Glaucoma

What is Glaucoma?

Glaucoma is a leading cause of vision loss and blindness in the US. The term Glaucoma refers to a group of diseases that cause damage to the optic nerve with resulting vision loss. High eye pressure is a risk factor for glaucoma, but some patients with glaucoma never have high eye pressure. Glaucoma is generally caused by aging and genetics, but it can also be caused by eye injury, blocked blood vessels, inflammation, or severe infection in the eye. Often glaucoma is asymptomatic until fairly advanced with irreversible optic nerve damage, so early diagnosis and treatment are essential. While glaucoma is generally not curable, it can be treated and controlled to prevent vision loss, especially when diagnosed early.

What Are The Different Forms of Glaucoma?

Open angle glaucoma is the more common form of glaucoma and involves failure of the fluid inside the eye to drain properly. This leads to a pressure buildup in the eye, which damages the optic nerve. In some people the pressure is not actually high, but their optic nerve is fragile and so even normal pressure can cause damage. While not all glaucoma patients have elevated pressures, our goal is always to protect the nerve by lowering pressure. Open angle glaucoma causes a very slow deterioration of peripheral (side) vision, which is usually asymptomatic until more severe. The vast majority of patients with glaucoma have no symptoms until the disease is moderate to severe and is much more difficult to treat.  Glaucoma damage is generally not reversible. Early detection and treatment can prevent loss of vision and control glaucoma.

A less common form of glaucoma is angle closure. This is caused by blockage of the drain that allows fluid to leave the inside of the eye. This sometimes occurs suddenly, resulting in a rapid buildup of pressure in the eye and possible damage to the optic nerve. Angle closure is often symptomatic with eye pain, redness and blurred vision with halos around lights. Regular eye exams can detect eyes that are at risk for angle closure glaucoma. When appropriate, treatment with a quick in-office laser procedure can treat at-risk eyes to prevent this type of glaucoma.

How is Glaucoma Diagnosed?

Diagnosis of glaucoma requires a full eye exam. While many patients with glaucoma have high eye pressure, the eye pressure alone is usually not enough to diagnose or rule out glaucoma. About one third of glaucoma patients in the US will have normal pressures, and many patients with high pressure never develop glaucoma. For this reason, an eye pressure check alone is not adequate to screen a patient for glaucoma. An exam of the optic nerve, computerized nerve analysis, automated visual field testing, corneal thickness measurement (because corneal thickness affects eye pressure readings), and gonioscopy (a special lens is used to look at the drain of the eye) are all used to diagnose glaucoma. Click here for more information about the exam and testing for glaucoma.

How is Glaucoma Treated?

If glaucoma is diagnosed, treatment should begin promptly to minimize the risk of permanent vision loss. Angle closure glaucoma must be treated with in-office laser or microsurgery. This is often needed urgently. Most patients with open angle glaucoma can be treated with in-office laser or medicated eye drops. 

Laser for open angle glaucoma, called Selective Laser Trabeculoplasty (SLT) is now commonly used as the first treatment for glaucoma. For more on SLT click here. Eye drops reduce the pressure inside the eye. Different drops work in different ways: they may decrease fluid production inside the eye, or they may increase the outflow of fluid from the eye.

Minimally Invasive Glaucoma Surgery (MIGS Procedures) are a newer development in glaucoma treatment. MIGS refers to a group of procedures that are much less invasive than traditional glaucoma surgery. For more on MIGS click here

What is a “Glaucoma Suspect”?

Some patients just have a few risk factors for glaucoma, or borderline test results, but do not have a definite diagnosis of glaucoma. We call these patients “glaucoma suspects”. In this case, we will recommend follow up (often in 6 to 12 months) to recheck the exam and repeat some of the tests. While we don’t want to miss a case of glaucoma, not everyone with borderline pressures or test results needs treatment. Some glaucoma suspects will never by diagnosed with glaucoma and do not need treatment. On the other hand, follow up of any risk factors is very important. A person may have such early glaucoma that it cannot yet be confirmed, and with time the diagnosis may become apparent. Treatment once glaucoma is diagnosed is important to prevent irreversible vision loss.

How Often Should I be Checked for Glaucoma?

Adults should schedule an appointment with their eye doctor to be checked for glaucoma every 1-3 years depending upon age, family history, and risk factors. If there are no special risk factors and no family history, about every 3 years in the 40s, every 2- 2.5 years in the 50s, and every 1-1.5 years in the 60s is reasonable. At age 70 and above, you need to be checked every year. Those with risk factors or a significant family history need to be checked more often.

Pigment Dispersion Syndrome and Pigmentary Glaucoma

Pigment dispersion syndrome (PDS) is a relatively uncommon condition that affects about 1% of the population.

Pigment clumps that are normally attached to the back surface of the iris (the colored part of the eye) fall off the iris into the clear fluid in the eye called the aqueous humor.

These little clumps of pigment can clog the drainage structures of the eye that drain fluid produced inside the eye (this is different from the tears on the surface of the eye and is not related to tearing).

When fluid pressure builds up inside the eye because drainage is impaired, eye pressure can rise enough to cause damage to the optic nerve resulting in glaucoma. Glaucoma that is caused by pigment clogging the outflow system of the eye is called Pigmentary Glaucoma

This syndrome is felt to occur based on subtle differences in the shape of the structures in an individual’s eye.  In pigment dispersion, the back of the iris rubs against the lens of the eye causing the pigment to flake off the back of the iris.  These little clumps of pigment form a line of pigment on the inner surface of the cornea that an ophthalmologist can see on exam.  This little line is called a Krukenberg spindle and is very helpful in diagnosing PDS.  Loss of pigment from the iris causes thinning of parts of the iris. When viewed under high magnification during the eye exam, light can be seen shining through the thinner areas of the iris. These areas are called iris transillumination defects.  Pigment can also be seen inside the eye resting on the internal drainage structures of the eye.  This is checked using a special lens and is called gonioscopy. The presence of two or more of these key features — a Krukenberg spindle, iris transillumination defects, and excessive pigmentation on gonioscopy — confirm the diagnosis of PDS.

Pigment dispersion syndrome tends to affect relatively young people (20-45), most commonly Caucasians and those who are nearsighted.  Many patients with pigment dispersion syndrome will develop high eye pressures and about half of those who develop high eye pressure will develop pigmentary glaucoma. For this reason, a person diagnosed with pigment dispersion needs to be checked by an eye doctor at least once per year, more often if the eye pressure is elevated.

If a patient has elevated eye pressure or an optic nerve that looks suspicious for glaucoma damage, further testing is done. This testing may include side vision testing (a visual field test), computerized optic nerve head analysis, and corneal thickness measurement. If there are signs of damage to the optic nerve, loss of side vision, or eye pressure is very elevated, the patient is diagnosed with Pigmentary Glaucoma. Glaucoma is treatable, typically with eye drops or laser. More advanced cases may require surgery. It is very important to detect glaucoma early because it causes irreversible vision loss. In addition, the more advanced the glaucoma, the more difficult it is to treat. When detected early and treated early, the prognosis for pigmentary glaucoma is excellent.

Unlike other types of glaucoma, pigmentary glaucoma tends to affect younger people. In men it often occurs at ages 20-45, and in women it develops in the 50s and 60s. Early glaucoma is not symptomatic, and younger patients don’t see an eye doctor as frequently, so this condition is often diagnosed after significant damage has already been done.

While PDS occurs equally in men and women, men have a higher risk of getting pigmentary glaucoma. This is most common in young, nearsighted men. Pigment dispersion is hereditary, so if you have this condition, it is wise to let your relatives know to be checked.

Pseudoexfoliation and Pseudoexfoliative Glaucoma

Pseudoexfoliation is a relatively common condition of the eye that increases the risk of developing glaucoma. Flaky deposits develop on the surface of the natural lens inside the eye and can clog the internal drainage apparatus of the eye. Clogging of this drain can cause fluid pressure to build up in the eye which can result in glaucoma. Glaucoma is a condition where pressure causes damage to the optic nerve and can result in permanent vision loss. Importantly, pressure does not have to be higher than normal for glaucoma to exist, as some people have fragile optic nerves that are damaged by normal pressure. This is why a complete exam with evaluation of the optic nerve is so important.

Pseudoexfoliation becomes more common with age. Though it often starts in one eye, with time it is often noted in both eyes. Patients with pseudoexfoliation need to be followed at least once per year to look for signs of glaucoma. If glaucoma is diagnosed early, it is very treatable, usually with eye drops or laser. Early detection is important, however, to prevent irreversible vision loss.

Evaluation for glaucoma starts with a check of the eye pressure and examination of the optic nerve. If the eye pressure is elevated or the nerve is suspicious, further testing is indicated. These tests may include evaluation of the peripheral (side) vision, corneal thickness, and a computerized nerve analysis. These are only done if the eye pressure or optic nerve are suspicious. This testing is covered by medical insurance.

Medical studies have shown varying rates of glaucoma development in patients with pseudoexfoliation. Up to 80% of patients with pseudoexfoliation develop elevated eye pressures, and about 50% of these patients will develop glaucoma. This is called Pseudoexfoliative Glaucoma. It is important to diagnose and treat this condition as early as possible because Pseudoexfoliative Glaucoma is a somewhat more aggressive form of glaucoma that can lead to permanent vision loss or blindness if not treated. Fortunately treatment is usually very effective, generally starting with laser or eye drops and sometimes requiring surgery.

More recent studies have shown that specifically for pseudoexfoliative glaucoma, ultraviolet light exposure over a lifetime may increase the risk of this particular type of glaucoma. For this reason, sunglasses when outdoors in bright light are advisable. Also, the risk of this specific type of glaucoma is higher in those who drink more than 3 cups of coffee per day. So while patients with pseudoexfoliation may drink coffee, they should probably limit it to 3 cups per day.

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    Wyse Eye Care
    900 Skokie Blvd. – Suite 150
    Northbrook, IL 60062
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    (847) 497-2020 | 900 Skokie Blvd., Suite 150 Northbrook, IL 60062