GLAUCOMA

At first, there are no symptoms. Vision stays normal, and there is no pain.

However, as the disease progresses, a person with glaucoma may notice his or her side vision gradually failing. That is, objects in front may still be seen clearly, but objects to the side may be missed.

As glaucoma remains untreated, people may miss objects to the side and out of the corner of their eye. Without treatment, people with glaucoma will slowly lose their peripheral (side) vision. They seem to be looking through a tunnel. Over time, straight-ahead vision may decrease until no vision remains. Glaucoma can develop in one or both eyes.

What is glaucoma?

Glaucoma is a disease of the optic nerve, which is the part of the eye that carries the images we see from the eye to the brain. The optic nerve is made up of many nerve fibers (like an electric cable containing numerous wires).

Retinal Nerve Fibers

Glaucoma damages nerve fibers, which can cause blind spots in our vision and vision loss to develop.

Normal Vision Simulation of the same scene as viewed by a person with Glaucoma

Glaucoma has to do with the pressure inside the eye, or intraocular pressure (IOP). When the clear liquid called the aqueous humor--which normally flows in and out of the eye--cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve.

The most common form of glaucoma is primary open-angle glaucoma, where the aqueous fluid that normally circulates in the front portion of the eye is blocked from flowing back out of the eye through a tiny drainage system.

Open-Angle Glaucoma

This causes the pressure inside your eye to increase, which can damage the optic nerve and lead to vision loss. Most people who develop primary open-angle glaucoma notice no symptoms until their vision is impaired.

In angle-closure glaucoma, the iris (the colored part of the eye) may drop over and completely close off the drainage angle, abruptly blocking the flow of aqueous fluid and leading to increased IOP or optic nerve damage.

Angle-Closure Glaucoma

In acute angle-closure glaucoma there is a sudden increase in IOP due to the buildup of aqueous fluid. This condition is considered an emergency because optic nerve damage and vision loss can occur within hours of the problem. Symptoms can include nausea, vomiting, seeing haloes around light, and eye pain.

Acute-Angle Glaucoma

Even people with "normal" IOP can experience vision loss from glaucoma. This condition is called normal tension glaucoma. In this type of glaucoma, the optic nerve is damaged even though the IOP is considered normal. Normal tension glaucoma is not well understood, but we do know that lowering IOP has been shown to slow progression of this form of glaucoma.

Childhood glaucoma is rare, and starts in infancy, childhood or adolescence. Like primary open-angle glaucoma, there are few, if any, symptoms in the early stage. Blindness can result if it is left untreated. Like most types of glaucoma, this type of glaucoma may run in families.

Dr. Najafi-Tagol may tell you that you are at risk for glaucoma if you have one or more risk factors, including elevated IOP, a family history of glaucoma, a particular ethnic background, advanced age, or certain optic nerve conditions. Regular examinations with your ophthalmologist are important if you are at risk for this condition.

Glaucoma: People of African Descent are at Risk

If you are of African ancestry, especially if you have a known family member with glaucoma, you are at risk for vision loss from this eye disease.

Primary open angle glaucoma is the leading cause of blindness among people of African descent, occurring at a rate four times higher than among Caucasian patients. It also occurs about ten years earlier among people of African ancestry than among Caucasians, and develops more rapidly. Studies show that in the United States, people of African descent between the ages of 45-64 are approximately 15 times more likely to go blind from glaucoma than Caucasians with glaucoma in the same age group.

It is not clear why people of African ancestry have higher rates of glaucoma and subsequent blindness than Caucasians. One factor may be that African-Americans are more susceptible to developing elevated eye pressure (IOP) earlier in life, which is thought to contribute to optic nerve damage and eventual vision loss. Another reason may be that patients of African descent are less likely than Caucasians to have early eye examinations that may detect and treat glaucoma.

The best way to protect yourself and your family members against vision loss from glaucoma is by being aware of the higher risk of developing this disease, and by having regular eye examinations for glaucoma at appropriate intervals.

If you are at risk for developing glaucoma, you can help to protect yourself from vision loss by having regular eye examinations for glaucoma at appropriate intervals. Recommended intervals for a comprehensive eye evaluation in people of African descent are:

• Age 20-29: every 3-5 years
• Age 30-64: every 2-4 years
• Age 65+: every 1 to 2 years

If you are diagnosed with glaucoma, please make sure you tell your family members and urge them to have an eye exam for glaucoma.

For more information on glaucoma:

The Glaucoma Foundation
116 John Street, Suite 1605
New York, NY 10038
Phone: 1-800-GLAUCOMA (1-800-452-8266)
www.glaucoma-foundation.org

The National Eye Institute
2020 Vision Place
Bethesda, MD 20892-3655
Phone: (301) 496-5248
www.nei.nih.gov

Prevent Blindness America
1-800-331-2020
www.preventblindness.org

The American Academy of Ophthalmology
P.O. Box 7424
San Francisco, CA 94120-7424
www.aao.org

Glaucoma is detected through a comprehensive eye exam that includes:

1. Visual acuity test. This eye chart test measures how well you see at various distances. A tonometer measures pressure inside the eye to detect glaucoma.

2. Visual field test. This test measures your side (peripheral) vision. It helps your eye care professional tell if you have lost side vision, a sign of glaucoma.

Dialated Eye Exam

3. Dilated eye exam. Drops are placed in your eyes to widen, or dilate, the pupils. Dr. Najafi-Tagol uses a special magnifying lens to examine your retina and optic nerve for signs of damage and other eye problems. After the exam, your close-up vision may remain blurred for several hours.

4. Tonometry. An instrument measures the pressure inside the eye. Numbing drops may be applied to your eye for this test.

5. Pachymetry. A numbing drop is applied to your eye. Dr. Najafi-Tagol uses an ultrasonic wave instrument to measure the thickness of your cornea.

Glaucoma Detection

Can glaucoma be treated?

Yes. Immediate treatment for early stage, open-angle glaucoma can delay progression of the disease. That's why early diagnosis is very important.

Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma.

Medicines

Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye.

Before you begin glaucoma treatment, tell Dr. Najafi-Tagol about other medicines you may be taking. Sometimes the drops can interfere with the way other medicines work.

Glaucoma medicines may be taken several times a day. Most people have no problems. However, some medicines can cause headaches or other side effects. For example, drops may cause stinging, burning, and redness in the eyes. Many drugs are available to treat glaucoma. If you have problems with one medicine, tell Dr. Najafi-Tagol. Treatment with a different dose or a new drug may be possible.

Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take their medicine. You need to use the drops or pills as long as they help control your eye pressure. Regular use is very important. Make sure Dr. Najafi-Tagol shows you how to put the drops into your eye.

Glaucoma Medicines

While there is no cure for glaucoma, it can be controlled.

Glaucoma Medicines

Elevated intraocular pressure (IOP) may damage the optic nerve, which can lead to vision loss. Treatment for glaucoma focuses on lowering IOP to a level that is unlikely to cause further optic nerve damage. This is known as the “target pressure” or “goal pressure.” The target pressure differs from individual to individual. Your target pressure may change during your course of treatment.

If you have glaucoma, Dr. Najafi-Tagol may prescribe medication to lower your eye pressure. There are many more choices for topical treatment of glaucoma today than there were only a few years ago.

Prostaglandin Analogs and Prostamides for the treatment of Glaucoma

How do Prostaglandin Analogs or Prostamides Work?
These medications lower the intraocular pressure by increasing the outflow of the fluid that the eye continually makes, called the aqueous humor. These medications are all taken once a day (except Rescula, which is taken twice per day).

What are the Prostaglandin Analogs or Prostamide medications?

• Latanoprost (Xalatanâ)
• Bimatoprost (Lumiganâ)
• Travoprost (Travatanâ)
• Uniprostone (Resculaâ)

No generic versions are available at this time.

Possible side effects of Prostaglandin Analogs or Prostamides
All medications, including eyedrops, have benefits, but they may also have side effects. Some people taking these eyedrops may experience:

• Redness of the eye
• The iris (the colored part of the eye) may darken or turn brown (this change in color occurs slowly and may not be noticeable for months or even years)
• Increased growth, thickness and pigmentation of the eyelashes
• Eye irritation or itching
• Blurred vision
• Darkening of the eyelid skin
• Muscle aches (rare)
• Headache (rare)

Patients with a history of uveitis (inflammation in the eye), ocular herpes infection or a history of swelling in the retina (called cystoid macular edema) should use this medication with caution. If you have a history of any of these conditions, please discuss this with Dr. Najafi-Tagol.

Back to Glaucoma Medications

Alpha Agonists for the treatment of Glaucoma

How Do Alpha Agonists Work?
Alpha agonist medications are reliable for lowering the intraocular pressure. They work by decreasing the production of the fluid that the eye continually makes, called the aqueous humor.

What Are the Alpha Agonists?

There are two alpha agonist drugs:

• Apraclonidine (Iopidineâ)
• Brimonidine (Alphaganâ)

Generic versions of these medications are not yet available.

Possible side effects of Alpha Agonists

All medications, including eyedrops, have not only benefits but may also have side effects. Some people taking alpha agonist eyedrops may experience:

• Dry mouth
• Ocular allergy with a red eye and/or red eyelids
• Headache, fatigue, irritability or sleep disorder
• Low or high blood pressure and possible slowing of heart rate (less than with beta blockers)
• Joint aches
• Upset stomach, nausea or constipation

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Beta Blockers for the treatment of Glaucoma

How Do Beta Blockers Work?
Beta blocker (beta andrenergic antagonists) medications are reliable for lowering intraocular pressure. They work by decreasing the amount of fluid that the eye continually produces, called the aqueous humor. For many years, beta blockers were the mainstay of treatment. Hence, we have a lot of experience with this medication for the treatment of glaucoma.

Types of Beta Blocker Medication
There are two general classes of beta blockers: nonselective and selective. Nonselective beta blockers have more effects on the body's beta receptors system-wide, and are associated with more side effects. The nonselective beta-blockers are also more effective at lowering intraocular pressure.

The nonselective beta blockers include:

• Levobunolol (Betagan)
• Timolol hemihydrate (Betimol)
• Carteolol (Ocupress)
• Metipranolol (Optipranolol)
• Timolol maleate (Timoptic) and Timolol maleate gel (Timoptic XE)

(Generic versions of Timolol are now available. Check with Dr. Najafi-Tagol to make sure that a generic product is an acceptable alternative for you.)

The only available selective beta blocker medication is:

• Betaxolol (Betoptic-S)

While a selective beta blocker eyedrop has a better safety profile, especially in terms of breathing symptoms, it still must be used with caution in patients with asthma or emphysema. The eye pressure lowering effect is slightly less with selective beta blockers. There is only a minimal additive effect in terms of lowering eye pressure in patients already taking oral beta blockers and there is the risk of further additive side effects. If you are already taking a beta blocker medication by mouth or if your primary care doctor newly prescribes a beta blocker, please notify Dr. Najafi-Tagol.

Possible side effects of Beta Blockers
All medications, including eyedrops, have not only benefits but may also have side effects. Some people taking beta blocker eyedrops may experience:

• Increased or worse asthma or emphysema
• Slow or irregular heart beat and/or decreased response of heart rate to exercise
• Increased risk for heart failure
• Depression or change in sex drive (impotence)
• Headache or dizziness or weakness
• In diabetics, difficulty sensing blood sugar changes
• Eye irritation or allergy

Back to Glaucoma Medications

Carbonic Anhydrase Inhibitors (CAIs) for the treatment of Glaucoma

How Do Carbonic Anhydrase Inhibitors (CAIs) work?
Carbonic anhydrase inhibitor medications are very reliable at lowering the intraocular pressure. They work by decreasing the production of the fluid that the eye continually makes, called the aqueous humor.

What are Carbonic Anhydrase Inhibitor medications?

Topical drugs:

• Dorzolamide (Trusopt)
• Brinzolamide (Azopt)

Oral Medications:

• Acetazolamide (Diamox)
• Methazolamide (Neptazane)

Generic versions of the eyedrop formulations are not yet available.

Possible side effects of Carbonic Anhydrase Inhibitors
All medications, including eyedrops, have benefits, but may also have side effects. Some people taking carbonic anhydrase medications may experience:

• Blurred vision
• Change in taste (especially with carbonated beverages)
• Dry Eye
• Eye irritation or allergy with a red eye and/or red eyelids
• Headache or dizziness
• Upset stomach

The oral (pill) form of these medications has more side effects, including:

• Increased need to urinate
• Tingling sensation in fingers and toes
• Rarely, severe allergic reactions or blood disorders can occur

WARNING: These medications are sulfonamides, therefore, if you are allergic to sulfa antibiotics, the same types of adverse reactions can occur with carbonic anhydrase inhibitors. Also, rare adverse drug interactions have occurred in patients taking high doses of aspirin and carbonic anhydrase inhibitors.

Back to Glaucoma Medications

Medication Tips:
With each new medication that Dr. Najafi-Tagol prescribes, make sure you understand the following:

• The name of the medication
• How to take it
• How often to take it
• How to store it
• If you can take it with your other medications (make sure each of your doctors knows about all the different medications you take, including non-prescription medications)
• What the possible side effects may be
• What you should do if you experience side effects
• What you should do if you miss a dose

For glaucoma medications to work, you must take them regularly and continuously as prescribed by Dr. Najafi-Tagol.

Laser trabeculoplasty helps fluid drain out of the eye. Dr. Najafi-Tagol may suggest this step at any time. In many cases, you need to keep taking glaucoma drugs after this procedure.

Laser trabeculoplasty is performed in our office.

Before the surgery, numbing drops will be applied to your eye. As you sit facing the laser machine, your doctor will hold a special lens to your eye. A high-intensity beam of light is aimed at the lens and reflected onto the meshwork inside your eye. You may see flashes of bright green or red light. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better.

Argon Laser Trabeculoplasty

Like any surgery, laser surgery can cause side effects, such as inflammation. Dr. Najafi-Tagol may give you some drops to take home for any soreness or inflammation inside the eye. You need to make several follow-up visits to have your eye pressure monitored.

If you have glaucoma in both eyes, only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart.

Studies show that laser surgery is very good at reducing the pressure in some patients. However, its effects can wear off over time. Dr. Najafi-Tagol may suggest further treatment.

Conventional surgery makes a new opening for the fluid to leave the eye. Dr. Najafi-Tagol may suggest this treatment at any time. Conventional surgery is often done after medicines and laser surgery have failed to control pressure.

Conventional surgery is performed in a hospital. Before the surgery, you will be given medicine to help you relax. Dr. Najafi-Tagol will make small injections around the eye to numb it. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye.

For several weeks after the surgery, you must put drops in the eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery.

As with laser surgery, conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart. Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if you have not had previous eye surgery, such as a cataract operation.

In some instances, your vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, and inflammation or infection inside the eye. The buildup of fluid in the back of the eye may cause some patients to see shadows in their vision. If you have any of these problems, tell Dr. Najafi-Tagol so a treatment plan can be developed.

Conventional surgery makes a new opening for the fluid to leave the eye.

If eyedrops have been prescribed for treating your glaucoma, you need to use them properly and as instructed by Dr. Najafi-Tagol. Proper use of your glaucoma medication can improve the medicine's effectiveness and reduce your risk of side effects. To properly apply your eyedrops, follow these steps:

• First, wash your hands.
• Hold the bottle upside down.
• Tilt your head back.
• Hold the bottle in one hand and place it as close as possible to the eye.
• With the other hand, pull down your lower eyelid. This forms a pocket.
• Place the prescribed number of drops into the lower eyelid pocket. If you are using more than one eyedrop, be sure to wait at least five minutes before applying the second eyedrop.
• Close your eye OR press the lower lid lightly with your finger for at least one minute. Either of these steps keeps the drops in the eye and helps prevent the drops from draining into the tear duct, which can increase your risk of side effects.