Glaucoma

Symptoms and Types

Glaucoma is the second most common cause of blindness in the United States. There are four major types of glaucoma:

• Angle-closure (acute) glaucoma
• Congenital glaucoma
• Open-angle (chronic) glaucoma
• Secondary glaucoma

All four types of glaucoma are characterized by increased pressure within the eyeball, and therefore all can cause progressive damage to the optic nerve.

The front part of the eye is filled with a clear fluid called the aqueous humor. It is constantly made in the back of the eye then leaves the eye through channels in the front chamber of the eye. In angle-closure(acute) glaucoma, when the exit of the aqueous humor fluid is suddenly blocked, pressure increases and loss of vision and pain develop.  Dilating eye drops and certain systemic medications may trigger an acute glaucoma attack if you are at risk.

In open-angle (chronic) glaucoma, the cause is essentially unknown. An increase in eye pressure pushes on the junction of the optic nerve and the retina at the back of the eye, reducing the blood supply to the optic nerve. Open-angle glaucoma tends to run in families. Your risk is higher if you have a parent or grandparent with open-angle glaucoma. People of African descent are at particularly high risk for this disease.

Congenital glaucoma often runs in families (hereditary) and is present at birth.

Secondary glaucoma is caused by the use of drugs such as corticosteroids, several eye diseases, and systemic diseases.

All four types of glaucoma are characterized by increased pressure within the eyeball, and therefore all can cause progressive damage to the optic nerve. Open-angle (chronic) glaucoma is by far the most common type of glaucoma.

The front part of the eye is filled with a clear fluid called the aqueous humor. This fluid is constantly made in the back of the eye. It leaves the eye through channels in the front (anterior) chamber of the eye in an area called the anterior chamber angle, or simply the angle.

Diagnosis

 When should you contact a doctor?

• If you have severe eye pain or a sudden loss of vision, especially loss of peripheral vision
• If you have risk factors for glaucoma and have not been screened for the condition
• Everyone over age 40 should have an eye examination at least once every 5 years, and more often if in a high-risk group.

An examination of the eye may be used to diagnose glaucoma. However, checking the intraocular pressure alone (tonometry) is not enough because eye pressure changes. The doctor will need to examine the inside of the eye by looking through the pupil, often while the pupil is dilated.

Usually the doctor will perform a complete examination of the eyes.

Tests may include:

• Gonioscopy (use of a special lens to see the outflow channels of the angle)
• Intraocular pressure measurement by tonometry
• Optic nerve imaging (photographs of the interior of the eye)
• Pupillary reflex response
• Refraction
• Retinal examination
• Slit lamp examination
• Visual acuity
• Visual field measurement

Treatment and Care

Glaucoma treatments reduce intraocular pressure by improving aqueous outflow, reducing the production of aqueous, or both. Glaucoma can’t be totally cured, and damage caused by the disease can’t be reversed, but treatment and regular checkups can prevent visual loss in people with very early glaucoma. If visual loss has already occurred, treatment can slow or prevent further vision loss.

Eye drops
Glaucoma treatment often starts with medicated eye drops. Be sure to use the drops exactly as prescribed; otherwise, your optic nerve damage could get even worse. If your doctor prescribes more than one type of eye drop, make sure to ask how long to wait between applications. Because some of the eye drops are absorbed into your bloodstream, you may experience side effects unrelated to your eyes. To minimize this absorption, close your eyes for one to two minutes after putting the drops in. Press lightly at the corner of your eye near your nose to close the tear duct, and wipe off any unused drops from your eyelid.

The types of most commonly prescribed eye drops include:

• Beta blockers. These reduce the production of aqueous humor. Examples include levobunolol (Betagan), timolol (Betimol, Timoptic), betaxolol (Betoptic) and metipranolol (OptiPranolol). Possible side effects include difficulty breathing, slowed pulse, hair loss, lower blood pressure, impotence, fatigue, weakness, depression and memory loss. If you have asthma, bronchitis or emphysema, medications other than beta blockers may be recommended because beta blockers may worsen breathing problems. Your doctor also may recommend avoiding beta blockers if you’re taking insulin for diabetes.
• Alpha-agonists. These reduce the production of aqueous humor and increase drainage. Examples include apraclonidine (Iopidine) and brimonidine (Alphagan). Possible side effects include fatigue; dizziness; red, itchy or swollen eyes; dry mouth; and allergic reactions.
• Carbonic anhydrase inhibitors. These also reduce the production of aqueous humor. Examples include dorzolamide (Trusopt) and brinzolamide (Azopt). Frequent urination and a tingling sensation in the fingers and toes are possible side effects, occurring more often with oral carbonic anhydrase inhibitors than with anhydrase inhibitor eye drops. If you have an allergy or sensitivity to sulfa drugs, don’t use these medications unless there’s no alternative.
• Prostaglandin-like compounds. These eye drops increase the outflow of aqueous humor. Examples include latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost (Travatan). Possible side effects include mild reddening and stinging of the eyes and darkening of the iris, changes in the pigment of the eyelid skin, and blurred vision from swelling of the retina.
• Miotic or cholinergic agents. These also increase the outflow of aqueous humor. Examples include pilocarpine (Isopto Carpine, Pilopine) and carbachol (Isopto Carbachol). Possible side effects are pain around or inside the eyes, brow ache, blurred or dim vision, nearsightedness, allergic reactions, a stuffy nose, sweating, increased salivation, and occasional digestive problems.
• Epinephrine compounds. These compounds, such as dipivefrin (Propine), also increase the outflow of aqueous humor. Possible side effects include red eyes, allergic reactions, palpitations, increased blood pressure, headache and anxiety.

Oral medications
If eye drops alone don’t bring your eye pressure down to the desired level, your doctor may also prescribe an oral medication. Doctors commonly prescribe carbonic anhydrase inhibitors, such as acetazolamide (Diamox Sequels) and methazolamide (Neptazane), for glaucoma. Take these pills with meals to reduce side effects. Add bananas and apple juice to your diet to minimize the potassium loss caused by these medications.

Initially, carbonic anhydrase inhibitors may cause frequent urination and a tingling sensation in your fingers and toes. After several days, these symptoms usually disappear. Other possible side effects of carbonic anhydrase inhibitors include rashes, depression, fatigue, kidney stones, lethargy, stomach upset, a metallic taste in carbonated beverages, impotence and weight loss.

Neuroprotective drugs
Lowering the intraocular pressure provides only a partial solution when it comes to preserving vision in people with glaucoma. Ongoing clinical trials are evaluating certain drugs, such as brimonidine (Alphagan) and memantine (Namenda), to determine if they may help protect the optic nerve from damage associated with glaucoma.

Surgery
You may need surgery to treat glaucoma if you can’t tolerate medications or if they’re ineffective. Sometimes a single surgical procedure may not lower eye pressure enough, in which case you’ll need to continue using glaucoma drops or have another operation. Possible complications from glaucoma surgery may include infection, bleeding, abnormally high or low eye pressure, and, potentially, loss of vision. Having eye surgery may also speed up the development of cataracts. Most of these complications can be effectively treated.

Surgeries used to treat glaucoma include:

• Laser surgery. In the last couple of decades, a procedure called trabeculoplasty (truh-BEK-u-lo-plas-tee) has had an increased role in treating open-angle glaucoma. After giving you an anesthetic eye drop, the doctor uses a high-energy laser beam to open clogged drainage canals and help aqueous humor drain more easily from the eye.

This is an office procedure lasting 10 to 20 minutes, and you can usually resume normal activities without discomfort. The doctor will need to check your eye pressure several times in the following weeks. It may take a few weeks before the full effect of the surgery becomes apparent.

In almost all cases, laser surgery for glaucoma initially lowers intraocular pressure. After time, however, intraocular pressure may begin to increase.

• Filtering surgery. If eye drops and laser surgery aren’t effective in controlling your eye pressure, you may need an operation called a filtering procedure, usually in the form of a trabeculectomy (truh-bek-u-LEK-tuh-me).

This procedure is done in a hospital or an outpatient surgery center. You’ll receive eye drops, a medication to help you relax and usually an injection of anesthetic to numb your eye. Using delicate instruments under an operating microscope, your surgeon creates an opening in the sclera — the white of your eye — and removes a small piece of the trabecular meshwork. The aqueous humor can now freely leave the eye through this hole. As a result, your eye pressure will be lowered. The hole is covered by the conjunctiva, so trabeculectomy leaves no open hole in your eye. This procedure works best if you haven’t had any previous eye surgery. Your doctor will check your eye during several follow-up visits and you’ll need to use antibiotic and anti-inflammatory eye drops to fight infection and scarring of the newly created drainage opening.

A new procedure performed within the eye removes a targeted strip of trabecular meshwork with a tiny electrocauterizing tool. The tool is introduced into the eye’s drainage canal through a 1/16-inch (1.5-millimeter) incision at the edge of the cornea. A predetermined section of the trabecular meshwork can be removed from the inside of the eye with this instrument. Early reports indicate this procedure is effective and associated with few complications.

Drainage implants. Another type of operation, called drainage implant surgery, may be an option for people with secondary glaucoma or for children with glaucoma. Drainage implant surgery takes place in a hospital or an outpatient clinic, and consists of a doctor inserting a small silicone tube in your eye to help drain aqueous humor. After the surgery, you’ll wear an eye patch for 24 hours and use eye drops for several weeks to fight infection and scarring.

Treating acute angle-closure glaucoma
Acute angle-closure glaucoma is a medical emergency. When you come in with this condition, doctors may administer several medications to reduce eye pressure as quickly as possible. You’ll also likely have an iridotomy, a laser procedure that creates a small hole in your iris so that aqueous humor can pass into the trabecular meshwork. Many doctors recommend an iridotomy on the other eye at a later date because of the high risk that its drainage angle will close as well.

If left untreated, glaucoma will cause progressive vision loss, typically in these stages:

• Blind spots in your peripheral vision
• Tunnel vision
• Total blindness

Living Your Life

With some adjustments, people with low vision can live independently in their own homes, continue to carry out daily activities and take pleasure in hobbies. In the home, remember the following general guidelines: increase lighting for tasks; control glare; use magnification; and increase contrast. Over time, people with low vision will likely come up with individual, innovative solutions to reflect their needs, help them function better in the home and increase their enjoyment of life. Seek help through friends, family and volunteer groups to implement these adaptations.

Improving other Senses

Hearing Better

Listening to books on tape and CDs, and using listening skills more may seem difficult at first, but will become easier over time. After an initial period of adjustment, most people with low vision are surprised to find out how much information they can obtain from their senses of hearing, touch and even smell.

Listening more means remembering more. Most people never fully develop the ability to remember what they hear because there is no need. Improving listening skills means giving full attention to what is heard rather than dividing attention between what is seen and what is heard. Those with low vision may still receive visual cues from eyesight, but most of their attention will now need to be shifted to listening. As people grow more accustomed to listening to books, newspapers and magazines on tape and CDs, and working with screen-reader software, gradually more of what is heard will be remembered.

People can learn to “tune in to” their sense of hearing in many practical ways that will assist in daily activities. For example, learning to locate the sound of the hum of the refrigerator can signal you are entering the kitchen. Or, the sound of cars and other outside street noises will indicate an open window and its location.

Using Touch

Those with low vision can also learn to rely more on the sense of touch in many practical ways. Selecting clothes from the closet, for example, will be easier if a person focuses on the textures of fabrics and associates them with mental pictures of certain garments.

When there is severe vision loss, using a cane or walker outdoors allows an individual to use the sense of touch to get more information about the environment. These “feelers” will help detect changes in the pavement, the closeness of objects and the presence of stairs. Even without a cane or walker, using the feet to feel the way, especially when climbing or descending stairs, can augment diminished vision and prevent dangerous falls.

Protection from the Sun

While excessive exposure to sunlight has not been linked to glaucoma, protection from the sun’s ultraviolet (UV) radiation is a good idea. UV radiation is composed of invisible, high-energy, sunlight just beyond the violet or blue end of the visible spectrum. It is usually divided into three categories of radiation, UV-C, UV-B and UV-A. UV-C radiation is absorbed in the ozone layer, but UV-A and UV-B are damaging to skin and eyes.

To protect eyesight, physicians recommend sunglasses that block 98-100 percent of both UV-A and UV-B rays and screen out 75-90 percent of visible light. Sunglasses don’t have to be expensive, but they should be properly labeled. Those that meet minimum standards established by the American Optometric Association (AOA) can use the AOA seal of acceptance. The best sunglasses are those that completely cover the eye and eyelids, and wrap around to the temples to prevent light from entering the sides. Brimmed hats provide additional protection.

Ways to Make Life Easier

Dealing with any loss of vision isn’t easy, but there are a variety of physical and psychological ways people with glaucoma and their families can adjust to “a new way of seeing.”

• Consult a low vision therapist who can make personalized recommendations for daily living activities. More information can be found on our website.
• Consider using low vision aids.
• Measure your own eye pressure by using a portable tonometer. Portable tonometers allow people to check eye pressure at home. Correct use of these tonometers requires training, but they can be helpful for those who have difficulty visiting a doctor for multiple readings that may be needed for an accurate diagnosis. The patient (or family member) can take readings at various times of the day, per a doctor’s instructions, and then bring the results to the doctor for the final reading.  Check with a physician about the practicality and affordability of portable tonometers.