. Rick Wilson:  Yes, I have to get ready.  Have a great couple weeks till I see you again.

Monitor:  Thanks, Dr. Rick.  Have a good trip.

End of highlights for November 7, 2001.

On November 21, Dr. Arch McNamara, a retina specialist at Wills, joined the glaucoma chat support group for a discussion about retina problems associated with glaucoma in the Chat room. Click here for highlights of that meeting.

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