The Eye Practice

Glaucoma is about pressure in the eye.  Maybe not!

Research on any disease takes time, and needs to be verified carefully before doctors can start making claims that they know better treatment options. The same is said for glaucoma.

Over the past two years, some very exciting research has developed on glaucoma, which may soon begin to revolutionize treatment of glaucoma, and, we hope, will give us ways to reverse damage that has already been done in some glaucoma cases.

Currently, the best treatments for glaucoma are all centered around relieving IOP – Intraocular Pressure – in order to prevent further damage to your vision. The entire disease treatment is centered around the eye rather than around the root of the problem. The root of the problem starts in what's called the retinal ganglion cells. That's the collector of visual information from the other optic cells, and it's the first type of cells that are damaged by glaucoma. 

This is why you can get glaucoma even though your pressure might be "normal".  Some people have "high" pressure yet never develop glaucoma.  The theory is if the nerves are healthy and with good blood flow, the chances of developing glaucoma is less.

Another part of discovery of glaucoma as a neurodegenerative disease is that the LGN – Lateral Geniculate Nucleus gets damaged by the disease. Think of the LGN as a processing center for the optic nerve. There are also changes in the visual cortex (the part in the way back of the brain that interprets information from the other areas). When these areas show changes in conjunction with the retinal ganglion cells, we know that glaucoma is present.

This could make detecting damage done by glaucoma easier, and give us some clues on supportive neuroprotection therapies that may prevent more cells from dying, and help keep greater cell support with a process called neuroenhancement.

Rather than getting caught up in the technical terms, think of these terms as tools which we can use to either stop glaucoma before it stops, or improve our treatment options for those with treatment-resistance.

Of course, these treatments could lead to more preventive measures taken for people who have the risk factors for glaucoma, such as a genetic link (family history of glaucoma). Currently, the best way to treat glaucoma is to catch it as early as possible, and while that will still most likely be the case, the more we learn about how the disease destroys these optical areas of the brain, the more likely we will become better equipped to fight it – and – we hope, maybe even find a cure.

Screenings for glaucoma are still your best bet for saving your vision. Call us on 9290 1899, or book an appointment online by CLICKING HERE.

 

Glaucoma in children is a serious condition that can lead to blindness if not treated early and appropriately. In uncomplicated cases, however, early detection can save your child's sight – through surgery. Sometimes, surgery and medications must be used together in order to stop the progression of the disease, and make the best out of your child's remaining vision.

As we have stated in previous posts, there is nothing that can be done to reverse the damage of glaucoma. This is why early detection is so important.

8 out of 10 children who have been diagnosed with glaucoma have been diagnosed within the first year of life. Yet glaucoma can strike children of all ages, and those especially at risk are children who have sustained eye injuries.

Very young children can't really tell you if they cannot see well, and, if you've read our other articles, you likely already know that the gradual changes in vision are often not noticeable until extensive damage has been done. However, there are some things you can do as a parent to protect your child's vision.

Get screenings regularly. Take your child to regular checkups, and be on the lookout for specific signs.

 

Children under age two have certain symptoms of glaucoma that are not present in older children, such as:

• Unusually large eyes

• Excessive tearing

• Cloudy or milky eyes

The damage can be treated early by staying on top of symptoms, and getting regular checkups.
Children under age 18, but over age two, have different symptoms to look for – but remember, usually by the time these symptoms are noticeable, there has been extensive damage done to your child's sight.

Symptoms include –

• Sensitivity to sunlight, or flashing bright lights (such as a camera flash)

• Loss of visual acuity

• Child has difficulty adjusting to changes in light conditions (difficulty seeing in the dark)

• Complaints of headaches and eye pain

• Blinking and squeezing eyes frequently

• Red eyes (as if they've been exposed to an irritant or have allergies)

Complete eye exams are necessary to ensure that your child does not have to get to the stage where symptoms are noticeable.

Be aware of risk factors.

When a child has had an eye injury, it's important to recognize this as a greater risk for glaucoma development. When coming in for an appointment, make sure you let your optometrist know about any history of eye injury, so they will understand the increased risk factors for development of glaucoma.

Additionally, if your child has had cataract surgery, he or she is at an increased risk for developing glaucoma (nearly 25% of children develop glaucoma after cataract surgery).

Filtering surgery, laser therapy, eye drops, and oral medications can be used to treat a child for glaucoma, to relieve intraocular pressure (IOP) and protect your child's vision.

Early detection is vital – call us on 9290 1899 for an appointment.

Glaucoma is a complex disease.  To be comprehensively tested for glaucoma can be a complex process.

Like most people, you're probably familiar with two kinds of glaucoma tests – checking inner eye pressure (called tonometry – the warm puff of air that is blown into the eye), and getting your pupils dilated so the doctor can check the shape and color of your optic nerve and detect any damage (called opthalmoscopy).

Some people greatly dislike tonometry – the warm puff of air is uncomfortable to them or it surprises them too much. Luckily, tonometry can also use a tiny tool that applies pressure to the eye instead of the puff of air.

There are many different tests – more than just the above-mentioned two.  Glaucoma can be a tricky disease to detect – which is why it's important for us at The Eye Practice to run additional tests if we find something that looks out of the ordinary.

Remember, there is no cure for glaucoma, but early detection can mean that you keep your eyesight longer, and prevent further damage to your eyes.

A third test that you might be familiar with (some doctors like to perform this one on a regular basis) is called a perimetry test. Basically, it “maps out” a pattern of your peripheral vision (side vision).

You may have been through this test before – you sit and stare straight ahead into an instrument called a field anaylser. A small spot of light is switched on and off many times at different positions. 

Each time you are aware that the light is on you hit a buzzer that tells the instrument you have seen the spot of light.

This test is useful to see if there has been any “tunneling” of vision – a common symptom of glaucoma that needs to be monitored. If you've been diagnosed with glaucoma, this test is an absolute necessity once or even twice a year to check for vision changes.

Another test that is used to diagnose glaucoma is called a gonioscopy. With this test, the eyes are numbed with drops, and a contact lens is placed on the eye directly – which is why the numbing drops are necessary. The lens has a mirror that shows what kind of glaucoma is affecting the eye, either acute, closed-angle glaucoma, or chronic, open-angle glaucoma.

Corneal thickness also can be measured to determine if glaucoma is a problem, or if your corneas are just thick or thin. An instrument called a pachymeter is placed on the corneas to measure their thickness, and then the measurements are taken into consideration when interpreting eye pressure readings. This test is known as – you guessed it – pachymetry.  The thinner your cornea, the more likely a given pressure in the eye can cause damage.

Finally the optic nerve can be scanned with an instrument called an Optical Coherence Tomographer (OCT).  This very advanced technology has been in use at the Eye Practice since 2005.  Not only does it have use for glaucoma, but is also useful in macular degeneration assessment and monitoring for Diabetic Retinopathy.  It truly is a marvelous piece of technology that is invaluable in glaucoma management.

When it comes to glaucoma, early detection is vital for protecting your sight and ensuring proper treatment is administered. Of course, once glaucoma has set in, the damage that has been done cannot be undone, but further damage can be prevented to save your sight.

Hopefully what should be evident from this post is that glaucoma testing can be quite a specialised process.  If you have visited your optometrist and the eye test is completed in 15 - 20 minutes, it is unlikely that you have had a comprehensive glaucoma assessment, unless the whole 20 minutes was spent looking for glaucoma!

At The Eye Practice our passion is preserving your vision.  Call us on 9290 1899 or CLICK HERE for an online appointment.

Glaucoma comes in two common forms – open-angle and angle-closure, chronic and acute – and can be extremely difficult to detect, especially chronic, open-angle glaucoma. But no matter what, early detection and treatment can help save your sight. Naturally, damage that has been done to the optic nerve cannot be undone (yet), but further damage can be prevented.

In order to save your sight, know the most common forms of glaucoma and their associated symptoms.

Open-Angle, Chronic Glaucoma

This type of glaucoma is difficult to detect on your own because the symptoms are vague and gradual. It is absolutely necessary to see your eye doctor regularly to be tested for this type of glaucoma. The major symptom of open-angle glaucoma is a gradual tunneling of the vision. At first, it is just a subtle loss of peripheral vision on one or both sides (usually both). Then, in the advanced stages, vision is completely “tunneled.”

People with diabetes, and people over age 60 are at greater risk for developing this kind of glaucoma – therefore, annual screenings are necessary for you if you fit into these categories. Prevention is superior to cure, even in modern medicine – and the case is the same when considering glaucoma.

Lack of peripheral vision is difficult to notice on your own – it's not something you think about or notice until it's almost completely gone.  Studies have shown that if a patient comes in for an eye test and complains of vision disturbance that is directly related to Open-Angle Glaucoma, it is likely that they have lost 60% of their vision at that stage!

Angle-Closure Glaucoma

This type of glaucoma is more dramatic – but can be confused with other conditions. That's why it's important to seek emergency treatment right away if two or more of these symptoms occur simultaneously:
    •    Severe eye pain or pain in the eyebrow (referred pain)
    •    Nausea and/or vomiting that accompanies the eye pain
    •    Reddening of one or both eyes
    •    Blurred vision
    •    Seeing halos that look like rainbows or prisms around lights
    •    Sudden visual disturbances, often seen in low lighting conditions

Because these symptoms are not just associated with acute angle-closure glaucoma, and can be symptoms of other serious conditions, it is imperative to get emergency care as quickly as possible if two or more of these symptoms occur.

 

Primary or Secondary Glaucoma?

Sometimes you'll hear glaucoma referred to as primary or secondary. These aren't types of glaucoma, necessarily – they are terms used to describe the conditions of the glaucoma. If the cause is unknown, then it is called primary. If the glaucoma can be traced to a root cause, such as a tumor or injury, then the term secondary is used.

Glaucoma will result in blindness if left untreated, and any damage it does prior to treatment is permanent. Regular eye exams can lead to early detection and treatment, which can save your vision and arrest glaucoma's further development.

Don't wait for damage to occur – it won't go away on its own.

Glaucoma for the majority of people that are diagnosed early means very simple treatment with as little as one eye drop in each eye just before going to bed - no big deal.

About one in ten people do not respond to traditional glaucoma treatment – in the form of eye drops and oral medications – and that used to mean they would go blind for sure.

Luckily, modern science and technology has brought about three newer treatment options for treatment-resistant glaucoma. They are laser therapy, and two types of eye surgery.
But before we have you look at the alternatives, let's have a look at the traditional, conservative treatment for glaucoma – eye drops and oral medications.

Primary Treatment – Pharmacotherapy

Eye drops and oral medications help relieve intraocular pressure (IOP) through biological changes to the eye structures (that's the ultra-simplified version of what those medications do). They either increase drainage of eye fluid to release the pressure, or they prevent additional production of eye fluid (also known as aqueous humor).

Sometimes they don't always work for a variety of reasons. If you have a tremor in your hands, or you have very painful arthritis in your hands, you understand that eye drops can be extremely difficult to administer. This can interfere with treatment of glaucoma through drops. Another reason for medications not working is due to the fact that if you can't “see” the problem, you'll forget to take your medicine! Some other reasons for medications not helping to treat glaucoma are the inability to cope with side effects of the medications, or they simply aren't responding to the medications they are given.

When it becomes obvious that medication will not help, it's time to look at the alternatives.

Laser Therapy

Known as laser trabeculoplasty, a laser is used on the eye in order to relieve IOP. This is a non-invasive procedure that will cause an increase in eye fluid drainage. This treatment is effective for roughly 60% of patients. For the remaining 40%, additional medications or surgery is required within five years of the initial laser treatment.

        

Filtration Surgery

Termed as trabeculectomy in the medical field, this procedure is surgical, creating a drainage channel for eye fluid. The excess fluid will be reabsorbed by blood vessels around the eye, and a drainage flap with adjustable sutures can be created by the surgeon which will control IOP.

Drainage Implants

For those who would not do well with a trabeculectomy (or have not done well with it) and their IOP is not under control, or if they have other eye problems preventing filtration surgery as a viable option, there are drainage implants. Another surgical option, these are drainage tube implants that are placed in the front chamber of the eye (called “shunts”). Small plates are then sewn into the side of the eyes, and the drainage tubes direct fluid to those plates. Then, the excess fluid is absorbed by the tissues that surround the plates.

As knowledge and research continues to grow on the subject of glaucoma, more effective medications and therapeutic options are coming out that can help arrest the development of glaucoma.

It is also reasonable to say that maybe we already have adequate treatment options for glaucoma.  What we need is better education.  Better education of the patient so they are more likely to be compliant with their medications and better education of undiagnosed patients so that they have regular eye examinations.

At The Eye Practice, Dr Jim Kokkinakis has lectured to both university students and to qualified optometrists about glaucoma, its diagnosis and its treatments.  Make an appointment for your regular eye test now on 92901 1899 or BOOK AN APPOINTMENT ONLINE HERE.

Glaucoma affects around 2% of the population but as we age the risk of developing glaucoma becomes greater.  In other words in an age group of 20 to 30 years of age the risk of developing glaucoma could be 1/100 people but in an age group of 70 to 80 it could be as high as 1/10. 

These numbers are not meant to be exactly accurate but to give you an idea of how much more likely you are to develop glaucoma as you age.

What is for certain though is that the earlier one is diagnosed with glaucoma and begins treatment the greater the chance of not losing your eyesight.

It is Glaucoma week in America at the moment.  We urge you to view the video below but then most importantly make a habit of getting your eyes tested for glaucoma every year or two.

Glaucoma can be treated fairly simply.  The earlier it is diagnosed the simpler the treatment normally is.  Most patients require a drop in each eye just before going to bed.  How simple is that!

 

Glaucoma is well known amongst the general population.  This is partly by government advertising and partly by eye practitioners advising their patients about it.

There are many risk factors for developing glaucoma:

1. Age
2. Race
3. Cardiovascular problems
4. Migraines
5. Cold fingers and toes (Raynaud's syndrome)
6. Central Corneal Thickness
7. Intraocular pressure
8. Suspicious looking optic nerve
9. Abnormal visual field
10. Narrow eye drainage system
11. Pseudoexfoliation
12. Pigment dispersion
13. Myopia
14. Taking steroid medication, especially in eye drop form
15. Others...

There are a number of different types of glaucoma.  Occasionally a mixed mechanism glaucoma can occur, which requires a number of different treatments.  At the end of the day the main treatment is to somehow reduce the pressure of the eye.

The above image demonstrates optic nerve appearance vs visual field disturbance in the presence of glaucoma.

Treating the pressure in the eye can occur in a number of ways. This will depend on the type of glaucoma, taking into consideration possible side effects of any medications and the severity of the initial presentation of the disease.  Treatment once it has started can vary depending on how the individual patient responds.

Even though glaucoma management does follow a recipe to a certain degree, it is imperative to individualise the treatment because like any disease treatment the spectrum of individual responses is huge.

Many patients that are diagnosed with glaucoma are treated with glaucoma eye drops.  There are a number of different classes of drugs.  Careful instruction on how to use the eye drops is critical for a favourable and maximum possible response.

What is unfortunate is that occasionally the patient is either not educated properly in using the drops or what is very common is not complying with the use of the drops.  Often patients just forget to take the drops.  In future posts we will discuss what drops are used in glaucoma management and most importantly how to use them effectively.

 

THE IMAGE ON THE LEFT SHOWS THAT WITH INCREASING EYE PRESSURE THE RISK OF GLAUCOMA RISES. 

THE IMAGE ON THE RIGHT DEMONSTRATES THE PRESSURE BEING MEASURED IN THE EYE.

Other glaucoma pressure reduction techniques include taking Diamox tablets, lasering the drainage system of the eye so that it drains more effectively, surgical drainage formation called trabeculectomy, implanting drainage devices and often just performing cataract surgery will reduce the pressure.

In very severe cases of glaucoma, the ciliary body of the eye is destroyed using a laser.  The ciliary body makes the fluid which causes pressure in the eye.  If all other treatments have been tried unsuccessfully then ciliary body destruction might be the only option left.

Glaucoma historically was diagnosed by a measuring a pressure inside the eye of over 21mm of mercury.  To put this in context we are all familiar with blood pressure.  Normal readings for blood pressure as the heart beats is 120mm of mercury while when the heart relaxes drops the blood pressure when normal to 80mm of mercury. Hence when a blood pressure is documented it looks something like: 120/80.

When measuring the eye pressure even though it is documented as a single number, there is in fact a normal fluctuation of 4mm of mercury.  It is too difficult to measure this exactly in a clinical setting so it is just averaged.  Just like blood pressure varies quite significantly during the course of the day, the eye pressure in certain individuals can also vary dramatically.

Relying on just one measurement for a glaucoma assessment can be very misleading, as in certain cases of glaucoma the pressure can be normal at certain hours of the day yet be dramatically abnormal at other hours.

A recent patient of Dr Jim Kokkinakis had been diagnosed with glaucoma in China.  In China he was hospitalised over night and was awakened very hour to have his pressure measured.  The results are summarised as follows:

8.00am : 24mmHg; 10.00am : 18mmHg; 2.00pm : 17mmHg; 2.00am : 32mmHg; etc

It can be seen that the pressure varied from 17mmHg to 32mmHg during the course of 24 hours.  Certainly the pressure measurement of 32mmHg is indicative of glaucoma but here is something to ponder?  Were these pressure readings accurate?

Hospitalising glaucoma suspects for 24 hour pressure measurements are not done in Australia, as it is felt to be a waste of resources.  Dr Jim Kokkinakis definitely agrees with this but...

Wouldn't it be great if there was some simple way of measuring eye pressure around the clock?  After all it is known that eye pressure is just a risk factor for glaucoma and no definite number means you will have glaucoma damage to the eye.  What is certain that as the pressure increases more and more people will develop glaucoma.  Even though no definite pressure is definitive of glaucoma, once progressive glaucomatous damage is seen, the only real treatment we have is to reduce the pressure normally by at least 30%.

It seems that a high tech contact lens has been developed that incorporates a microchip and wireless transmission of the eye pressure.  The patient therefore can be fitted with the contact lens and allowed to go home, go about normal daily activities, go to sleep and then return to the treating practitioners office where a complete download of all pressure measurements can be documented on the patients eye health record.

Apparently this device called "The TriggerFish" is currently being used in some countries of Europe and in Japan.  What begs the question though is how accurate is it - I guess time will tell with ongoing studies.  What is certain though is that as the technology to measure eye pressure throughout the day becomes easily accessible our management of glaucoma will just get better and better.

For more information on "The TriggerFish" CLICK HERE for an interesting news article.

If we go back to Dr Kokkinakis' patient who had his eye pressure measured at 2.00am in the morning woken up each hour, one must question the accuracy of a test with a tired patient, trying to sit still hour after hour - we have our reservations.

Glaucoma was once thought to be a raised eye pressure, which slowly compressed the optic nerve until it stopped functioning.  The optic nerve is the cable at the back of the eye that provides the connection to the visual cortex of the brain.  If the nerve is not functioning properly this in turn interferes with the vision.

At one point because it was thought that excess eye pressure was solely responsible for glaucoma, it was a simple treatment.  Drop the pressure to some point and then the glaucoma is managed.

Unfortunately it was discovered to not be so simple. Over the years various risk factors were discovered to be associated with glaucoma disease progression.  Currently a full glaucoma test involves:

1. Ask for a full family and medical history.
2. Measure the pressure (sometimes at different times of the day).
3. Measure the central cornea thickness. The thinner the cornea the more likely that a given eye pressure will cause damage.
4. Do a peripheral vision test. Glaucoma tends to affect the peripheral vision before the central vision.
5. Careful observe the optic nerve looking for characteristic changes, which can represent glaucoma.
6. The observation is best done by taking a photograph of the optic nerve.
7. Taking a Optical Coherence Tomography of the optic nerve (OCT).  This can be compared to an MRI. An OCT is able to monitor an optic nerve over time looking for change that can represent glaucoma.

 

At The Eye Practice you can be guaranteed of a comprehensive glaucoma evaluation on every visit.  We have the most advanced technology available, while our resident optometrist Dr Jim Kokkinakis is endorsed to treat it.

The Eye Practice was one of the first optometrical practices in Australia to invest in OCT technology.  This was done in 2005.  Since then there have been multiple upgrades with statistical analysis software that allows early and more accurate detection.

What is scary is that at any given time, of all the people that have glaucoma, only about half of them have a diagnosis and are being treated.  The other half either have not been tested comprehensively and been missed or have not been tested at all.

It is tragic that this occurs in this day and age.  Make sure that you are screened for glaucoma, especially if you are over 40 years of age.

Call us on 9290 1899 and make an appointment or make  an online booking HERE.

In a future post we will discuss what happens if you are diagnosed with glaucoma.

Glaucoma in most cases is asymptomatic until very late in the process.  In fact if a patient attends a comprehensive eye examination and complains of blurry vision and it is discovered that the blurry vision is directly caused by glaucoma - they will have lost around 60% of their vision!

Because glaucoma normally affects peripheral vision first it is far less obvious to the individual.  It usually develops so gradually that they tend to compensate without realizing vision loss is occuring.

        

There are a number of forms of glaucoma.  In most cases there is no pain involved.  The moral to the story then is, sit in the examination chair at least once every two years so it can be discovered.

In the very early stages of glaucoma it is difficult to be certain if in fact glaucoma is present.  It is not uncommon to label someone as a glaucoma suspect and then follow them very closely for more definite signs in the future.

If a patient is labelled as a glaucoma suspect, comprehensive eye examinations are required more often. At least annually in these cases and sometimes more often if suspicion level is high.

There are a number of important tests that need to be performed when screening for glaucoma.  At The Eye Practice we have the most sophisticated technology that is available for glaucoma management. 

Dr Jim Kokkinakis is therapeutically qualified to treat it.  He regularly attends Australian and overseas conferences on Glaucoma and even lectures on the topic.  You can be assured you are in good hands.

Stay tuned for future posts on Glaucoma and its management.