Glaucoma - A Patient's Symptoms, Treatment, Concerns, and Observations.

My wife Mary was diagnosed with Glaucoma about 10 years ago at age 45. This section of our Health Awareness Forum will follow Mary’s glaucoma case from its inception in 1995 to present day glaucoma treatment. These articles document the many issues we encountered with her glaucoma symptoms, diagnosis, and treatment over the years and the dire consequences of this disease. If Glaucoma is not treated timely it can lead to blindness. Parts I through VI of this series discuss Mary’s Glaucoma diagnosis, treatments and surgeries, and summary of our findings. They also present glaucoma treatment options, questions to ask your doctor, and things to consider if you are diagnosed with this disease.

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Copyright by Dennis V. Damp. All rights reserved. No part of these articles may be reproduced or transmitted in any form or by any means, electronic or mechanical. Including photocopying, without the written permission from the author, except for the inclusion of brief quoted excerpts or in reviews. Contact Bookhaven Press at Bookhaven@aol.com or write to Bookhaven Press LLC, P.O. Box 1243, Moon Township, PA 15108. Web sites may link to these pages and include a short review without prior permission as long as they give full credit to this forum with the link.

Glaucoma – The Day of Reckoning - Part 1
A Glaucoma Patient’s Perspective and Observations

Glaucoma is a disease that damages the optic nerve. This disease is often referred to as the “silent thief” because many don’t know they have it until much of their peripheral vision is lost. This is just one reason why you should schedule time for an annual eye exam. The Optometrist not only checks your general vision they also check your Intraocular Eye Pressure (IOP), look at the optic nerve with an Ophthalmoscopy, and use a mirrored lens called a Gonioscopy to view the angle where the cornea and iris meet. In most cases high IOP pressure damages the optic nerve over time. I interviewed Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified Ophthalmologist and Medical Director of the Florida Eye Center in October. He stated that, “glaucoma causes the drains inside the eyes to clog up. The eye makes fluid internally and the pressure can’t escape causing nerve damage and eye sight loss.” Glaucoma treatment includes the use of drugs, laser, and surgical procedures to improve the flow of the fluids in the eye and reduce pressure. There are also cases of what is called low tension glaucoma where nerve damage progresses even with very low IOPs. My wife was diagnosed with Primary Open Angel Glaucoma (POAG), Narrow Angle Glaucoma, and two years ago she was diagnosed with a rare optic nerve birth defect called Schisis. There are many sub classifications within these groups. Many Internet web sites provide abundant information on glaucoma treatment and symptoms including the University of Pittsburgh Medical Center, Florida Eye Center, and the University of Maryland Medicine to name a few.

My wife went for a routine eye exam in 1995. She was experiencing what is called “ocular Migraines,” strange visual disturbances usually lasting for short durations without a headache. Her eye sight checked 20/20 however she had elevated IOPs of 20R/21L millimeters of mercury (mmHg). Average IOP ranges from 14 to 20 mmHg. High IOP readings are one of glaucoma’s three primary indicators. To make a Glaucoma diagnosis the doctor measures the patient’s IOP with a Goldmann Tonometer, performs a visual field test, and checks the condition of the optic nerve. High IOP in and of itself doesn’t confirm a glaucoma diagnosis. Pressure readings are relative and effected by many variables. More on this later.

Mary was referred to an Ophthalmologist and he measured her IOP at 26R (right eye) and 27L (left eye) mmHg and ordered a visual field check. The visual field check showed indications of optic nerve damage and the doctor prescribed Timoptic, a beta blocking agent. Mary had allergic reactions to the drops and her IOP didn’t decrease so they prescribed Trusopt which also caused severe allergic reactions.

Through the course of the first year to 16 months of her glaucoma treatment she was prescribed pretty much all of the available drugs, sometimes two at a time, with little to no benefit and the side effects such as red eyes, facial swelling, hives, rashes, cramping, respiratory problems, and general eye irritation were severe. Her eyes were constantly irritated; she suffered from upper respiratory problems, and had to avoid smoke of all types. It appeared that the more changes they made to her treatment the more pronounced her glaucoma symptoms were and the higher her IOP went. After about 16 months her eye pressure was in the mid 30s in both eyes.

The doctor recommended and performed Argon Laser Trabeculoplasty (ALT) Laser surgeries on both eyes about a year and a half after initial diagnosis and the pressure fell to the low to mid 20s. This procedure burns holes in the trabecular meshwork to improve eye drainage and reduce pressure. New procedures have pretty much eliminated the use of the ALT for this purpose. Most doctors now use the newer and much less invasive Selective Laser Trabeculoplasy SLT for this purpose. More on this later.

She had to continue taking Xalatan drops, a prostaglandin with many side effects including respiratory problems, etc. Her pressure fluctuated in the safe range until about two years ago.

A New Doctor and SLT Laser Treatments - Part ll
A Glaucoma Patient’s Perspective and Observations

My wife and I learned a costly and valuable lesson. Don’t assume anything, research your condition online, and get a second opinion. Anytime you are diagnosed with a chronic disease, illness, prescribed medications, or recommended for surgery get a second opinion. At the very least, research the procedure or medicine online. You are potentially impacting the quality of your life every time you take medications or have surgeries or out patient procedures. You need to verify that all diagnostic tests have been done – under the right conditions – BEFORE proceeding and evaluate all other treatment options. You also need to evaluate:

5. The effects of stress, caffeine, and other substances have on your IOP readings and much more.

We didn’t have enough information concerning Mary's glaucoma treatment and symptoms ten years ago or knowledge to ask her first doctors critical questions or question the integrity of tests. The internet has changed all of this and now you can research about anything online with success.

Several years ago we elected to go to another Ophthalmologist to explore new glaucoma treatments and IOP lowering techniques. Mary’s current doctor had been recommending invasive Filtering Microsurgery since she had the ALT laser surgery in 1997. The surgeon operates on the eye with a scalpel to create a new drainage structure. Patients typically loose 10% or more of their vision immediately with this surgery and they are highly susceptible to cataracts and other serious complications.

I was researching my wife’s condition online and discovered that many doctors were having great success with the new Selective Laser Trabeculoplasty (SLT) laser surgery. Mary’s doctor didn’t have the SLT Laser and could not do the surgery. This new procedure stimulates the cells in the trabecular meshwork, located in the angle between the cornea and the iris, to increase their fluid pumping action without damaging the meshwork. Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified Ophthalmologist and Medical Director of the Florida Eye Center offered this excellent analogy of how this works. He stated that the SLT’s red laser light cleans out the blockage by agitating the clogged material in the drainage system. “It’s like thumping dried mud until it breaks up the clog into sand so the body can wash the debris out of the system.” The SLT can be repeated and does not damage the meshwork unlike the ALT laser treatment that physically burns holes in the meshwork. ALT surgeries can’t be repeated.

Her new doctor took extensive tests including nerve density, pachymetry cornea thickness readings, and OTIScans (an ultrasound of the eye) that showed the complete eye structure and can reveal conditions such as pupillary block and plateau iris components. The test results caused Mary and I to question much of what had transpired over the past 8 years. Her optic nerve was thick and healthy except for a small birth defect in the right eye – Schisis, a rare optic nerve defect, her corneas were thicker than normal which meant her actual eye pressure was lower than what the Tonometer was reading in the doctor’s office. We learned about the Goldmann Tonometer IOP adjustment factors from my optometrist by chance. The OTIS scan proved that her angles were very narrow and needed immediate iridotomy surgeries to avoid the possibility of angle closure. The doctor wouldn’t do the SLT surgery until Mary had the iridotomy surgeries. Angle closure could cause the eye drainage to plug up suddenly resulting in extensive eye damage if not treated.

Glaucoma is diagnosed through a minimum of three tests, optic nerve damage, visual field tests, and lastly IOP. The tests that were mentioned in the previous paragraph showed that even after 10 years with the disease Mary’s optic nerve was in excellent condition except for a small birth defect on the right eye. Schisis caused the visual field test to show loss of sight in that area. All previous perimeter tests also showed eye sight loss limited to that area except the first one that she took under stressful conditions.

My wife initially went to the doctor to explore SLT surgery options to lower her IOP and was now scheduled for two iridotomy surgeries the following week. We both had reservations about the surgery because my wife’s IOP was elevated to the mid 20s and susceptible to spiking into the mid to high 30s. At the time we were not aware that Mary’s IOP was actually lower due to her thicker corneas. Her actual IOP (after adjusting them for cornea thickness) in her left eye was approximately 21 mmHg and her right eye about 24 mmHg, not the 25R/25L that the Tonometer measured. Many doctor's don't use the adjustment factors however I believe that all eye doctors do agree that thicker corneas can tolerate higher GAT IOP pressure readings. Even this was higher than her actual readings and I will fully explain why in Part 4 and 5 of this series. Secondly, Mary felt that the debris from the laser surgery, the minute pieces of tissue that remain after the laser burned holes through the Iris to relieve the pressure and open the angles, would clog the drainage in the meshwork further. Her doctor wasn’t concerned about this at the time.