Ocular Emergencies
Chat Highlights
May 12, 2004

Norma Devine, Editor

On Wednesday, May 12, 2004, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Ocular Emergencies."

Moderator:  Tonight we would like to talk about ocular emergencies.  I am an angle-closure glaucoma patient who knows first hand about that kind of emergency. 

Dr. Rick Wilson:  Patients with narrow angles are prone to acute angle-closure glaucoma.  That is when the iris is so close to the drain that it gets pulled into the drain with the flow of fluid and blocks the drain. The pressure rises acutely.  Most of the time, a peripheral iridectomy can reduce the high IOP (intraocular pressure).  Unfortunately, sometimes, releasing the adhesions of the iris from the drain is necessary, or a bypass drain needs to be made surgically.

P:  What are the symptoms of acute angle-closure glaucoma?

Dr. Rick Wilson:  The symptoms of acute angle-closure glaucoma are a severe ache in the eye, hazy vision, colored halos around lights, a red, irritated eye, and a feeling of nausea, possibly vomiting.

Moderator:  Can a sudden rise in IOP happen in any type of glaucoma?

Dr. Rick Wilson:  Chronic open-angle glaucoma usually has a slow, even rise in pressure.  Acute angle-closure glaucoma has a sudden rise in pressure, with IOPs often over 70 mm Hg (millimeters of mercury). 

P:  I have open angles (normal-tension glaucoma, supposedly). What ocular emergencies could I possibly have besides a blow to the eye or an object penetrating the eye?  Are there any emergencies specifically related to open angles?

Dr. Rick Wilson:  If you haven't had any eye surgery, I can't think of a specific emergency related to normal-tension glaucoma (NTG).  Patients with normal-tension glaucoma are more susceptible to an eye pressure rise or a systemic blood pressure drop, such as with shock or general anesthesia. 

P:  One of my biggest fears is that I won't recognize an ocular emergency.  What are some of the symptoms of a failing bleb?

Dr. Rick Wilson:  If your intraocular pressure rises slowly, you will have no symptoms.  If your IOP rises rapidly, your eye will ache, and there may be visual changes, such as blurred vision.

P:  What are the possible eye emergencies for an eye that has had a trab (trabeculectomy)? 

Dr. Rick Wilson:  Patients with a trabeculectomy may find that the conjunctiva, the top layer of the eye, becomes thin from the force of the fluid pressure exiting the eye over time.  The thin conjunctiva will then be prone to developing a hole that will leak, lowering the eye pressure to below normal levels and blurring vision, or allowing access of bacteria to the eye.  If harmful bacteria enter the eye, the result can be calamitous.

P:  Can anything be done to prevent thinning of the conjunctiva and the problem of harmful bacteria entering the eye? 

Dr. Rick Wilson:  The only thing that would reduce the percentage of patients who develop a leak would be to start an aqueous suppressant to take the pressure off the bleb.  That isn't done unless the patient is already far down the road to developing conjunctival thinning.

P:  Can't a doctor detect thinning of the conjunctiva before disaster strikes? 

Dr. Rick Wilson:  Doctors can tell whether the conjunctiva is thin, but cannot determine who will later develop a leak or an infection.  

P:  Does the use of MMC (mitomycin-C) cause the conjunctiva to be thinner than usual?

Dr. Rick Wilson:  Yes.

P:  Can patients tell if their IOPs are very high?

Dr. Rick Wilson:  If the pressure goes up slowly, the patient may have no inkling that the pressure is high.  If the pressure goes up rapidly, there will be an ache in the eye and possibly cloudy vision.

P:  What are the causes and symptoms of subconjunctival hemorrhage?

Dr. Rick Wilson:  Many times it seems that there has been gentle trauma to the eye, such as rubbing the eye or coughing.  Many patients, however, suffer subconjunctival hemorrhages without any provocation.  Some people feel that there is an ache in the eye when they suffer a subconjunctival hemorrhage.

P:  About a month after I developed a scotoma, I had sudden, severe pain that shot from the damaged eye to the back of my head.  Monocular vertical diplopia (vertical double vision in one eye) followed immediately and lasted all day.  Was that an emergency? And what was it, anyway?

Dr. Rick Wilson:  What you had sounds like a ministroke or transient ischemic attack (TIA).

Moderator:  What is "red eye?"

Dr. Rick Wilson:  A red eye is usually caused by an infection (pink eye) or an allergy.  An infection usually has a watery discharge if it is a virus.  If the infection is bacterial, the eye will have a thick, yellow discharge.   If the red eye is due to an allergy, there will be symptoms of itching. 

P:  There can also be ocular emergencies not related to glaucoma, such as retinal tears.  What are the symptoms of a torn retina, and how do you know when it's serious enough to be treated as an emergency?  

Dr. Rick Wilson:  Often, flashing lights and a bunch of new floaters occur with a retinal tear.  But some patients get retinal tears with far fewer symptoms, so you need to be on the lookout for anything distinctly unusual.

P:  Is there always an ophthalmologist available in emergency rooms?

Dr. Rick Wilson:  Unfortunately, most emergency rooms have to call in an ophthalmologist to see an emergency patient.  Few places like Wills have three doctors on duty at all times.  

P:  Isn't there a type of open-angle glaucoma in which the angle can close periodically?  

Dr. Rick Wilson:  Intermittent angle-closure glaucoma is only seen in patients with narrow, occludable angles.  Instead of the angle closing at one time and requiring laser or cutting surgery to control IOP, the IOP may fluctuate with the amount of angle closure.

P:  After four eye operations, my Mom has low IOP (now about 10 mm Hg), very low vision, and always says things are dark till evening, when they are bright.  Any idea what's going on? 

Dr. Rick Wilson:  Patients with glaucoma damage often complain of the loss of contrast sensitivity.  That means they can see black on white, but not gray on a lighter gray.

P:  In the past I've had severe iritis, which cleared up after treatment.  I used Pred Forte and a dilating eye drop.  About five  years later, my eye pressure went up to 40 mm Hg.  I couldn't tolerate Cosopt, and am now using Travatan.  If the iritis returned,  how would it be treated?  How would treatment affect the  medication for my eye pressure?   My iritis attack comes on  suddenly.  Would the iritis affect my eye pressure?  Would that be serious?  Would the treatment for iritis be any different now that I have an IOP problem?  The last time I had iritis, the receptionist said to use hot compresses to help relieve the pain until I could see the doctor.  Should I stop the Travatan immediately?

Dr. Rick Wilson:  Sorry, without seeing you I can give only general observations that may not pertain especially to you.  If your inflammation returned, the first thing I would do would be to stop the Travatan, as it can cause increased inflammation.  I would probably turn to a medication like Ocupress (a beta blocker) plus Alphagan (an alpha-2 adrenergic receptor agonist).

P:  You mentioned that Travatan can affect the cornea.  Does that happen over a time period?  How would that affect vision? 

Dr. Rick Wilson:  It does happen over time.  I have seen the most corneal side effects with Xalatan, since it has been in use far longer than Travatan.  The symptoms are hazy vision with light sensitivity and corneal irritation.

P:  Do you find that persons whose eyes are compromised by glaucoma are more prone to other eye problems? 

Dr. Rick Wilson:  Yes.  I think some eyes that develop glaucoma are not healthy eyes and may well develop multiple problems.

[Editor's Note: The following off-topic information is included because many patients ask about treatment for dry eyes.]

P:  A glaucoma patient in Buffalo who finds GenTeal Gel helps with her eye problems says she can no longer find it in stores there. What could she use instead of GenTeal Gel?

Dr. Rick Wilson:  There are other thick solutions that last a while, but not as long as GenTeal Gel.  What I am prescribing most often now for my dry-eye patients is ingesting one tablespoon of flaxseed oil per day.  It seems to change the constitution of the tears and make them last longer.  I get the flaxseed oil at a health food store, not a pharmacy.

P:  I've been using flaxseed oil (in gel cap form) for a couple of months now.  My eyes are overall less dry than they've ever been.

Dr. Rick Wilson:  The gel caps are expensive, and you have to take eight or more capsules to get the same effect as with one tablespoon of the oil. *

Moderator:  Thank you, Dr. Rick.  See you in two weeks.  

Dr. Rick Wilson:  Night all.

End of highlights for May 12, 2004.

[Postscript: Dr. Rick Wilson has asked that the following information be added to the Chat Highlights.

"I started taking flaxseed oil and ground flaxseed for my arthritis, for which it did nothing, but I found it abolished my dry eyes, dropped my triglycerides an unbelievable 40%, and lowered my total cholesterol 15%. Since I had many years of serum lipid profiles before and now after the start of flax, it even convinced my cardiologist, who is using it for his patients. This experience has been replicated for most of my patients and even some of my fellows who have tried it."

A patient sent Dr. Rick an interesting article, entitled "What's the Scoop on Flaxseeds?," which appeared in "Health Extra" on the Web site of the Cleveland Clinic. http://www.clevelandclinic.org/healthextra/]

On May 19, Dr. Werner discussed "Pigmentary Glaucoma" in the Chat room. Click here for highlights of that meeting.

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