What Treatment is Best for Me?
Chat Highlights
March 9, 2005

On Wednesday, March 9, 2005, Dr. Rick Wilson a glaucoma specialist at Wills, and the glaucoma chat group discussed "What Treatment is Best for Me?"

Moderator:  Tonight's topic is: "What Treatment is Best for Me?"

Dr. Rick Wilson:  That's easy. As my father used to say, "It depends."

Moderator:  How is treatment usually started?

Dr. Rick Wilson:  We try to lower IOP (intraocular pressure) 25 to 40% from the level at which the patient has been getting worse.  The more damaged the optic nerve, the higher is the desired reduction of IOP.  We also try to level out the IOP, since multiple studies have shown that fluctuating IOPs are more of a risk factor than a somewhat higher, but level, IOP.  We want to know about the patient's health, so the medicine doesn't cause too many side effects, both systemic and ocular.

P:  How do you decide when treatment is needed?

Dr. Rick Wilson:  Well, we look carefully at the optic nerve and retinal nerve fiber layer.  They nearly always show us the earliest signs of damage.  If there is damage, then there is no question.  If the call is questionable, we take into account family history, race (African-American, Hispanic, Caucasian), health, and life expectancy.

P:  Does age influence your choice of treatment?

Dr. Rick Wilson:  On average, the older the patient is, the worse the circulation and resistance to damage.  However, if the optic nerve is minimally damaged and the patient is elderly, with a limited lifespan, I wouldn't want to push treatment too hard, if it would not make a difference in the ability to function during the patient's lifetime.

P:  A mother whose child was born with PCG (primary congenital glaucoma) told me that surgery is the only solution. Forget about drops.  Knowing now that my daughter has literally no trabecular meshwork (genetically), I wonder whether surgery is the best option.

Dr. Rick Wilson:  Yes, we rarely use drops as the first option in infants and toddlers.

P:  As a glaucoma specialist, do you spend much time informing patients about why you have selected a particular treatment?

Dr. Rick Wilson:  I spend more time educating them about their disease, and the absolute necessity of their taking their medications, and discussing the side effects, without being too suggestive.

P:  How can measuring IOP once every three months, or even twice in two months, be adequate for determining fluctuation?

Dr. Rick Wilson:  It cannot. We trust a good medical regimen to dampen down the IOP fluctuations.  If the patient is still getting worse with what looks like good pressure control, the usual culprit is sporadic use of glaucoma medicine.  At that point, I usually do a diurnal curve.  That is, the IOP is checked every two hours from 7:00 a.m. to 3:00 or 4:00 p.m.

P:  If a patient starts to show progression after being fairly stable on maximum medication for five years, should she have a shunt implanted?

Dr. Rick Wilson:  Yes, if she has already had a laser trabeculoplasty, or if she is a poor candidate for laser because she is too young, or had the wrong diagnosis or, most commonly, doesn't have sufficient pigment in the trabecular meshwork.

Moderator:  Can progression be determined from just one visual field test?

Dr. Rick Wilson:  No. We need two, the second to validate the first, unless there is also a change in the optic nerve, or the doctor judges the IOP is too high for the health of the optic nerve.

P:  What about consideration of a precipitating factor, such as optic nerve damage induced by steroid use?  Would you treat the patient or adopt a wait-and-see approach?

Dr. Rick Wilson:  If the IOP is elevated, I would still treat it at the same time I am trying to ameliorate the precipitating factor.

P:  Why would a doctor try SLT (selective laser trabeculoplasty) instead of ALT (argon laser trabeculoplasty)?

Dr. Rick Wilson:  The SLT is more benign than the ALT.  But that is the only benefit of the SLT proven so far.

P:  I thought the SLT was better because it could be repeated.

Dr. Rick Wilson:  So far, the SLT has not been proven to be any more repeatable than the ALT.  Because the SLT is less damaging to ocular tissue, theoretically it is possible to repeat it more than the one time possible with ALT.

P:  I have been offered the option of SLT.  I've also been told I have hardly any pigment in the meshwork.  I thought SLT targeted only pigmented cells.  If so, how would I be a candidate for SLT?

Dr. Rick Wilson:  I have not had much luck with ALT or SLT in patients without pigment to absorb the laser energy.  You could try it out of desperation before surgery, but I doubt if any effect would be long lasting.

P:  I had SLT in half of each of my eyes, and it only lowered my IOP for two and a half months.  Recently, my doctor used SLT on the other half of my right eye.  Any thoughts on that?

Dr. Rick Wilson:  Usually, most of the effect comes with the treatment of the first half of the circumference of the eye.  If SLT treatment of the first half of the eye did not last for a year or more, treating the second half adds little benefit.  If I were you, I would not be optimistic.  Let me know if I am wrong.

P:  If SLT and glaucoma medications don't reduce the IOP enough, what would be the next treatment to consider?

Dr. Rick Wilson:  A trabeculectomy would be next.

P:  At what point should a patient consider getting a second opinion?

Dr. Rick Wilson:  If you are happy with your doctor, you may not need another opinion.  If you have any doubts, however, it is always better to reassure yourself and get another opinion before making any major decisions.

P:  How do you decide which glaucoma medication to prescribe after a person has been diagnosed with glaucoma?

Dr. Rick Wilson:  Presently, we usually turn first to a prostaglandin like Xalatan, Travatan, or Lumigan, because prostaglandins flatten the diurnal IOP curve better than any of the other drops.  The prostaglandins are also the most powerful, so we may turn to a beta-blocker if the patient doesn't need as much IOP reduction.  Beta-blockers also have a fairly good duration of action and can usually be used once a day, except for Betoptic S, which needs to be used twice a day.

P:  How do you decide what will be the first course of treatment?

Dr. Rick Wilson:  Usually, we use laser as equal to a strong medication.  We try it after trying different combinations of medicine and before trabeculectomy.  Trabeculectomy is usually done before a shunt, except in special cases.

P:  My doctor said he has seen Lumigan work for about a year, then stop working.  That was my experience, too.  What do you think?

Dr. Rick Wilson:  Perhaps the disease got worse and the Lumigan could no longer control it, or something occurred that we don't understand.  Xalatan, which has by far the longest track record for the prostaglandins, did not show a drop-off of effect, as do the beta- blockers.

P:  Are your treatment decisions complicated because each patient reacts differently to meds, surgery, etc.?  My doc told me that the surgical part of my trabeculectomy was only one component of my treatment.  He said that the many decisions about treatment after the surgery were just as important.

Dr. Rick Wilson:  That is what makes taking care of glaucoma patients so interesting and challenging.  Every case is different.  The final result of a trabeculectomy depends upon a good start with competent surgery, but also good -- and sometimes lucky -- post-operative therapy, such as cutting the flap sutures at just the right time, etc.

P:  My question concerns a 29-year-old patient whose trabeculectomy in the left eye healed shut.  He had another trabeculectomy with MMC in that left eye.  If the right eye also needs cutting surgery, would you choose a trabeculectomy again or try a shunt?

Dr. Rick Wilson:  I would try a trabeculectomy by someone with a lot of experience.

P:  How long are steroid drops usually used after the revision of a trabeculectomy?

Dr. Rick Wilson:  Three to ten weeks depending upon how extensive the revision was.

P:  I have been on steroid drops for four months.  Would you consider that to be too long?

Dr. Rick Wilson:  If your pressure is too low or if the eye is inflamed, continued steroid use would seem to be appropriate.

P:  I am suffering from a viral conjunctivitis that infiltrated my cornea and greatly affects my vision.  Is there any treatment for that?

Dr. Rick Wilson:  Is it herpes simplex, herpes zoster, or epidemic keratoconjunctivitis?  The treatment is markedly different.  Steroids make you feel better, but may lengthen the duration of the infection.  I am certainly not a corneal specialist, so there may be much better treatments with the present antivirals.

P:  What is the recommended treatment when the cause of viral conjunctivitis is the adenovirus?

Dr. Rick Wilson:  Usually it is just trying to keep the patient as comfortable as possible till the body fights off the virus.  I don't think any of the new antivirals are really effective against adenoviris, but as I said above, I am not a corneal specialist.

P:  How does the virus get into the eye?

Dr. Rick Wilson:  From the hands, from an aerosol spray, a sneeze or cough, a towel, etc.

P:  In November I had a shunt (Baerveldt).  It did what the two failed trabs did not.  My IOP is finally 9 mm Hg, and everybody, including me, is happy.  Sometimes treatment just takes the right combination of time and luck!  The difficulty for me is waiting to see what happens to my good eye that is at risk of angle closure.  Will I ever overcome the fear?

Dr. Rick Wilson:  Continued apprehension would be normal, but should lessen the longer the time that goes by without problems with the good eye.

P:  Can you tell me what a grade of AB - 10f means?

Dr. Rick Wilson:  AB is the iris insertion into the trabecular meshwork, so the working angle is closed.  The 10 is the degrees of the approach to the angle.  The f is flat, i.e., no anterior bow to the iris.  I assume you have an iridectomy in the good eye.

P:  Why do some medications have no pressure-lowering effect on certain patients?  What causes the resistance?

Dr. Rick Wilson:  In most cases, we don't understand.  About 10% of patients do not have any response to beta-blockers.  We don't know why.

P:  If a trab is good and functions well for several months, and then the IOP begins to rise, does it help to periodically give more 5-FU shots?

Dr. Rick Wilson:  I doubt it, as 5-FU is most useful during the intermediate healing phase, ranging from a couple of days after surgery to 14 to 17 days.  However, I haven't seen any good studies about that usage.

P:  Does any current glaucoma treatment completely stop progression?  Or does glaucoma always progress, even if only by small, barely perceptible amounts?

Dr. Rick Wilson:  We think progression will be stopped in almost everyone if the IOP is lowered enough.  Unfortunately, the IOP may be so low that the patient doesn't see clearly.

P:  When would a doctor choose to do cyclophotocoagulation?

Dr. Rick Wilson:  A cyclophotocoagulation is a last-ditch procedure after all other kinds of surgery have been exhausted, unless the visual potential is very poor.

P:  How long can cyclophotocoagulation last? What happens when the eye becomes sick again?

Dr. Rick Wilson:  Cyclophotocoagulation can last forever. Usually, if the IOP increases, it is because the eye is getting more healthy and producing more normal amounts of aqueous.

Moderator:  I think the take-home message for tonight's topic -- "What treatment is best for me?" -- is what Dr. Rick Wilson said at the beginning:  "It depends."

Dr. Rick Wilson:  I agree.

On March 16, Dr. Henderer discussed "Glaucoma Research" in the Chat room. Click here for highlights of that meeting.

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