Glaucoma – a Progressive, Treatable Condition
Glaucoma is a progressive disease of the optic nerve caused when the pressure inside the eye is higher than the optic nerve can withstand. The most common form of glaucoma will cause a patient to slowly lose vision, starting with their peripheral vision. For many years this loss of vision will go unnoticed by a patient. Left untreated, glaucoma will result in blindness.
Who is at Risk
Although anyone can get glaucoma, some people are at higher risk than others. Some of the most common risk factors include;
1Almost 2.0% of Americans ages 40 to 50 and almost 8% of those over age 70 have glaucoma. Numerous sources have estimated that only ½ of the 6 million Americans with glaucoma have been diagnosed. 2African Americans are 6 to 8 times more likely to diagnosed with glaucoma. Approximately 1/4th of those diagnosed with glaucoma are African Americans. Glaucoma accounts for approximately 12% of all new cases of legal blindness each year. 3Glaucoma is the second leading cause of blindness worldwide and by 2020 almost 80 million people in the world will be diagnosed with glaucoma. Worldwide, 2.4 million people per year are diagnosed with glaucoma.
Glaucoma Risk Increases with Age
The prevalence of glaucoma increases with age. For every 10 years of age the incidence approximately doubles, therefore, there are twice as many 60-year-olds diagnosed with glaucoma as there are 50-year-olds. By the year 2020, it is estimated that the number of Americans diagnosed with glaucoma will increase by 50% to 3.6 million patients.
What is the Optic Nerve’s Function?
The optic nerve is like a cable made up of over 1 million nerve fibers that carry the information collected by your eye (retina) to the visual cortex of the brain for processing. Glaucoma slowly decreases the ability of your optic nerve to carry this information to your brain.
Why Does Glaucoma Cause a Loss of Vision?
The build-up of pressure, in your eye, causes glaucoma. Attachments to the ciliary body (a small muscle) produce a fluid called aqueous humor in your eye. The pressure increases in the eye because aqueous humor is being produced too quickly or it is not being drained from the eye fast enough. The production and the drainage systems must be in sync or the pressure will build up causing glaucoma.
Theories of The Cause of Glaucoma
There are currently two basic theories as to why excessive ocular pressure causes glaucoma.
The Vascular Theory
High intra-ocular pressure decreases blood flow to the optic nerve.
The Physical Theory
The high pressure, over time, physically crushes and kills the individual nerve fibers.
What are the Symptoms of Glaucoma?
At first, open-angle glaucoma has no symptoms. Vision stays normal, and there is no pain. As glaucoma remains untreated, people may notice that although they see things clearly in front of them, they miss objects to the side and out of the corner of their eye. Typically, patients will notice no symptoms until the late stages of the disease.
Without treatment, patients may find they have no peripheral or “side” vision. It may seem as though they are looking through a tunnel. Over time, the remaining vision may decrease until there is no vision left. Glaucomatous optic nerve damage is permanent. Because of this, it is important to seek treatment in the early stages of the disease rather than waiting until symptoms are noticed.
What is the Relationship Between Pressure and Glaucoma
Most people think that they have glaucoma if their eye pressure is high. This is not always true. High pressure puts you at a higher risk, however, an elevated pressure by itself does not make the diagnosis. Whether or not you have glaucoma depends on the level of pressure your optic nerve can tolerate without being damaged. This level is different for each person. Although normal pressure is usually said to be between 12-21 mm Hg, a person might have glaucoma even if the pressure is in this range. That is why an eye examination is very important. Conversely, having a pressure over 21 does not mean a person has glaucoma.
What Tests are Used to Diagnose Glaucoma?
Traditionally glaucoma was diagnosed by evaluating a patient’s peripheral vision with a visual field. Recent advances in laser technology, along with new studies have improved the accuracy of early diagnosis. A patient that is being evaluated for glaucoma will typically have the following tests.
Comprehensive, Dilated Eye Exam
The first step is to start with an eye exam. The eye exam should include dilation of the pupils and a stereoscopic view of the retina. Often the pupil dilation is completed or repeated on a subsequent visit when the pupils are dilated for the visual field or fundus photos.
A special lens lets the doctor evaluate the trabecular meshwork. The trabecular meshwork is where the fluid in the eye drains into our lymphatic system.
Measuring the pressure in the eye. There are numerous ways to do this. The most common is with a Goldmann tonometer. Anesthetic eye drops with a dye are placed in the patient’s eyes and a blue light is then directed onto the tonometer tip. The tonometer tip measures the cornea by pressing on the patient’s cornea.
The process of measuring corneal thickness is called pachymetry. One of the major findings of the Ocular Hypertension Treatment Study (OHTS) was that if we were measuring the internal pressure of the eye through a thick cornea the pressure will measure higher then it truly is and conversely if the cornea is thin the pressure will be measured lower than it really is. Therefore, in order to know the true intra-ocular pressure, we measure the cornea’s thickness.
The fundus is the back of the eye or retina. Pictures of the eye are helpful to look for changes in the appearance of the optic nerve over time. Fundus photos can be performed dilated or undilated depending on the type of retinal camera.
Threshold Visual Field
Since the primary symptom of glaucoma is a progressive decrease in peripheral vision, one of the most important tests is a visual field. In the simplest terms, a visual field detects how dim of a light can be seen in the patient’s peripheral vision. Visual fields are often performed through dilated pupils. During the visual field, patients look straight ahead at a small light and press the button whenever they see a light. Visual fields are a tedious test and they almost always improve on subsequent sessions. Visual Fields are typically performed yearly.
Scanning Laser Ophthalmoscopy
One of the most recent advancements in the detection and diagnosis of glaucoma is the scanning laser ophthalmoscope. Scanning laser ophthalmoscopes are also referred to Optical Coherence Tomographers or OCT. They measure the retinal nerve fiber layer and map out the shape of retinal structures such as the optic nerve or macula. These high technology instruments then compare this information to a normative database to detect subtle changes. An OCT helps doctors predict if the condition is progressive or stable.
A recent study from the Bascom Palmer Eye Hospital showed that a 10% decrease in the Pattern Electroretinogram signal strength can be detected up to 8 years earlier than a 10% loss of nerve fibers detected by a scanning laser ophthalmoscope or optical coherence tomographer. What does this mean? It means the PERG allows us to detect glaucomatous nerve fiber loss much earlier allowing for earlier diagnosis and treatment.
How is Glaucoma Treated?
Glaucoma is a lifelong condition that will always require treatment much like hypertension and diabetes. We can control these conditions with medications; however, we can not, as of yet, cure them. Today there are numerous ophthalmic medications available. Some eye drops are used once or twice a day; others are used up to four times a day. More than one medication may be used to treat glaucoma. If your eye doctor continues to notice glaucomatous changes other medications or procedures, including surgery, may be considered.
The concern of most patients is will I go blind from glaucoma? That is difficult to answer and depends on numerous factors. Due to the many excellent medications available to us today most people, with early treatment, will not go blind from glaucoma. The rate of blindness is much lower today than ever before.
What Can I Do to Decrease My Chances of Going Blind?
Glaucomatous blindness is preventable with the currently available treatments. Using the medications as prescribed and regular office visits are crucial to preventing glaucomatous progression. It is best to monitor the pressure three to four times per year, repeat visual fields at least annually and take photographs of the optic nerve every one to two years. Some of these office visits will be brief pressure checks whereas others may include your annual eye exam, visual fields, photos of your optic nerves or imaging of your optic nerve with a scanning laser ophthalmoscope or electrodiagnostic studies.
You can also help protect the vision of family members and friends who may be at high risk for glaucoma – especially, African Americans over age 40 and everyone over age 60. Encourage them to have an eye examination through dilated pupils every year.
Taking Your Eye Drops
If you forget your drops one day don’t try to make it up on the next day. Try to be relatively consistent with the time of day you use your drops. If you are late taking your drop it’s best not to skip that dosing altogether, just move up your time schedule for that day and then resume your normal schedule the next morning. Taking more drops than prescribed will not make your pressure any lower. Only take your drops the prescribed number of times per day. On the day of your appointment remember to take your drops as you normally do.
If you happen to forget to take your drops on the day of your office visit please tell us. This will prevent an incorrect conclusion that the reason your pressure is high is because your current medication regimen is no longer working, rather than the correct conclusion that your pressure may be high because you forgot your drops.
Glaucoma Treatment at Total Eye Care
The eye doctors at Total Eye Care are Optometric Glaucoma Specialists certified in the treatment of glaucoma. If you wish to seek treatment for glaucoma at Total Eye Care please call us and schedule an appointment. You can reach our Colleyville office at 817.416.0333 or our Keller/Southlake office at 817.431.4900.
It is common to be surprised when you first learn you may have glaucoma. You may have many questions and concerns. Our job, as your eye doctor, is to educate you, therefore, no question is too small. Please feel free to ask us any questions. Glaucoma is very successfully treated today and there are many new medications in the research pipeline. We will always keep you up to date on your treatment.
Test Your Knowledge of Glaucoma by Taking the Glaucoma Eye-Q Test.
1The Eye Diseases Prevalence Research Group, Arch Ophthalmol. 2004.
2African Americans and glaucoma; Glaucoma.org.
3Number of people with glaucoma worldwide in 2010 and 2020; HA Quigley, AT Broman; Br J Ophthalmol. 2006 Mar.
Portions of this document were adapted, with permission, from the National Eye Institute document Facts about Glaucoma and the book “An Eye Doctor Answers: Explanations to Hundreds of the Most Common Questions Patients Wish They Had Asked Their Eye Doctors”.