Chat Highlights
Traumatic Glaucoma
April 5, 2000

Norma Devine, Editor

On Wednesday, April 5, 2000, Dr. Courtland J. Schmidt, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Traumatic Glaucoma."  Here are some highlights from the evening.

Moderator:  Hello Dr. Schmidt.  Welcome back.

Dr. Schmidt:  Thanks.  It's good to be back.

Moderator:  The topic is Traumatic Glaucoma.

P:  My doctor says the trauma I suffered long ago damaged the trabecular meshwork, leading to glaucoma now.  How many ways can trauma lead to glaucoma?

Dr. Schmidt:   A blow to the eye can damage the meshwork, but there is a lot of reserve built in, so it may only be later, when a little more outflow is lost, that the IOP goes up.

P:  Yes, that is what happened in my case.  How else can trauma lead to glaucoma?

Dr. Schmidt:  Trauma can lead to glaucoma by causing bleeding in the eye, dislocating the lens, or causing a cataract. 

P:  How long would it be after suffering trauma to the eye before glaucoma showed up?

Dr. Schmidt:  It can be immediate, i.e., that day, or many years down the road.

P:  Is all traumatic glaucoma the result of direct trauma to the eye, or can it result from head trauma not directly involving the eye?

Dr. Schmidt:  Usually a blow to the eye itself.  The eye is cushioned beautifully in the skull, so blunt head trauma is less likely.

Moderator:  What if the person already had glaucoma and then had a blow to the head?

Dr. Schmidt:  If one already has glaucoma, a blow to the head is unlikely to affect it.

P:  Can surgery be considered trauma to the eye and make glaucoma worse?

Dr. Schmidt:  Surgery is definitely condsidered as an "insult" or trauma to the eye.  There is no question that multiple eye surgeries, whether cataract, retina, or cornea, all increase the risk of developing glaucoma.

Moderator:  What about chalazion removal.  Is that trauma?

Dr. Schmidt:  No, not chalazion removal.  A chalazion is a tiny infected lump in a gland in the eyelid - usually goes away by itself.   

P:  Could concussions from falls off horses and auto accidents suffered years ago cause glaucoma?

Dr. Schmidt:  Is it possible?  Yes.  Is it likely?  No.  Unfortunately, there's no way to tell.  The usual rule of thumb is that blunt head trauma bad enough to injure the eye probably is causing other, worse problems.

P:  Is there any difference in prognosis for glaucoma due to trauma?

Dr. Schmidt:  Prognosis is no better or worse for overall control, but some doctors feel that surgery is more likely to be necessary.  That may not be true now with all the good glaucoma medications. 

P:  What about a burn to the eye from a sunscreen?

Dr. Schmidt:  If you mean chemical irritation from sunscreen, no.

P:  What if your pressure is very high, as mine is, and you fly four days a week.  Can that cause the pressure to increase?

Dr. Schmidt:  That shouldn't affect eye pressure unless the schedule makes you forget to use your drops.

P:  Can an eye give up after too much surgery?

Dr. Schmidt:  In a sense, yes, if the ciliary body, which makes the fluid that nourishes the eye and allows us to measure a pressure, stops making fluid.  The pressure goes to zero and the eye essentially slowly dies and becomes soft.

P:  It dies because it is soft?

Dr. Schmidt:  The eye loses function when the pressure gets too low, because no fluid is made.  The cornea and retina swell, and the blood flow is poor.  

P:  Can you explain better how very low IOP can help improve vision?

Dr. Schmidt:   Very low IOP can help optic nerve function and improve vision, or it can cause corneal or retinal swelling and poor vision.  Similarly, high IOP can cause increased corneal clarity in some people, helping vision, or cause increased corneal clouding, obscuring vision.  Any significant change in vision is worth at least a phone call, or maybe a trip to the doctor.

P:  Dr. Wilson said once he'd rather treat traumatic or acute glaucomas, because the results can be more definite.  Is there a difference in prognosis with traumatic glaucoma?

Dr. Schmidt:  I don't feel the prognosis is better or worse.

P:  I just want to confirm that, in general, unless trauma occurs directly to the eye, versus the head, traumatic glaucoma should not be the outcome?

Dr. Schmidt:  Unless the eye suffers direct trauma, traumatic glaucoma is very unlikely.

P:  Isn't EVERY kind of glaucoma a traumatic kind of glaucoma?

Dr. Schmidt:  We use traumatic glaucoma to refer to some injury to the outflow system.  But you are right in that in primary open angle, some insult to the meshwork ---genetic, chemical, whatever combination it is -- is causing poor outflow.  Let's limit the term here to a tennis-ball-type injury. 

P:   Is the corneal clouding you mentioned a permanent effect, or will that go away when the pressure is lowered again?

Dr. Schmidt: It is usually transient, but a high IOP over time can cause permanent corneal clouding.

P:  I have been diagnosed with glaucoma after being hit in the eye with a stick a month ago.  My intraocular pressure is now, I think, 32.   I am on a regimen of  three kinds of eyedrops to lower the pressure.  Is the damage I suffered likely to be permanent, or is there a healing process  that allows drainage to resume as normal?  If so how long might that take?

Dr. Schmidt:  The damage to the outflow system is likely to be permanent.  Repopulation of the cells of the meshwork can occur, but this may not be significant.

P:  What about the other eye with no trauma? Is that eye at risk of glaucoma?

Dr. Schmidt:  It's not well known that people with traumatic glaucoma in one eye have a higher risk of primary open-angle glaucoma in the other eye.  We assume that for a given level of trauma, some people are more likely than others to have meshwork damage, and are also at risk in the other eye.

P:  If a high IOP over time can cause permanant corneal clouding, how long does that take?  I have ICE syndrome and think that is more likely to be causing my cloudy vision.

Dr. Schmidt:  The ICE syndrome (irido-corneal-endothelial syndrome) by itself can cause significant clouding, but the high IOP makes it worse.  The time it takes to see clouding varies, depending on how gradually the IOP rises, the underlying corneal health, etc. Unfortunately, any estimate would be useless.  Certainly a given level of IOP is more likely to cause clouding in ICE.

P:  What if someone's vision becomes blurry after drinking anything containing caffeine.  Do you know anything about that?

Dr. Schmidt:  Studies of caffeine have not shown reproducible effects on IOP over groups of people.  For a given individual, it could be possible, though not common.

P:  My daughter has glaucoma as a complication from a tumor in her eye.  The tumor was removed in September.  If I understand it correctly, rubiosis "clogged" the drainage system. Is she now susceptible to glaucoma in the other eye?

Dr. Schmidt:  What kind of tumor and how old is your daughter?

P:  She is three years old.   I'm not spelling it correctly, but the tumor was meduloepehtimola.  Dr. Augsburger of Cincinnati did the surgery.

Dr. Schmidt:  Dr. Augsburger is excellent; you are lucky to have him.  The tumor causes new blood vessels to grow in the angle, blocking outflow.  Surgery is ofter necessary.

Moderator:   Can a tumor grow back?  Is it a benign type?

Dr. Schmidt:  Even benign tumors can grow back, but they usually don't invade other tissues or spread to other parts of the body, i.e. metastasize.  You daughter is definitely NOT at higher risk for glaucoma in the other eye.

P:  Doctor, she actually had surgery for an Ahmed valve last week.  We see a doctor on Friday for a check up.  I'm planning on calling him in the morning about yellow drainage from her eye that happened only once and left a yellow streak down her face.  Should I be worried about that?  

Dr. Schmidt:  I wouldn't worry, especially if that happened only once.  Possibly it was from the yellow-green dye used during examinations.  

P:  I need to take a flight soon.  Is there a risk, if my intraocular pressure is high, in flying because of lower cabin pressure?

Dr. Schmidt:   No.

Moderator:   No risk flying?

Dr. Schmidt:  That is right.

P:  How long can one tolerate pressures of three or four?  And should anything be done to try to raise it?  Are attempts to raise IOP usually effective?

Dr. Schmidt:  Some people, especially over 60 or so, can see 20/20 indefinitely.  Others can have blurred vision, and if low IOP is the cause, an attempt should be made to raise it.  

P:  How long will my doctor persist with drops before deciding to move on to more drastic measures, i.e., surgery, if pressure remains high.  The injury was a month ago.  

Dr. Schmidt:  It's better to delay surgery if the IOP is low enough to allow it.  Waiting will allow the inflammation from the injury to decrease, which increases the chance of surgical success.

P:  My pressure is 32.

Dr. Schmidt:  An IOP of 32 usually doesn't need surgery right away.

P:  Is a pressure of 32 painful?

Dr. Schmidt:  For most people, no.  Usually, pain is not felt until the IOP reaches 45 or so.  

P:  I used to feel a throbbing in my eyes if IOP's were over 30.

Dr. Schmidt:  Occasionally, someone walks into the office with an IOP of 70 and has no symptoms, either visual or pain.

P:  I was vomiting both times that my pressures were in the 40's.

P:  Me too.

Dr. Schmidt:  Thanks for taking part tonight everyone.  Dr. Wilson will be back next week! Good night

.

Moderator:  Thanks, Dr. Schmidt.

Dr. Schmidt:  My pleasure.

End of highlights for April 5th chat.

On April 12th, Dr. Wilson discussed Exfoliating Glaucoma in the Chat room. Click here for highlights of that meeting.

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