|
FEDERAL EMPLOYEE'S
HEALTH AWARENESS FORUM
Glaucoma - A
Patient's Treatment, Symptoms, & Concerns
Parts III and IV
Continuation from Parts I and
II of this series. My wife Mary
was diagnosed with Glaucoma about 10 years ago. This section of
our Health Awareness Forum follows Mary’s case
from its inception in 1995 to present day treatment. These articles
document the many issues we encountered with diagnosis and
treatment over the years. Parts I through VI of this series discuss Mary’s
Glaucoma diagnosis, treatments and surgeries, and summary of our
findings. They also present treatment options and things to
consider if you are diagnosed with this disease.
Disclaimer &
Copyright
Iridotomy & SLT Surgeries - Part lll
A Glaucoma Patient’s Perspective and Observations
Mary’s IOP
pressures were in the mid 20s, actually lower due to her thick corneas, when she
went in for the Iridotomy laser surgeries. One hour after the surgery her IOP
elevated to the high 30s. What we had feared happened. Apparently, the debris
from the holes they burned in both irises were clogging the eye drainage canals.
The doctors said that Mary was one in 100, most after surgery experienced lower
IOPs. They gave her multiple drops of various IOP lowering drugs until the
pressure decreased to the low 30s and she was advised to come back in two weeks.
Two weeks
later her IOP dropped to the mid 20s and she changed medicine to Xalatan which
she tolerates a little better. She returned to her original doctor for routine
checks. After about 9 months her IOP elevated and she went back on Lumigan, a
stronger prostaglandin. The doctor again recommended
Filtering Surgery and Mary
insisted on going back to the new doctor to be evaluated for SLT laser surgery.
The new doctor
agreed that the surgery could help lower her pressure and Mary insisted that
they only do the SLT procedure on her right eye first, the eye with the highest
IOP. She was apprehensive after what happened with the Iridotomy surgery
earlier. The SLT surgery was painless and only took a few minutes to
complete.
The surgery
went well and initially her IOP dropped to the mid to high teens, actually lower
because of her thick corneas. At the two week post op visit her IOP was in the
high teens and she was advised to return in two months. At the two month check
her IOP had increased to the mid 20s. Several medical specialists and doctors
took her pressure and each obtained widely varying IOP readings from 23/25 to
29/29. The doctor then prescribed a second eye drop, a Beta-Blocker called
Timoptic, without preservatives. Mary had allergic reactions to this drug when
she was first diagnosed with Glaucoma and she was scheduled for a follow-up
visit 4 weeks later.
Note: We were
concerned about wildly varying Goldmann Tonometer IOP readings at the
doctor's office. The staff and doctors would take as many as three IOP
readings per visit and the readings increased dramatically from the first to
last check, sometimes by as much as 9 to 12 mmHg in one eye. I
questioned the Tonometer calibration, the expertise of the persons taking
the tests, the procedures used, and couldn't determine why the readings
varied so much. It's hard to put any faith in a test where the readings
varied from a low of 14mmHg to 26 mmHg in the same eye within 15 to 30
minutes between readings. Later on, after Mary started using the Proview IOP
monitor, she confirmed that her IOP readings were relatively steady and
varied + or - 1 mmHg at the most throughout the day.
I noticed one common
denominator for all of these tests. The numbing drop they use prior to
taking IOP readings. The standard drug used for this is called Fluress.
Could my wife have an allergic reaction to this medication? She is
allergic to the majority of glaucoma drugs. I asked the doctor about this
and he pretty much discounted it. Fluress must be refrigerated before
it is used and then after it is opened it only has a shelf life of 30 days.
I sent a letter to the doctor asking him if the Fluress was outdated or
contaminated or were they using the generic brand of Fluress. The generic
brands may use Timeorsal as a preservative that causes a number of allergic
reactions. I would like to locate more information on this subject. If
anyone has information or located research that shows similar
characteristics send an email message to
ddamp@aol.com.
There were just
too many inconsistencies in what we were experiencing and Mary and I knew for a
long time now that something just wasn’t right. I know that medicine isn’t an
exact science. However, there were too many contradictions and questions that we
could not get answers to.
Taking Control of the Situation
- Part lV
A Glaucoma Patient’s Perspective and Observations
Proview IOP Home Monitoring and the Ocular
Hypertensive Treatment Study
Nothing seemed
to be making sense with my wife’s treatment. It appeared that eye drops
increased her pressure, especially when she was placed on multiple drugs.
Surgeries that were designed to improve her IOP didn’t. Every time we went in
for checks her IOP fluctuated dramatically. Different doctors and specialist
would get wildly varying IOPs within 10 minutes of each other. We got the
prescription filled but Mary refused to take it. She wanted to wait a while to
think things over. I searched the internet for days to locate clues as to why
this was happening.
We started to
ask questions, e-mailed the doctor our concerns, called the doctor’s staff and
technicians to question procedures, equipment calibration, etc. We discovered
that many factors effect IOP readings including stress, vitamin and mineral
supplements, exercise, caffeine, systemic blood pressure, menopause, and life
style issues.
Prior to
Mary going to her follow-up visit we sent the doctor a three page letter
describing our concerns after doing considerable research and purchasing a
Proview IOP home monitor. Mary and I thought that her IOP pressure
was staying elevated all of the time. Fortunately, Bausch and Lomb manufactures
a home IOP pressure measuring device called the “Proview” and we
purchased one direct from
www.drugstore.com, local pharmacies didn’t carry it. You don’t need a
prescription for this device and it only cost $69.00 plus shipping. The doctor
that frequently suggested Filter Surgery often questioned what Mary’s pressure
was on the days she wasn’t at the doctor’s office. He was concerned that it may be
going even higher. Now we could check it at home. You can visit the Bausch and
Lomb web site at
http://bausch.com to review information on this excellent device. You can
also view a video
on the Proview monitor online.
When my
wife first went to the eye doctor 10 years ago her IOP readings were
20R/21L (unadjusted). The average IOP ranges between 14 –
20 mmHg. Here is the kicker. We discovered that my wife has thicker corneas than
most. When we purchased the Proview Monitor my local Optometrist
checked my wife’s IOP on her Goldmann Tonometer so that we could verify the
Proview’s accuracy and establish offset factors for home readings. She advised
Mary to have a cornea thickness Pachymetry test. Thicker corneas give high false
IOP readings on the Goldmann Tonometer pressure test set. I called my wife’s
second doctor and his staff confirmed from previous tests that her corneas were
R 561 microns and L 592 microns thick which equates to an adjustment factor of
-1 mmHg in her right eye and -4 mmHG in her left eye off of the Goldman
Tonometer readings. Mary’s actual IOP (adjusted by the Duke University's IOP
Correctional values Chart) was now only reading 22/22, in the low 20s
after using the correction factors. This was confirmed on our optometrist’s Tonometer and our Proview monitor.
Further research uncovered
information on Ocular Hypertension at the
Pacific Cataract and Laser
Institute’s web site, a condition that warrants monitoring but not
necessarily aggressive treatment. We were unaware that this condition existed
and the symptoms of Ocular Hypertension fit my wife to the tee. A case study
referenced on this site presented the following clinical observations for Ocular
hypertension:
·
High intraocular pressure (IOPs
Over 21 mmHg)
·
Normal ocular nerve head
·
Normal visual field
·
No response to glaucoma medications
When my wife was first referred
to the Ophthalmologist ten years ago her actual IOP was only 19R/17L (adjusted)
and would not have been referred for further evaluation. This is a double edge
sword. If she would not have been referred, her narrow angle glaucoma may not
have been diagnosed with serious consequences. On the other hand, if she hadn’t
been diagnosed in her mid 40s she would have avoided the medications that have
caused her considerable hardship these past 10 years. We both believe that her
erratic eye pressure is impacted by many factors other than Glaucoma and we
believe the medications at times actually cause higher IOP readings.
Many doctors don’t
adjust their Goldmann Tonometer’s (GAT) readings for cornea thickness and we have
debated this point on several visits. The Duke University Eye Center publishes
an IOP Correctional Value Chart that we use to calculate what we believe is
Mary's true IOP.
The Goldmann Tonometer is calibrated for a cornea thickness of 515 microns and
the Goldmann Tonometer’s IOP readings are not accurate for cornea thickness that varies
from the calibrated standard. The Goldmann IOP readings are adjusted from a -7
mmHg with corneal thickness of 645 microns to a +7 mmHg for corneal thickness of
445 microns. What a difference. I have read numerous studies confirming that thicker corneas give false
high Goldmann Tonometer readings. Conversely, thinner corneas read much lower
and this may be one of the reasons there is such as thing as low tension
Glaucoma. The GAT apparently can't accurately read low tension patients pressure
accurately either. Actually, we are finding that the Proview Monitor is more accurate, has less of an adjustment factor, than the
Goldmann Tonometer. The Proview reads 2 mmHg lower in each eye and the Goldmann
Tonometer reads +1 mmHg higher in her right eye and +4 mmHg in her left eye. I
apparently have normal cornea thicknesses because my Proview IOP readings mirror
my Optometrist’s Goldmann Tonometer readings.
The more we
researched and learned about Ocular Hypertension the more it made sense. When my
wife went in for her initial visual field test 10 years ago she went on the day
before Christmas and they were short staffed. She was nervous and uncomfortable
during the test and immediately questioned whether or not it would be accurate.
She also felt that the staff specialist was rushing her through the test
probably because of the holiday and we were the last ones in the waiting room.
This first test indicated some sight loss. However, all subsequent visual field
checks showed loss of sight basically in the area where the Schisis was
diagnosed two years ago. The doctor confirmed that the visual field test showed
sight loss in that area so apparently her visual field checks had been good all
these years. Mary didn't have any of the diagnostic tests the first eight years
she was being treated that would have detected the Schisis, confirmed her optic
nerve density, or cornea thickness.
My wife has had reactions to
all glaucoma medications and tolerates few. She did not take the second eye drop
her new doctor prescribed last visit due to her concern that her pressure would
increase as it did in the past when prescribed multiple medications.
The possibility exists that
Mary’s pressure variations may be due to Ocular Hypertension, stress, white coat
blood pressure syndrome, possible negative reactions to Fluress and other
glaucoma medications, secondary issues with debris caused by the two iridotomy
surgeries, and Goldman Tonometer readings that weren’t adjusted for cornea
density.
Contradictions
1. Tests that Mary took last
year indicated that her optic nerve thickness was good.
2. The perimeter tests were
good except for the area where the Schisis is located. The doctor compared the
location of the Schisis and the visual field tests. Eye sight loss was limited
to the area around the Schisis and not nerve damage attributed to glaucoma.
3. The three indicators for a
diagnosis are nerve head damage, perimeter test results, and
lastly IOP. All are good except for variations in IOP. Mary’s erratic IOP
may be attributed to other factors.
4. The Proview IOP Monitor
confirmed that her IOP does not vary more than + or – 1 mmHg morning to night
and the longer she is away from the doctor’s visit the more her IOP drops. It is
now measuring 14R / 16L.
Continue
to Part V (The Beat Foes On)
Return to the Health Forum
Main Page
|
