Finding the Right Treatment
Chat Highlights
March 3, 2004

Norma Devine, Editor

On Wednesday, March 3, 2004, Dr. Elliot Werner, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Finding the Right Treatment."

Moderator:  Welcome, Dr. Werner.  

Dr. Elliot Werner:  Hello, everybody. We're having an early spring in Philadelphia.  Today was absolutely gorgeous.  The American Glaucoma Society (AGS) is meeting this weekend in Sarasota, Florida, so I'm off early tomorrow.  Maybe Rick Wilson and I could prepare a summary of the highlights of the meeting and post it on the web site. 

Moderator:  That would be great.  We recently added some articles from the 2003 Scientific Symposium (Click here to read articles).  Tonight we will be discussing "Finding the Right Treatment." 

P:  Dr. Werner, is it true that no two glaucoma patients are alike?

Dr. Elliot Werner:  Not only are no two patients alike, but even the same patient is different at different times.

Moderator:  So finding the right treatment can sometimes be difficult?

Dr. Elliot Werner:  The "right treatment" is the one that preserves the patient's vision as long as he or she lives.    Unfortunately, it's not easy to determine that in advance.

P:  What is the most difficult glaucoma to find the right treatment for?

Dr. Elliot Werner:  Probably neovascular glaucoma is the most difficult common glaucoma to treat successfully.

P:  What is the easiest glaucoma to find the right treatment for, assuming there is one?

Dr. Elliot Werner:  Ocular hypertension, since most of those people never lose vision anyway.

P:  Does age play a role in determining a patient's treatment? 

Dr. Elliot Werner:  Age is important in deciding how aggressively to treat.  A very old patient who is likely to die before going blind is a very different treatment problem than a younger patient who has many years of potential lifespan.

P:  How have treatments changed in the years you've been a glaucoma specialist?

Dr. Elliot Werner:  When I finished my glaucoma fellowship, the following treatments did not exist:  Xalatan and related drugs, Alphagan, Timolol and beta blockers, Azopt, laser treatments, tube shunts, and mitomycin-C.  I now do virtually nothing that I did in training.

P:  Are drops usually the first course of action?

Dr. Elliot Werner:  In North America, most doctors still use drops as first-line treatment for most chronic glaucomas, although more of us are moving on to laser trabeculoplasty much earlier now in open-angle glaucoma.

P:  Is there a  risk for young patients that using eye drops for a long time will damage the eye, which would make surgery more difficult in later years?  

Dr. Elliot Werner:  There is some evidence that the long-term use of drops causes inflammation of the conjunctiva, which reduces the chance of success of filtering surgery.  I still believe, however, that the risk of surgery is greater than the risk of drops, if the glaucoma can be controlled with one or two medications.

P:  Is it true that glaucoma medications destroy corneal cells?  If so, is this damage severe, permanent, or disabling?

Dr. Elliot Werner:  It depends on the medication. The main offenders are beta blockers and adrenergics. They damage the surface cells, but the effects are generally reversible if the drops are stopped.

P:  Suppose a patient is going to be on eye drops for, say, 20 or 30 years, or more.  Is the cornea going to be so damaged as to limit eyesight?  And are glaucoma patients good candidates for corneal transplants under all circumstances?

Dr. Elliot Werner:  It is quite uncommon for patients to develop corneal problems of that magnitude from glaucoma drops.  Most of the time, the problems are more a nuisance than very serious and they usually get better when the drops are stopped.   I don't think I've ever seen a patient need a transplant from the effects of glaucoma eye drops.

P:  If a patient has been on Travatan, Cosopt, and Alphagan for two years, and the intraocular pressure (IOP) starts to rise again, would the first choice be to try different medications or go to surgery?  (The other eye had a trabeculectomy and the IOP is under control.)  

Dr. Elliot Werner:  Probably I would opt for surgery, but if the patient were reluctant, the drops could be switched from Travatan to Lumigan, and pilocarpine could be added.

P:  Which drop causes the worst sub-orbital venous congestion ("shiner"/"black eye" ) and why does it do so?  I'm tired of people asking if I have a black eye or saying that I look so tired.  I do  have allergies, but am already on zyrtec and Flonase.  Only the eye that gets the drops has really bad venous congestion under it.  Is there anything I can do to make it go away, besides hiding it with concealer when I have the time to put on make-up?

Dr. Elliot Werner:  The prostaglandins, such as Xalatan, Travatan, and Lumigan, cause this effect the most.  It appears to be a direct effect of the medication on the pigment of the skin.  There is some evidence that smearing Vaseline on your eyelids before using the drops will prevent the drop from coming in contact with the skin and reduce the hyper-pigmentation that results. 

P:  I now use Xalatan in my right eye only. The pressures in both eyes are almost always the same.  Does the Xalatan affect both eyes?  

Dr. Elliot Werner:  Xalatan is not generally reported to have a contralateral effect as, for example, beta blockers do. What were your pressures in both eyes before treatment?

P:  My pressures are anywhere from 16 to 22 mm Hg.

Dr. Elliot Werner:  Was there a difference between the right and left eye pressures?  

P:  My pressures are usually the same, or one or two points different, even before medication. 

Dr. Elliot Werner:  I don't have an explanation.  Often if one eye has a consistently higher pressure, treatment of that eye with Xalatan may then cause the two eyes to be equal by lowering the IOP of the eye with the higher pressure.  

P:  I have only used meds in one eye (ICE syndrome).  My first med was Xalatan, with others added. The pressure in the other eye dropped from 17 to 12 mm Hg.  The doctor (not a glaucoma specialist) said it was a crossover effect.

Dr. Elliot Werner:  I'll have to check it out.  It's possible, but I have not heard that before.

P:  When would you recommend using laser first, instead of going directly to a trabeculectomy?

Dr. Elliot Werner:  I now offer the patient the option of laser or drops as first-line treatment.  I try to explain the advantages and drawbacks of each and let the patient decide.  In my experience, about 80% of patients opt to try drops first.  People still seem to fear procedures more than medicines.

P:  At what point is treatment indicated?  

Dr. Elliot Werner:  Treatment is indicated in any patient who has evidence of optic nerve damage or a high risk of developing future damage.

P:  At what point would you decide that meds are not working and it's time for surgery?

Dr. Elliot Werner:  There are two ways to determine that.  First, the pressure has not been lowered enough below pre-treatment levels to significantly reduce the risk of future vision loss.  Second, you have documented evidence of progressive deterioration of the optic nerve.

P:  Do you offer laser first, even in younger patients who do not have pigmentary exfoliation?

Dr. Elliot Werner:  For patients over 40 years of age I will offer laser, but I explain that the chance of success is less in younger patients.  Below age 40, there is not much point in offering laser, unless pigmentary glaucoma is present.  

P:  If laser surgery didn't work and the patient didn't want to use eye drops, would you advise cutting surgery?  Would it be a bad idea to go directly to a trabeculectomy? 

Dr. Elliot Werner:  If the patient truly had progressive glaucoma, I would offer the patient filtering surgery (trabeculectomy).  If the patient rejected that, I would advise him or her of a significant risk of irreversible blindness.  But we have to respect each person's autonomy.

P:  At what point is treatment successful?

Dr. Elliot Werner:  When the optic nerve and visual field are stable over time.

P:  Laser isn't effective for closed-angle glaucoma, so is medication the only first-line treatment? 

Dr. Elliot Werner:  That's not correct.  Laser iridectomy is the first-line treatment for most angle-closure glaucoma.  If the laser doesn't bring the pressure down enough, then we would use medications.

P:  I was thinking of trabeculoplasty.

Dr. Elliot Werner:  It depends on whether the angle has been opened after the iridectomy.  If the angle opens up, but the pressure is still high, trabeculoplasty is often effective.  If the angle remains closed despite the iridectomy, trabeculoplasty is of no benefit.

P:  What are the chances of retinal detachment after laser surgery?

Dr. Elliot Werner:  Virtually nil. That's a rare complication.

P:  Is a central defect likely to represent true pathology, even if found in a first visual field test?

Dr. Elliot Werner:  If it is repeatable on a second or third test, yes.

P:  My ophthalmologist said my last visual field test was "fuzzy."  What does that mean?

Dr. Elliot Werner:  I have never heard that term used to describe a visual field test.  Ask your doctor and let me know.

P:  Visual field defects in the same area come and go before a reproducible glaucomatous field defect develops.  Is it known what causes these long-term fluctuations?

Dr. Elliot Werner:  It is not known for sure.  It may be the optic nerve fibers are "sicker" at some times than others.  It may also be an artifact of the way the test is done.  No one knows exactly.

P:  Does the 20% failure rate of trabeculectomies represent different types of glaucoma, such as NTG?  

Dr. Elliot Werner:  The 20% failure rate is the best-case scenario in open-angle glaucoma in low-risk patients.  Patients with risk factors for failure, such as young age, black race, previous eye surgery, or secondary glaucomas have a much higher failure rate.  Normal-tension glaucoma is not really a risk factor for failure of trab surgery.

P:  When a trab is failing, what is the average percentage of success of a first needling procedure? And a second one with 5-FU?

Dr. Elliot Werner:  Probably around 50% or so, but the effect will often deteriorate over time.

P:  Can you please explain neovascular glaucoma?

Dr. Elliot Werner:  NVG results from the overgrowth of abnormal blood vessels in the eye in response to poor circulation to the eye. NVG is seen in conditions such as diabetic retinopathy and retinal blood vessel occlusions.

P:  I found out I had pseudoexfoliation glaucoma syndrome when the iris in my right eye turned from green to brown.  I would like to understand what was physically happening in my eye to cause that change.   

Dr. Elliot Werner:  Pseudoexfoliation is a degenerative condition of the structures in the front part of the eye that is sometimes associated with a severe glaucoma.  It causes atrophy and degeneration of the iris, which is why the color can change.

P:  Do you have suggestions for finding the right treatment?

Dr. Elliot Werner:  Get your visual field and optic nerves examined at frequent intervals, and ask the doctor to compare the results with previous tests to be sure you are stable.  If there are signs of deterioration, the treatment should be augmented.

P:  If I had found this chat room sooner, I would have found the right treatment sooner!

P:  I wish I heard the words "ocular hypertension" 13 years ago.

P:  What IOPs can be reached by using shunts?

Dr. Elliot Werner:  It varies, but in a successful shunt with a good result we usually get pressures between 8 and 16 mm Hg.

P:  What is the average success rate of shunts?  

Dr. Elliot Werner:  Depending on the diagnosis, about 50 to 80%.

P:  Which is the best shunt, in your opinion?

Dr. Elliot Werner:  I have used them all and have gravitated to the Baerveldt.  I have found the best and most consistent results with the Baerveldt.

P:  What kind of maintenance work is typical for a shunt, especially in a young person?

Dr. Elliot Werner:  Once you have recovered from the surgery and the inflammation has settled down and the eye has stabilized (usually about 3 to 6 months), no maintenance is required. You can ignore the shunt and let it work.

P:  Thanks.  That's the best news I've heard all month.  Why does the healing take so long?  Recovering from my cataract surgery was much quicker.

Dr. Elliot Werner:  Shunt surgery is much more traumatic to the eye than cataract surgery, and glaucoma eyes are generally "sicker" than eyes with routine cataracts.

P:  I heard about a new minishunt recently approved for use.  Is it a winner?   

Dr. Elliot Werner:  I think you are referring to the Ex-PRESS  mini shunt.  It is controversial.  Some people claim very good results.  Most glaucoma docs have not been impressed.

P:  I recently read that the plate used in shunt surgery can erode the surface of the eye. Under what conditions is that likely to occur? What happens to the eye when that happens?  Can it be fixed?  Please clarify as much as you can  for me.  My doc has recommended shunt surgery and I'm very concerned.

Dr. Elliot Werner:  Erosion is a complication of shunt surgery. Fortunately, it's an uncommon one.  Most often the shunt erodes outward, not into the eye.  If that happens, we can try to cover it up, but sometimes it has to be removed.

P:  Can a shunt be removed without causing damage to the eye or vision?

Dr. Elliot Werner:  If a shunt causes complications that require its removal, it usually doesn't damage the eye in the short run.  But control of the glaucoma becomes a problem again, because that was the reason for using the shunt in the first place.  Removal of shunts for complications is fairly uncommon.  I do a lot of shunts and have only had to remove three or four in my career.

P:  Can someone who has intraocular pressure around 14 mm Hg get glaucoma?  If so, why?  

Dr. Elliot Werner:  Yes. That is normal-tension glaucoma. "WHY?" All of us glaucoma docs scream that question to the heavens daily.

P:  I was diagnosed with NTG.  Actually, that's a "maybe".  I have vision loss in one eye only (central scotoma).  The highest IOP  measurement has been 22.5 mm Hg.  The current pressures are 18 mm Hg. in both eyes.  I've had no further damage in two and a half years.  My doc doesn't seem to be worried that the eye drops haven't brought pressures down the desired 30%.  Do you always find it necessary to lower IOP by at least 30%?   

Dr. Elliot Werner:  If you have been stable, then your treatment is adequate.  We aim for targets of 20%, 30%, or 40% in the hope of controlling most patients, but not every patient requires that much lowering for control.  Some patients, however, require 50% or 60% lowering of IOP for control.

P:  My Dad has glaucoma.  His IOP is around 14 mm Hg.  Would that pressure be too high for him?  

Dr. Elliot Werner:  It may or may not be too high for him, depending on whether or not his visual fields and optic nerves have been stable.  Patients with progressive glaucoma at a pressure of 14 mm Hg can be very difficult to treat, because it is very hard to lower the pressure significantly below 14 mm Hg.

P:  My Dad had a visual field test two years ago and again just two days ago.  The area of change is darker, but it is in the same area as two years ago.

P:  Isn't it true that you can't tell about progression just because a visual field printout looks "darker"?  Couldn't that just be the quality of the printout?  My doctor says the only really important things are the numbers (on the printout).  The graphic just points to where to look.

Dr. Elliot Werner:  Determining progression from a visual field test is notoriously difficult.  A lot of active research is trying to develop computer programs that will do that.  It usually requires graphing and statistical analysis of the numbers.  You are right:  just the area of darkness is not a reliable indicator.

P:  My Dad has AMD (age-related macular degeneration) in his left eye and normal-tension glaucoma in the right eye.  Do you have any comments for his treatment or any suggestions?

Dr. Elliot Werner:  For the most part, macular degeneration has no good treatment.  NTG can be treated with drops, lasers, or surgery designed to lower the eye pressure even more.  That has been shown to be beneficial, but in people with normal-tension glaucoma and fairly low pressures, we don't usually recommend more aggressive treatment unless we see definite evidence the eyesight is getting worse.

P:  What is the best way to treat NTG.  Will it make my Dad's vision get worse fast -- within several years?

Dr. Elliot Werner:  A large NTG study was recently completed.  About half of the NTG patients could be adequately treated with medications.  The rest required surgery, so there is no best way to treat.  It depends on the individual patient's response to the different treatments we have available.

P:  I have been using Betoptic S in both eyes for many years.  Could that be the reason I feel tired after lunch most afternoons?  

Dr. Elliot Werner:  That's possible, because beta blockers can cause fatigue.  But fatigue is such a non-specific symptom it is difficult to tell without stopping the Betoptic to see what happens.

P:  Can the iris of one eye atrophy or get smaller than the other? Is the iris a muscle? The iris in my damaged eye seems smaller.

Dr. Elliot Werner:  Yes it can, if the pseudoexfoliation is also asymmetric.  The iris is a complex structure that has some muscle tissue in it, but also consists of nerves, blood vessels, and connective tissue called stroma.

P:  I'm sorry, Doctor Werner, but  I do not know what pseudoexfoliation, etc.,  means.  

Dr. Elliot Werner:  I'm sorry.  Were you the one who said you had pseudoexfoliation with the change in eye color?

P:  No, I'm the one who asked about iris atrophy.  

Dr. Elliot Werner:  Okay. Sorry.  Iris atrophy can cause one pupil to be smaller or larger than the other because of the effects on the nerves and muscles in the iris.

P:  In the HRT images of my eyes, the rim of the optic nerve of my damaged eye has a depressed defect in it that looks like a moon crater or a splash in a pond -- a ragged hole -- corresponding to the field loss.  To me, the appearance suggested an even, rather than a gradual, wasting away of the optic nerve.  Does all nerve damage have this appearance?

Dr. Elliot Werner:  Optic nerve appearance varies from patient to patient but, in general, patients tend to have what is called localized or generalized damage.  In localized damage, one part of the nerve is damaged much more than the rest.  In generalized damage, the entire nerve is damaged more or less equally.

P:  Somewhere in the Wills archives I noticed one of your colleagues advised weight loss. What does weight have to do with glaucoma?

Dr. Elliot Werner:  There is no direct relationship between weight and glaucoma that has been shown, but obesity is often associated with a variety of circulatory and other health problems, such as diabetes and high blood pressure that can make treating glaucoma more difficult.

P:  My daughter, who is 41 years old, had an IOP of 9 mm Hg.  I presume in both eyes.  She was pregnant at the time of the measuring.  Would pregnancy have an effect on lowering the eye pressure? She doesn't take eye meds.

Dr. Elliot Werner:  Pregnancy has different effects on eye pressure in different patients.  A drop in eye pressure is not unusual in pregnancy due to the hormonal changes. 

P:  Is treatment for advanced glaucoma different for blacks and whites?

Dr. Elliot Werner:  Not really.  Black patients are more likely to have glaucoma and to be less responsive to treatment, but the principles of treatment are the same.  Once a patient has glaucoma, you do whatever is necessary to bring the disease under control.

P:  It must be frustrating for you (and other doctors) when a patient does not seem to be responding to treatment and it becomes difficult to find the "right" treatment.

Dr. Elliot Werner:  Yes,  it's the most frustrating thing in the world, especially since filtering surgery has at best about an 80% success rate.  That means there is a significant number of patients who do not respond to any treatment.  It's horrible.  Sleepless nights over that one.

P:  That reminds me of what Marty Wax said about normal-tension glaucoma (which I have).  Dr. Wax called it the "cancer" of glaucoma.

Dr. Elliot Werner:  I think of it more as the schizophrenia of glaucoma:  devastating, hard to treat, and long-lasting.

P:  I like your analogy better.

P:  Since the treatment protocol for most glaucoma doctors is about the same, would you say that the patient-doctor relationship is the single most important factor in treatment?  Has anything changed in the training of specialists to close the gap of glaucoma as a disease versus glaucoma as it affects the patient as a person? I mean in treatment of the whole person? 

Dr. Elliot Werner:  That's a tough one. The problem you define is really a cultural one.  Most glaucoma docs are oriented to saving vision, not, unfortunately, to making people feel better.

P:  Dr. Werner, you managed to pack a lot of good information into this 60 minutes. Thank you. 

Dr. Elliot Werner:  Thank you.  Got to catch that early morning plane to Florida tomorrow.  See you at the end of the month.

End of highlights for March 3, 2004.

On March 10, Dr. Wilson discussed "Glaucoma Around the World" in the Chat room. Click here for highlights of that meeting.

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