Secondary Glaucoma
Chat Highlights
September 25, 2002

Norma Devine, Editor

On Wednesday, September 25, 2002, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Secondary Glaucoma."

Moderator:  Welcome back, Dr. Werner.  Our topic tonight is "Secondary Glaucoma." 

P:  Dr. Werner, what is the difference between primary glaucoma and secondary glaucoma?  

Dr. Elliot Werner:  Secondary glaucoma is a glaucoma due to some other identifiable eye or systemic disease, such as uveitis, trauma, diabetes, etc.  Primary glaucomas result from an isolated abnormality of the aqueous outflow mechanism.

Moderator:  Is the course of treatment different for secondary glaucoma? 

Dr. Elliot Werner:  In general, the first line of treatment is aimed at the underlying problem.  If that fails to cure the glaucoma, the other treatments are much the same as for any glaucoma, but may be modified by what is known specifically about a particular secondary glaucoma.

P:  Are secondary glaucomas more challenging to treat and control?

Dr. Elliot Werner:  Sometimes.  Many secondary glaucomas are refractory to treatment, but some such as pigmentary or pseudoexfoliation respond quite well.  The last time I was here, a patient said she had glaucoma due to aniridia.  That would be a secondary glaucoma.

Moderator:  What does "refractory" to treatment mean?

Dr. Elliot Werner:  Refractory to the treatment means not responsive.

P:  In the treatment of uveitis and glaucoma, should there be two doctors involved -- an eye doctor and a uveitis specialist?

Dr. Elliot Werner:  Not necessarily.  It depends on the experience and expertise of the treating doctor. I treat many patients with uveitis and glaucoma.  Unless the uveitis is particularly severe or not responding to treatment, I don't refer such patients to another specialist.

P:  Can you tell us anything about Copaxone as a treatment for uveitis/iritis?  Wouldn't that be a better way to treat it since most uveitis cases are autoimmune?

Dr. Elliot Werner:  I've never heard of Copaxone.  Does it have another name?   Immunosuppressives,  such as methotrexate and cyclosporine, are often used to treat uveitis, but they tend to be more toxic and have more side effects than steroids.  [Editor's note:  Copaxone (glatiramer acetate) is one of the drugs used in the treatment of multiple sclerosis].

P:  Are your hands tied if there is no response to conventional treatment?

Dr. Elliot Werner:  We can always find something to do.  It doesn't always work.  Sometimes you lose the ball game, and the vision is lost no matter what treatments are used.

P:  How does diabetes cause glaucoma?

Dr. Elliot Werner:  Diabetic retinopathy decreases blood circulation to the retina, and produces what is called ischemia.  Retinal ischemia causes the growth of abnormal new blood vessels in the eye that interfere with the flow of aqueous and cause a form of glaucoma called neovascular glaucoma.

P:  What is the visual prognosis for ICE (irido-corneal) syndrome/Chandler's syndrome after a trabeculectomy with mitomycin C?  How long can the trabeculectomy function?

Dr. Elliot Werner:  The severity of this condition varies a lot from person to person.  About 50% of patients with ICE syndrome achieve good, long-term control with filtering surgery.

P:  Can the herpes virus cause ICE syndrome?   Is it known why the virus would attack the eye?

Dr. Elliot Werner:  A number of years ago, a study suggested a higher prevalence of anti-herpes antibodies in people with ICE syndrome.  It has never been duplicated and not everyone believes it.

P:  What are peripheral anterior synechiae and how are they associated with ICE syndrome?  Can they return after filtering surgery?

Dr. Elliot Werner:  Peripheral anterior synechiae (PAS) are adhesions of the peripheral iris to the peripheral cornea and trabecular meshwork.  In ICE syndrome, PAS are usually permanent, but in other conditions they can be reversed.

P:  Will a corneal graft stop or slow down the progression of ICE?

Dr. Elliot Werner:  Usually, but in some cases the abnormal membrane that grows over the structures of the eye in ICE syndrome continues to grow.

P:  What types of eye trauma can cause glaucoma?

Dr. Elliot Werner:  Any type, but the most common type is blunt trauma,  such as being struck with a fist or ball.  Penetrating trauma is often also associated with glaucoma, but usually has so many other devastating effects that the glaucoma is the least of the problem.

P:  I know that severe trauma to the head can cause glaucoma many years later.  For instance, my glaucoma was diagnosed 27 years after I was kicked in the head.  But what about lesser, repeated trauma, as when a boxer's head is hit repeatedly? 

Dr. Elliot Werner:  Post-traumatic glaucoma is extremely common in boxers.  It is a little-known, but major, health problem for former boxers.

P:  Since post-traumatic glaucoma often involves one eye, how many patients develop double vision or problems with depth perception due to the glaucoma and treatments in the one eye?

Dr. Elliot Werner:  Glaucoma in one eye can be associated with the problems you mention, but they are usually due to the loss of vision in one eye.  Less commonly, complications of treatment can cause diplopia (seeing double) or loss of depth perception.

P:  Could getting hit in the eye with a tennis ball cause glaucoma?

Dr. Elliot Werner:  Yes, but tennis ball injuries are unusual because most people can't put enough speed on the ball.  Racquet ball and squash injuries are much more common causes of glaucoma.

P:  My mother always said forceps used during my birth caused trauma to my eye.  My glaucoma, in both eyes, was diagnosed when I was 40 years.  Would that be considered secondary glaucoma?  

Dr. Elliot Werner:  That depends on the appearance of the eye and whether you have any specific evidence of the type of traumatic lesions that would be associated with glaucoma.  Forceps could have caused your glaucoma or it could be a coincidence.

P:  Could a secondary glaucoma occur in a 50-year old person who had lost one eye due to a firecracker injury as a child?  

Dr. Elliot Werner:  Yes, it is not unusual for post-traumatic glaucoma to develop many years after the original injury.

P:  Is it possible for trauma to one eye to develop into secondary glaucoma in both eyes?

Dr. Elliot Werner:  Not usually.  But people with trauma to one eye often have had trauma to the other eye as well, even if they don't remember it.  I see patients who have obvious signs of past eye trauma who have no memory of ever having injured their eyes

.

P:  In post-traumatic glaucoma, does the damage appear suddenly, or does it develop slowly, as with primary open-angle glaucoma?

Dr. Elliot Werner:  Usually slowly.  It presents much like primary open-angle glaucoma.

P:  Does frequent eye rubbing cause secondary glaucoma?

Dr. Elliot Werner:  Yes, but usually in retarded or severely mentally ill patients who rub their eyes excessively and extremely hard.  Most normal eye rubbing would not do that.

P:  Can you tell in post-traumatic glaucoma whether the loss of visual field was gradual and went undiagnosed until it was too evident to be missed?

Dr. Elliot Werner:  You never know that for sure when patients present with extensive field loss the first time you see them.  But we assume it develops slowly, unless the pressure is extremely high.

P:  Can you tell by examination whether the glaucoma is secondary?  For example, do children who are physically abused, hit repeatedly on the head, often develop secondary glaucoma?

Dr. Elliot Werner:  Generally, seeing signs of eye trauma suggests that the glaucoma is secondary.  

P:  Is glaucoma caused by chemicals in the eye harder to treat than other types of glaucoma?  

Dr. Elliot Werner:  The only chemical that typically causes glaucoma is alkali, such as lye or ammonia.  Such burns are devastating injuries and very difficult to treat, or even save the eye, in severe cases.

P:  Can secondary glaucoma from trauma be in the form of normal-tension glaucoma?  

Dr. Elliot Werner:  That's unlikely, but anything is possible.

P:  Steroids are used to treat intraocular inflammation, but isn't it true that steroids are not good for eyes with glaucoma? 

Dr. Elliot Werner:  It is a difficult dilemma when a patient needs steroids to treat inflammation, but at the same time may develop complications, such as glaucoma, from the steroids.  It is a real challenge to the skill of the treating doctor to manage such patients.

P:  Are you saying you can develop glaucoma from the use of steroids?  Our son was basically on them for six months solid for a clogged tear duct.

Dr. Elliot Werner:  Yes, glaucoma can be a complication of long-term steroid use, but doesn't occur in everyone.

P:  I thought steroid-induced glaucoma does not progress once the steroids are discontinued.  Is that true? 

Dr. Elliot Werner:  In most cases that's true.  In some cases, which are the exception, the glaucoma does not go away when the steroids are stopped. 

P:  I am currently using Pred Forte three times a week in both eyes to keep my trabs working.  What are your thoughts on this?

Dr. Elliot Werner:  There is a risk that you could develop an infection from the immunosuppressive effect of the steroids, but if you need them, then you and the doctor may be willing to assume that risk.  There is always a risk/benefit calculation for any treatment in medicine.

P:  Is the treatment for pigment-dispersion glaucoma different from primary glaucoma?

Dr. Elliot Werner:  We are more likely to recommend laser trabeculoplasty earlier, since it works so well in pigmentary glaucoma.  Pigment dispersion does not require treatment unless the glaucoma develops.

P:  Do you know of anything in general anesthesia that could cause either damage to the optic nerve or angle closure in eyes with open angles?  I believe that after jaw surgery (opposite side of face) I developed a rather large blind spot.

Dr. Elliot Werner:  It is unlikely the anesthesia caused the problem.  That's difficult to answer without actually examining you and determining the cause for your vision loss.

P:  Chandler's syndrome involves the cornea, making it swell.  If the swelling is brought under control and there is still a problem with glare, can the glare also be caused by an irregular pupil?

Dr. Elliot Werner:  Chandler's syndrome can be associated with pupil abnormalities that can cause problems with glare.

P:  Have you seen many cases of glaucoma caused by Axenfeld-Reigers?

Dr. Elliot Werner:  Some, but not a lot.  It is mainly a pediatric condition and I don't see many children in my practice.

P:  Is the appearance of the optic nerve in secondary glaucoma the same as in primary open-angle glaucoma?

Dr. Elliot Werner:  Generally, yes.  The nerve appearance is pretty much the same in all chronic glaucomas.

P:  To what various disease processes or abnormal body functions outside the eye is glaucoma secondary?

Dr. Elliot Werner:  A large number of processes can cause secondary glaucoma.  The most common are inflammation, trauma, congenital deformities, and ischemia.

P:  In a case where an inflammatory process leads to glaucoma, is the glaucoma automatically controlled if the inflammation is controlled?

Dr. Elliot Werner:  Unfortunately, no.  It depends on how much permanent damage has occurred to the structures of the eye as a result of the inflammation before it was controlled.

P:  I had laser twice in each eye to lower the intraocular pressure due to Graves disease.  Now I've been told that I should have decompression done.  If I do that, what are the chances of my pressures becoming too low?

Dr. Elliot Werner:  I'm assuming you mean orbital decompression.  That would not make your pressure too low.

P:  Is a peripheral iridectomy always performed along with a trab for closed-angle glaucoma?  If so, why?

Dr. Elliot Werner:  Iridectomy is performed with a trab for any reason to prevent the iris from prolapsing into the trab opening and clogging it up.

P:  What kind of inflammation outside the eye can cause glaucoma?

Dr. Elliot Werner:  Inflammation outside the eye would not cause glaucoma, but many systemic inflammatory diseases are associated with ocular inflammation that can cause glaucoma.

P:  Through what mechanisms do these diseases or injuries make secondary glaucoma develop?

Dr. Elliot Werner:  Generally, by damaging the trabecular meshwork or Schlemm's canal, so that the aqueous cannot get out of the eye and circulate normally.

P:  What systemic inflammatory diseases specifically can cause eye inflammation that leads to glaucoma?

Dr. Elliot Werner:  There are dozens of them, too numerous to list.  The common ones would be sarcoidosis, ankylosing spondylitis, syphilis, rheumatoid arthritis, and so on.

P:  Would having an autoimmune disease predispose a patient to glaucoma?

Dr. Elliot Werner:  Yes, because many autoimmune diseases are associated with ocular inflammation that can produce glaucoma.  Also, there is some evidence of an increased prevalence in autoimmune markers in people with normal-tension glaucoma.

P:  I came in late.  Doctor, are you saying that things like ankylosis spondylitis and rheumatoid arthritis can lead to glaucoma?

Dr. Elliot Werner:  Yes, if there is associated ocular inflammation.

P:  My angles are considered to be wide open.  Is it possible for anything whatsoever to cause intermittent closure in such a case?

Dr. Elliot Werner:  If your angles are wide open, it is unlikely.  There are isolated case reports of intermittent angle closure due to spontaneous aqueous misdirection, but it is very rare.  It has only been reported perhaps six times in the medical literature.

P:  Can someone with aqueous misdirection syndrome, being controlled with atropine, have intermittent attacks?

Dr. Elliot Werner:  Yes, but that doesn't happen often.

End of highlights for September 25, 2002.

On October 2, Dr. Wilson discussed "Laser Treatments" in the Chat room. Click here for highlights of that meeting.

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