Chat Highlights
Glaucoma and Pain
November 22, 2000

Norma Devine, Editor

On Wednesday, November 22, 2000, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed "Glaucoma and Pain." 

Moderator:  Are there questions for Dr. Rick about glaucoma and pain?

P:  Yes.  Dr. Rick, can you describe the common pain associated with glaucoma?

Dr. Wilson:  Most glaucoma has no symptoms.  Drops may burn as they go in and pilocarpine causes a periocular ache. Acute angle closure glaucoma and very high IOPs may cause pain.

P:  A few weeks after my trabeculectomy, I began to have severe headaches, dizziness, and nausea.  My IOP (intraocular pressure) went from 8 to 50 mm Hg. due to scarring.  The doctor needled the bleb to reduce the pressure. Why the pain? Is that typical?

Dr. Wilson:  Any time there is a big change in IOP,  there will be pain. That is true whether the IOP changes from 3 to 25 or from 25 to 60.  It can be very painful.  Sorry you've had such trouble.

P:  Most text books and doctors say that there is no pain with glaucoma, that it's a silent disease. Yet most glaucoma patients I know have eye pain. 

Dr. Wilson:  That may be after they have been treated.  I have people come in with IOPs of high 40's without any discomfort, if the IOP rose slowly.

P:  Do swings in pressure affect vision, too?  I still have visual distortions. 

Dr. Wilson:  Yes, they can, if the cornea or the circulation is affected.

P:  Is there a way to increase the IOP if it keeps dropping too low?

Dr. Wilson:  Blood injections into an overacting bleb can help, or a surgical revision may sometimes be needed.

P:  I have pain at night that wakes me up.  Is this due to pressure changes?  Why does this happen mostly during sleep?

Dr. Wilson:  What kind of pain is it?

P:  It's hard to describe.  It's mostly around the eye, like a headache.  My vision doesn't seem to be as good in that eye during those times.  If I blink, sometimes it gets better, but not always.  

Dr. Wilson:  The pain may  be due to drying of the cornea, if the eyelids are slightly apart when you sleep.  Can you have someone look at you when you sleep to see if the lids don't quite close?

P:  Would drying also cause my vision to darken?

Dr. Wilson:  It would be more like looking through ground or dirty glass.

P:  If the pain is due to drying, what can I do to prevent it?

Dr. Wilson:  You can use GenTeal gel or Refresh PM ointment just before going to sleep at night. Wipe the excess off in the A.M.

P:  I have had a trab and also have pain around the eye,  mainly after being in a sunny place.  The pain increases in my head and only goes away if I sleep for some time. Medications do not help.  What could be the cause?  

Dr. Wilson:  You may be getting much more light into that eye through your peripheral iridectomy or a pupil that does not close as it used to.  That would cause a spasm of your iris sphincter muscle and aches that might require closing the eyes to get relief.     

P:  I didn't have an iridectomy; just a trab.  And my pupil is small because of the use of pilocarpine for years. 

P:  You  said visual distortion could be due to cornea or circulation problems after pressure swings.  (I also had a cataract removed in that eye.)  Is this a temporary condition?

Dr. Wilson:  If the changes are due to your IOP swings post your recent surgery, then, hopefully, they will be transient.

P:  How serious is drying? Can it cause irreparable damage to the cornea, etc.?  I use Pilocarpine 6%.  When I started to use it, it burned "big time," but stopped.  Now that I have dry eye, the burning is back and it is "big time!"

Dr. Wilson:  You might try putting in an artificial tear about 5 minutes before you put in the Pilocarpine.  The burning occurs when the slightly acid drop hits the cornea with dry spots on it, and no tears to dilute the drug.

Moderator:  Recently a pain survey, in which 13 glaucoma patients participated, was posted on the Bionic Eye.  Nine of the thirteen reported suffering pain after treatment for glaucoma.  Only two of the nine patients' doctors suggested a remedy for their pain.

Dr. Wilson:  Those results are disappointing, not only because of  the number of patients with pain, but also because they receive little help from their doctors.

P:   I had high pressures before without pain, so it was the swing of pressure that was bad.  I don't know if my doctor could have given me anything for it.

Moderator:  Why do so few doctors (according to the survey) make suggestions for dealing with pain related to glaucoma?  Is it because they don't know the cause and so can't help?

Dr. Wilson:  I assume so, although it is hard to ascribe motives to others.

P:   I found that no amount of aspirin or acetaminophen would touch the pain I had.  I had to have the pressure lowered to get relief from the pain.  

P:  When I sleep, I hold an arm over my head.  The weight of the arm causes the filter to flow. I wake up  in pain and with fluid running down my face. The bleb is not leaking.  Is there any way to slow down the bleb? 

Dr. Wilson:  You could wear a plastic shield to bed to prevent any pressure on the eye. 

P:  Artificial tears, no matter what kind, make my eyes feel even drier, especially at night.  After using them, I wake up with crusts on my eyelids.  My doctor wants me to use the drops more often, but I just can't.  Any suggestions?

Dr. Wilson:  It could be the elevated bleb causes dryness on the cornea just in front of the bleb.  Try GenTeal Gel.  If  that doesn't help, try Refresh PM or Hypotears PM.

P:  I have tried them all and I still feel like they make my eye DRY. So I rarely use them.

Dr. Wilson:  You might look into having your tear ducts plugged to prevent the drainage of the few tears that you do produce.

P:  Can scarring cause pain in the eye?

Dr. Wilson:  Scarring can distort the conjunctiva and could conceivably cause pain.  Calcification of the cornea, a kind of scarring, can cause pain.

P:  How is calcification of the cornea detected?  

Dr. Wilson:   It can been detected by a slit-lamp examination.

P:  Are the signs of cornea calcification obvious during such an exam? 

Dr. Wilson:  The signs might be subtle.  It's more likely there's another cause.

P:  Sometimes I have pain in the tissue surrounding the orbit.  Is this caused by glaucoma or dry eyes?

Dr. Wilson:  Possibly, but it could also be caused by sinuses, eye strain, etc.

P:  I was just wondering what the scale of pain from glaucoma is like.  For example, on a scale of  1 to 10, an earache with fluid behind the drum is an 8.  Would glaucoma pain mentioned here be more than that?

P:   When my pressure was in the high 40's, it was a 100 on a scale of 10!

P:   It can be a 12 if your pressure jumps up to the mid 60's. 

P:  Most of the time I have no pain.  Dryness is more like a slight headache for me.  But pressure spikes can be more like a 10, or as someone just said, more like 100.  Luckily, this doesn't happen too often.

Dr. Wilson:  And  the extreme pain comes from a huge IOP spike, not an increase to 30 or 35.

P:  Right.  I was talking about a spike from 8 to 50.

P:   I found that no amount of aspirin or acetaminophen would touch the pain I had.  I had to have the pressure lowered to get relief from the pain.

P:  Are eye shields worn while sleeping because the pressure increases when the eye and pillow are in contact?

Dr. Wilson:  Any pressure on the eye transfers that pressure to the thin tissues of the bleb and may cause rupture of the bleb or leaking.

P:  Is the IOP increased while sleeping when the eye is pressed up against the pillow?

P:  Someone told me that the eye on the side you lie on at night can be higher in pressure.

Dr. Wilson:  Eye pressure usually drops at night, as the eye doesn't make as much aqueous.  If you press constantly on the eye, you will press fluid out of the eye.  The pressure will stay about the same with the pressure on, and drop dramatically when the pressure is removed.  

P:  I'm frustrated and don't know what to do.  I probably go to the foremost glaucoma and cornea doctors in this area.  I think they do not know what to do for me anymore.  They are both extremely busy doctors and after waiting between one and three hours, I usually get a five or ten minute appointment. I have a lot of frustration and anxiety and pain.  Would it be time to go for another opinion?  I have been seeing these doctors for about 12 years now.

Dr. Wilson:  Another opinion never hurts, especially if its from a well-known doctor. It puts your doctor on notice that others are offering you their opinions as well.

P:  I have decided to go ahead with the cataract surgery on the eye that had a trab in January.  I've read about lenses, stitch/no stitch, and all the possible complications.  It is not an easy decision.  Will I have pain?  What will the recovery period likely be before I can return to work?

Dr. Wilson:  I don't think it makes much difference between stitch and no stitch.  The wounds are real small.  Most people use foldable lenses these days and the ones from the major companies are all excellent.  There should be no pain, but a slight foreign-body sensation.  If your work is not physically taxing or in a dirty environment, you can usually go back to work within a day or two.

Dr. Wilson:  Everyone have a wonderful Thanksgiving.  See you in a week.

On November 29nd, Dr. Wilson discussed "Glaucoma and Stress" in the Chat room. Unfortunately the chat was not recorded. We will plan another Chat in 2001 and discuss "Glaucoma and Stress" at that time.

On December 6th, Dr. Wilson discussed "Glaucoma and the Elderly" in the Chat room. Click here for highlights of that meeting.

Click here for the most recent glaucoma chat highlights and links to the chat archives.

Click here for upcoming glaucoma chat events.