Chat Highlights
Pigmentary Glaucoma
March 29, 2000

Norma Devine, Editor

On Wednesday, March 29, 2000, Dr. Jay Katz, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Pigmentary Glaucoma." Here are some highlights from the evening.

Dr. Katz:   Hi!

Moderator:   Welcome back, Dr. Katz. The topic tonight is Pigmentary Glaucoma. Only two people in the room have that type of glaucoma.  

P:   Is it true that after a certain number of years the pigment stops flaking off?

Dr. Katz:   Yes. As people get older, there is often less pigment.

Moderator:   So does that mean in time people with pigmentary glaucoma can get better?

P:   Is there a certain age at which that happens? I've already had a trabeculectomy in my left eye and may be headed for one in my right eye. I am 48 years old.

Dr. Katz: Yes. In certain cases there can be improvement with time, often at ages of greater than 60. In certain people, the changes are not reversible and improvement does not occur.

P:  One of the group just had a trabeculectomy today.  How long will the actute irritation last?

Dr. Katz:  It may last two months or longer.

Moderator:   I had a reaction to my drops after surgery that made my eye feel like it was on fire.  Eventually, it got better. I used a handkerchief instead of Kleenex and it helped. I still use a hanky.

P:   Could you explain the pigmentary problem, please?

Dr. Katz:   Pigment is not normally shed inside the eye. In certain young, near-sighted patients it is, and it damages the drainage system of the eye with a resulting increase in eye pressure.

P:   Why is it more common in males?

Dr. Katz:   We think it is more common in males because their eyes are slightly larger and more predisposed to shed pigment because of that.

Moderator:   So is it like an angle closure where pigment sheds and closes the drain?

Dr. Katz:   Pigmentary glaucoma is a secondary open-angle glaucoma.

P:    Is the age at which you become nearsighted a factor? I was six or seven.

Dr. Katz:   Being near sighted is part of the syndrome, and most people start becoming near sighted at a relatively young age.

P:    I just had a laser PI on my right eye and I have noticed a difference in pupil size in that eye vs. the other eye. Is this normal?

Dr. Katz:   The pupil size may be different now, but could revert back to the same as the other eye.

P:    What do you think of a shunt implant?

Dr. Katz:   Shunt implants are extremely helpful in refractory types of glaucoma. We often use them.

P:   What is refractory glaucoma?

Dr. Katz:   Refractory glaucomas are those cases that don't respond to medical and standard laser or surgical procedures.

P:    I've read that abnormal iris size or shape is a birth defect that occurs in utero, at seven months of development. Is that accurate?

Dr. Katz:   Odd-shaped pupils, called colobomas, are developed in utero, as you stated.

P:   Does having pigmentary mean you have an odd-shaped pupil?

Dr. Katz:   No. The iris in pigmentary glaucoma is bowed backward more than normal, which is why pigment is shed.

P:   Is that an abnormality like a birth defect, or just a different shape?

Dr. Katz:   It is probably genetically determined, but does not appear until young adulthood.

P:   If a parent has glaucoma, what age should a child be checked?

P:   Good question.

Dr. Katz:   That depends on the type of glaucoma. In general, at age eight or above children should be examined anyway.

P:   Thank you. My mother, uncle and great grandmother all have open-angle glaucoma.

Dr. Katz:   The risk for open-angle glaucoma generally is greatest in the middle-aged and older population.

P:   I'm the first in my family, Dr. Katz, but now my 20-year-old son has intraocular pressures of 19 and 20.  The doctor saw no evidence of released pigment. Would the pigment show up later?

Dr. Katz:   Yes, it can show up later.

P:   My doctor wants to see my son in six months. He is not using drops yet.  Does waiting six months sound right?

Dr. Katz:   Yes.

P:   My son's eye pressures jumped from 13 and 14 to 19 and 20 in one year. How worried should we be?

Dr. Katz:   IOPs do vary quite a bit.  I wouldn't worry yet, unless the overall trend is upward.

P:   Is a certain type of glaucoma inherited, or just a general disposition to glaucoma?

Dr. Katz:   The vast majority of glaucomas are genetically inherited.

P:   So my children will get NTG (Normal Tension Glaucoma) like I have?

Dr. Katz:   Your children are at higher risk for NTG, but it does not mean that they will definitely get it.

P:   I understand, but might they come up with pigmentary or some other type?

Dr. Katz:   Glaucoma is not rare.  Therefore, having different types of glaucoma in the same family would not be unusual.

P:   Regarding visual fields, can you discuss the significance of numbers that appear in the pattern diagram. I understand the higher the number, the dimmer the light one perceives. What number range is normal? My numbers are generally in the 20s with an occasional 30-3l. Is this good or bad? Also I understand a change of two or three is not significant, but five or six is. Can you elaborate?

Moderator:   We have a good article on visual field testing at the site in the testing section.

Dr. Katz:   The numbers are age-dependent. In other words, the normal values depend on how old you are. But the numbers you quoted are usually quite good. We often will look at clusters of abnormal points in certain locations that hint at glaucoma type of injury. The pattern figures help give us statistical significance to the abnormal points.

P:   How do you test for contrast sensitivity? I have a tough time with contrast sensitivity.

Dr. Katz:   Contrast sensitivity can be tested by looking at gradings of white and black and adjusting the contrast and measuring with numbers. Often glaucoma patients have abnormal results.

P:   How do shunts differ from trabs?

Dr. Katz:   Shunts direct the fluid toward the back of the eye, whereas trabeculectomies create fluid pockets, or blebs, on the top front of the eye.

P:   My pressures were never real high. My last doctor thought I had NTG, but this one says I have pigmentary.

P:   Does the doctor see the pigment? Do you have Krukenberg spindles?

P:   I don't know about the spindles, but the doctor is positive about the pigment.

P:   I think the spindles are clusters of pigment.

Dr. Katz:   Not everyone with pigmentary glaucoma necessarily has a pigment spindle.

P:   Dr. Katz, why do some people have them?

Dr. Katz:  There is so much pigment floating in the front anterior chamber of the eye that it cannot be cleared completely. The pigment  layers on the inside surface of the cornea in a spindle pattern.

P:   So does that mean I have more released pigment than is usual in pigmentary?

Dr. Katz:   It is not more than usual, since spindles are seen more often than not in pigmentary glaucoma.

Dr. Katz:   Sorry everyone, I have to run to a telephone conference at 9:30. I look forward to another chat in the near future. Best of luck to everyone. Goodnight.

End of highlights for March 29th chat.

On Wednesday, April 5, 2000, Dr. Courtland J. Schmidt, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Traumatic Glaucoma." Click here to read the highlights.

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