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Frequently Asked Questions

Glaucoma

Medicare part B benefit for High Risk Patients.

Glaucoma (POAG) - Take home information for our patients.
What is glaucoma?
Is there more than one type of glaucoma?

What is Primary Open Angle Glaucoma (POAG)?
What happens to the eye in glaucoma (POAG)?
What are the symptoms of early glaucoma POAG)?
What are the symptoms of late glaucoma (POAG)?

At a health screening my eye pressure was high. Do I have glaucoma?
How do you determine that there is nerve fiber loss?
What is Ocular Hypertension?

My eye pressure is normal. Is it safe to say I do not have glaucoma?
Does increased eye pressure mean glaucoma?
How can I be sure I do not have glaucoma?

How is glaucoma diagnosed (POAG)?
If I have glaucoma - How often do my eyes need to be examined (POAG)?
I was told I am a Glaucoma Suspect. What now?

My mother (sister, any blood relative) has glaucoma. How significant is this?
What are the chances my children will develop glaucoma?
Should my family members be checked for glaucoma?

What is the GDx test?
What is the Visual Fields test?
Why do you do the GDx and the Visual field tests?
What are fundus photos?

What medicines should glaucoma (POAG) patients avoid?
What medicines are generally considered safe for glaucoma (POAG) patients?

Why is it important to recognize glaucoma progression early?
Glaucoma treatment options (POAG)

How is glaucoma treated (POAG)?
ALT and SLT - Laser surgery for POAG.
Conventional surgery (not laser surgery) for glaucoma (POAG).
Can lost vision be restored by treatment?

What are "Beta-blocker" eyedrops?
I have been using Timoptic without problems. Recently I was diagnosed with chronic bronchitis (or heart disease). What should I do?
Cost of glaucoma drops.
How to instill eyedrops

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Medicare part B benefit for High Risk Patients.
In 2011 Medicare began covering an annual glaucoma screening exam for High-Risk patients. You are considered at high risk for glaucoma if you have diabetes, have a family history of glaucoma, are African-American over the age of 50 or Hispanic-American over the age 65.

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What is glaucoma?
Glaucoma is a condition in which the nerve fibers inside the eye are destroyed.

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Is there more than one type of glaucoma?
There are several types. The most important are the Primary Open Angle Glaucoma or POAG and the Narrow Angle Glaucoma (NAG). These two conditions are very different. If you have glaucoma make sure to ask the doctor which type you have.

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What is Primary Open Angle Glaucoma (POAG)?
This is the most common type of glaucoma. When we talk about "glaucoma", this is the type we are talking about. When we talk about the Narrow Angle Glaucoma (NAG) we will let you know about it.

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What happens to the eye in POAG?
Each eye has about 1 million nerve fibers. They come together in the back of the eye to make up the eye nerve. Glaucoma destroys nerve fibers. When many nerve fibers are lost, the eye becomes blind.

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What are the symptoms of early POAG?
There are no symptoms until very late in the disease. There is no pain.

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What are the symptoms of late POAG?
Side vision is lost. Central vision (used for reading and similar tasks) remains relatively good. The field of vision narrows. The patient feels as if he is looking through a long narrow tube. Just the central, straight ahead vision is clear. When driving across an intersection such a patient might be able to read the license plate of the car in front of him, but would not be able to see the bus coming at him from the side.

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At a health screening my eye pressure was high. Do I have glaucoma?
You have either glaucoma or ocular hypertension. If you have nerve fiber loss, you have glaucoma.

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How do you determine that there is nerve fiber loss?
By carefully examining the eye nerve and by doing certain tests (GDx, OCT, FDT, Visual Fields and taking Fundus photographs).

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What is Ocular Hypertension?
Ocular Hypertension is a mild increase in eye pressure with no nerve damage. It requires no treatment. It must be followed up carefully to detect nerve fiber loss as early as possible.

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My eye pressure is normal. Is it safe to say I do not have glaucoma?
No. Pressure screening detects about one-half to two-thirds of glaucomas. The rest are missed.

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Does increased eye pressure mean glaucoma?
The popular concept that glaucoma is simply high pressure inside the eye is not correct.
We know now that:

People with high eye pressure and nerve damage have Glaucoma.

People with high eye pressure and no nerve damage have Ocular Hypertension.

People with normal pressure but showing nerve damage have Normal Tension or Low Tension Glaucoma.

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How can I be sure I do not have glaucoma?
You need a complete, dilated eye exam. We routinely check the nerve, the eye pressure, and the eye fluid draining area. If this eye exam is normal, and you do not have family history of glaucoma, it is pretty safe to assume that you do not have glaucoma.

If you have a blood relative with glaucoma you may need, in addition to the eye exam, a nerve fiber analysis test (GDx or OCT test).

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How is glaucoma diagnosed (POAG)?
The key is to identify loss of nerve fibers. Loss of nerve fibers is suspected from the appearance of the nerve in the back of the eye. A positive Visual Fields test or a positive GDx or OCT test confirms it. Sometimes, when the pressure in the eye is very high, glaucoma is diagnosed even without proving nerve fiber loss.

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If I have glaucoma - How often do my eyes need to be examined?
When the glaucoma is first diagnosed you will be seen at short intervals to evaluate results of treatment. The desirable level of control is different for each individual. Once good control is obtained you will need to be examined every 3-6 months.

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I was told I am a Glaucoma Suspect. What now?
This means that your eye pressure is too high or the nerve looks abnormal. You may need repeat measurement of the eye pressure and baseline special tests - the Visual Fields tests, the GDx or OCT test and Fundus photos of the nerve head.

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My mother (sister, any blood relative) has glaucoma. How significant is this?
If one of your parents has glaucoma, your chance of developing glaucoma is increased 10 fold. If your brother or sister has glaucoma your risk is increased 20 fold (1 chance in 10 that you will develop glaucoma).

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What are the chances my children will develop glaucoma?
If you have glaucoma, your children's chance of developing glaucoma is 10 times greater than for other children (1chance in 25).

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Should my family members be checked for glaucoma?
Yes. If you are diagnosed with glaucoma your blood relatives (parents, children, brothers, sisters) should have a complete eye exam.

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What is the GDx test?
GDx stands for Glaucoma Diagnosis. It is a new computerized test that measures the thickness of the eye nerve tissue. It is similar to taking a picture of the inside of the eye. It is painless, quick and does not require that your eyes be dilated. It is used for diagnosis of early glaucoma; for follow up of glaucoma treatment and in early detection of glaucoma in relatives of glaucoma patients.

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What is the Visual Fields test?
It is a test of eye nerve function. Faint spots of light are projected on a screen and you press a button if you see them. The computer tells us if you are missing spots you should have been able to see.

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Why do you do the GDx (or OCT) and the Visual field tests?
They measure different aspects of the nerve. Both are necessary for best evaluation. The Visual Fields test measures functioning nerve fibers. About 300,000 nerve fibers (out of 1 million) have to be lost before the Visual Fields test becomes positive. GDx (and OCT) test is usually more sensitive than the Visual Fields test. Another visual fields test we use is the Frequency Doubling Technology.

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What is Fundus Camera?
Fundus Camera obtains images of the nerve head. These images are then used as a baseline against which later images are compared. Minute changes indicative of progression of glaucoma are detected early and treatment can be adjusted sooner.

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What medicines should glaucoma (POAG) patients avoid?
Steroids (cortisone, hydrocortisone, prednisolone, etc.) increase eye pressure. If you need to use steroids for longer than 2 weeks, your eye pressure has to be monitored during use. This includes use of steroid-containing eyedrops, steroid pills, and steroid creams over large areas of the body. Use of steroid creams for small skin lesions is unlikely to increase eye pressure. If you are taking steroids now, do not discontinue them - just tell us about it and come in for a re-evaluation. Steroid use for less than 2 weeks generally does not require special monitoring of eye pressures.

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What medicines are generally considered safe for glaucoma (POAG) patients?
Cold remedies containing Pseudoephedrine, Phenylephrine or Neo-Synephrine; anti-histaminics Chlorpheniramine, Diphenhydramine or Benadryl and overactive bladder remedies such as Detrol often carry a warning telling you not to use them if you have glaucoma. These warnings do not apply to your type of glaucoma (POAG). You can safely use them for a week or two; beyond that, monitoring may be needed. The warnings are intended primarily for patients with Narrow Angle Glaucoma because in such patients these drugs may produce pain and an acute glaucoma attack. If you are not sure what type of glaucoma you have, consult us before taking these medicines.

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Why is it important to recognize glaucoma progression early?
Because nerve fibers, once lost, cannot be replaced. Since treatment slows down the rate of nerve fiber loss, it should begin as soon as we detect progressive nerve loss.

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Glaucoma

Glaucoma treatment options (POAG).

For the type of glaucoma you have (POAG) there are two starting treatment options: Eye drops or Laser surgery.

Normally we start treatment with eye drops. If eye drops fail, we do Laser surgery. Eye drops may be expensive (about $100 monthly). If you do not have good drug coverage, or have problems using eye drops, you may consider Laser surgery as the first treatment choice. Information that follows is intended to help you make an informed choice.Long term, you will need the same follow-up regardless of the treatment (eye drops or laser) you choose.

Glaucoma treatment with eye drops.

This is the traditional treatment. Given once or twice daily, they control the glaucoma in most patients. Eye drops are generally well tolerated. The downside is that eye drops can be very expensive, a serious consideration when the need for medication is a lifetime need. Also, sometimes, they may have local side effects such as dry eye and discoloration of skin around the eye. They have the potential to cause allergic reactions.

Glaucoma treatment with Laser Surgery.

Laser surgery used to be done when eye drops failed to control glaucoma. Thanks to recent advances in lasers, its use as the starting treatment is now possible. It is an excellent option for those who tend to forget to use the eye drops, have problems administering them, can not tolerate them for any reason, do not wish to use medications because of pregnancy or find the eye drops too expensive. Laser surgery is a well established procedure, covered by Medicare and other insurances, with little or no out-of-pocket expenses.

Laser surgery controls the pressure in most (not all) patients for an unpredictable period of time. There is no need for eye drops while the pressure is under control. The length of time the pressure remains under control is unpredictable since it depends on patient's individual characteristics. Sometimes, laser surgery needs to be repeated to regain control of the pressure. Sometimes, eye drops may be needed for optimal pressure control.

The main risk of Laser surgery is a short-lasting increase in pressure which is treated with glaucoma medications. Complications are mild and short-lasting. They may include inflammation, a brief increase in eye pressure, brief period of blurred vision, headache, iritis, corneal edema, corneal lesion, conjunctivitis, or eye pain. Normal activities, such as driving and work, may be resumed the same day. Laser surgery is done at the Southgate Surgery Center. It is easy on the patient and it takes only a few minutes to perform. Anesthetic eye drops are used and the procedure is essentially painless.

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How do we treat glaucoma (POAG)?
Normally, we start treatment of chronic glaucoma (POAG) with eye drops. They are generally well tolerated and control glaucoma in most patients. The downside is that eye drops can be very expensive, a serious consideration when the need for medication is a lifetime need.

Laser surgery is used whenever eye drops fail to control glaucoma. It is also an excellent option for those who tend to forget to use the eye drops, have problems administering them, can not tolerate them for any reason, do not wish to use medications because of pregnancy or find the eye drops too expensive. Laser surgery is a well established procedure, covered by Medicare and other insurances, with little or no out-of-pocket expenses.

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ALT and SLT - Laser surgery for POAG type glaucoma.
Argon Laser Trabeculoplasty (ALT) and Selective Laser Trabeculoplasty (SLT) are painless, in-office laser treatment for glaucoma.

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Conventional surgery (not laser surgery) for glaucoma (POAG).
Generally reserved for patients whose glaucoma cannot be controlled with eyedrops and laser surgery.

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Can lost vision be restored by treatment?
No. Lost nerve fibers will not grow back.

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What are "Beta-blocker" eyedrops?
Some glaucoma eyedrops contain "Beta-blocker" medicine. They are absorbed into the blood circulation and may cause shortness of breath in patients with lung or heart conditions. The most common beta-blocker eyedrops are Timoptic and Timoptic-XE. They are excellent anti-glaucoma eyedrops and cause no problems in people with normal heart and lungs.

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I have been using Timoptic (or Timoptic-XE) without problems. Recently I was diagnosed with chronic bronchitis (or heart disease). What should I do?
Glaucoma patients on Timoptic who develop chronic bronchitis, asthma, COPD (chronic obstructive lung disease), emphysema or heart problems, should let us know about it. They should also remind their family doctor that they are using beta-blocker eyedrops for glaucoma.

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Cost of glaucoma drops.
Glaucoma is a lifetime condition. Over time the cost of drugs is high. You will pay less if you shop around for glaucoma drops. If cost is a major problem, you may consider Laser surgery (ALT, SLT). Initially, laser surgery controls the pressure in 4 out of 5 patients. The effect may fade with time but, one year after laser surgery, the pressure still remains under control in about one half of patients. Medical insurance and Medicare cover laser surgery.

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How to instill eyedrops.
The proper technique to instill eye drops is very important.
Detailed instructions are on the How To page.

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Glaucoma (POAG) - Take home information for our patients

We are committed to inform our patients thoroughly about their condition. A well informed patient will benefit from that knowledge and, over time, will be much better off because of it. With that in mind, we have gathered here for you important information about your type of glaucoma (POAG).

A special note to patients for whom we have prescribed timoptic (Timoptic XE):

Timoptic-XE is absorbed into blood circulation. Because it is a "Beta blocker" type of drug, it may cause problems in patients with lung and heart conditions. If you have now, or have had in the past, or should you develop in the future asthma, COPD (chronic obstructive lung disease), chronic bronchitis, emphysema or heart problems, let us know. Also, remind your family doctor that you are using beta blocker drops for glaucoma.

The complete name of your eye condition is Chronic Primary Open Angle Glaucoma (POAG).This chronic form is usually painless. Rarely, when the pressure within the eye increases markedly, eye pain may develop. When this happens, it must be evaluated promptly. Call us immediately and tell receptionist you have to be seen because you have glaucoma and eye pain.

To understand the loss of vision in glaucoma, you must be aware of the two main types of vision - central vision and peripheral vision. Central vision is the sharp vision you use to read. As you read this letter with your central vision, you are also aware of the room around you. You are aware of the room, and of the rest of the world around you, because you are using your side (peripheral) vision. In glaucoma, you lose your side vision while the reading vision stays sharp. This is why you would not notice vision loss until the loss is very great. To give you an idea of what the loss side vision is like: If you lost your side vision, and you were driving across an intersection, you would be able to read the license plate of the car in front of you but you would not see the bus coming at you from the side. Remember, by the time you notice vision loss, the loss is far advanced. It is too late to do anything about it. The damage can not be reversed. I can not emphasize it too strongly - follow recommendations faithfully!

To protect the nerve, the pressure inside the eye has to be brought down to a point where no damage to the nerve will occur. This point varies from patient to patient. Even when the pressure is lowered to what appears to be a reasonable level, in some predisposed people glaucoma may progress. Monitoring of the nerve appearance and of its function must continue, regardless of the pressure achieved

The first step in monitoring is the periodic eye pressure check. If the pressure is higher than "normal" or desirable, the treatment will need to be changed. On the other hand, a finding of "normal" pressure only means that it is normal at that particular time. It does not give us assurance that it is at the desirable levels at all times, day and night (there is variation in pressure during the day and night). To detect progressive nerve damage, periodic eye exams are needed in addition to pressure checks. The nerve head has to be carefully examined and its appearance compared against nerve photographs taken during previous eye exams.

A Nerve Fiber Analysis test (the GDx test or the OCT test) may be done in order to obtain a baseline picture against which later tests will be compared. If there is progression of nerve loss on subsequent tests, treatment will be adjusted. The GDx and OCT tests are currently the most sensitive tests available for detection and follow up of glaucoma. They are positive early, before the nerve changes appearance, before the Visual Fields test becomes positive and long before you have significant vision loss.

The GDx test and OCT tests measure how many nerve fibers still remain. The Visual Fields test checks the nerve function. These tests measure different aspects of glaucoma damage and both types are necessary for the best glaucoma care.

At each visit you will be told when to come back for another eye exam. Write that date in your calendar. For your 6 month visit we will send you a postcard to remind you to schedule your exam. If, for any reason, you do not get a reminder please check your calendar and call us for an appointment anyway.

There is some association between diabetes and glaucoma. It may be prudent to have your doctor check you for diabetes.

Glaucoma tends to run in families. Brothers and sisters of glaucoma patients are 20 times more likely to develop glaucoma than people without family history of glaucoma. Children of glaucoma patients have an almost 10 times greater chance of developing glaucoma.

Your blood relatives should be checked for glaucoma. Measuring the eye pressure is a common screening test for glaucoma, but is not enough. For a variety of reasons it misses up to one half of glaucoma cases. It may be fine for people who are not at high risk for glaucoma (do not have family members with glaucoma). Glaucoma patient relatives need periodic exams with detailed evaluation of the nerve, possibly including the Nerve Fiber Analysis (GDx or OCT tests).

Glaucoma is a lifetime condition. Over time the cost of drugs is high. You will often pay less for drops if you shop around. If cost is a major problem, you may consider laser treatment. Argon Laser Trabeculoplasty (ALT) and Selective Laser Trabeculoplasty (SLT) are well established, painless, in-office procedures. They are commonly done on patients who do not respond well to eye drops, have problems administering them, tend to forget to use them, can not tolerate them, or are otherwise unable to comply with eye drops treatment for any reason. Some pregnant women choose the laser procedure to avoid the use of medications during pregnancy. Initially, laser controls the pressure in 4 of 5 patients. The effect may fade with time but, one year after laser surgery, the pressure still remains under control in about one half of patients. ALT and SLT surgery are covered by medical insurance and Medicare.

To instill eye drops:

  1. Wash hands
  2. Invert the closed bottle and shake once
  3. Sit down, lean back, tilt your head back, look up toward your forehead
  4. With index finger pull down lower lid to make a pocket for the drop
  5. Hold bottle over the eye between thumb and index finger of the other hand. May rest one finger or thumb against bridge of nose or brow. Do not touch the tip of the bottle with lid or finger.
  6. Squeeze a single drop (extra drops won't hurt but are wasted)
  7. Press your index finger to the inner corner of the eye for 20-30 seconds to block the tear duct and prevent medication from draining away.
  8. Close the eye (while keeping the tear duct blocked) to distribute medicine evenly. Do not squeeze the eye shut (it will expel the medication from the eye).

If you are using more than one kind of drops wait at least 2 minutes and, preferably, 5 to 10 minutes between drops.

To prevent contaminating the solution in the bottle do not allow the tip to touch the eye, hand or any other object. This is critical if you also have an eye infection

Soft contact lenses absorb, and are stained by the benzalkonium preservative found in most glaucoma drops. Remove lenses before instilling glaucoma drops. Wait at least 15 minutes before reinserting the lenses.

Cold remedies containing Pseudoephedrine, Phenylephrine or Neo-Synephrin; anti-histaminics Chlorpheniramine, Diphenhydramine or Benadryl and overactive bladder remedies such as Detrol often carry a warning telling you not to use them if you have glaucoma. These warnings do not apply to your type of glaucoma. You can safely use them for a week or two; beyond that, monitoring may be needed.

Steroids (cortisone, hydrocortisone, prednisolone, etc.) tend to increase eye pressure.

If you need to use steroids for longer than 2 weeks, your eye pressure has to be monitored during use. This includes use of steroid-containing eye drops, steroid pills, and steroid creams over large areas of the body. Use of steroid creams for small skin lesions is unlikely to cause increased pressure. If you are taking steroids now, do not discontinue them - just tell us about it and come in for a re-evaluation. Steroid use for less than 2 weeks generally does not require special monitoring of eye pressures.

By following our recommendations, and faithfully complying with monitoring requirements, the chances of preserving your vision are excellent. Because chronic glaucoma has no symptoms, and people are not able to detect loss of vision, some patients are tempted to lower their guard. That's a big mistake - don't make it!

I trust that I have anticipated and answered most of your questions. If not, please let me know. Thank you for choosing Southland Eye Clinic for your eye care.

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