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MEDICAL EYE PROCEDURES REFRACTIVE PROCEDURES COSMETIC PROCEDURES
 
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Glaucoma | Philadelphia | Marlton

     
 

Glaucoma is a disease in which damage occurs to the optic nerve, the structure that carries visual messages from the eye to the brain. Most often, although not always, this damage results when the pressure of the nourishing fluid that circulates in the eye is too high for the delicate nerves and blood vessels near the optic nerve. The high pressure occurs most commonly in two ways: Chronic open angle glaucoma and acute narrow angle glaucoma.

Open Angle Glaucoma

Glaucoma Treatment | Philadelphia | MarltonIn open angle glaucoma, the fine drainage sieve of the eye becomes clogged, usually for unknown reasons. This is the most common type of glaucoma. Its onset is subtle and it is sometimes known as the "silent thief in the night" of vision. Because it is painless, people are unaware of the destruction of their side vision until very late. Therefore, regular eye examinations are necessary to detect and start treating glaucoma in the early stages.

In open angle glaucoma, the "beams" of the sieve through which the fluid exits the eye thicken and lose their rigidity or stiffness. In open angle glaucoma, we are treating the pressure to prevent its strangling the structures of the eye, but have no way to treat the still unknown cause. Occasionally, we do find a treatable cause, such as inflammation, and are able to treat that cause directly.

Open angle glaucoma, with its readily available but clogged drainage sieve, can be treated initially with either eyedrops or laser treatment or both. Since glaucoma tends to progress over the years, more than one kind of eyedrops, with or without laser, is often needed.  Glaucoma surgery may be necessary when these treatments are insufficient.

Laser Trabeculoplasty

Laser   Trabeculoplasty | Glaucoma Treatment | Philadelphia | MarltonLaser Trabeculoplasty is the laser treatment for open angle glaucoma in which the spots of highly focused light are placed within the drainage sieve (trabecular meshwork). The pigmented cells of the meshwork are heated with the Argon laser. With the Argon laser the collagen fibers (beams) stiffen and open the drainage holes more effectively. A more recent treatment, Selective Laser Trabeculoplasty, affects the pigmented cells without damaging the collagen framework, and both lasers increase the metabolic efficiency of the sieve. Selective laser trabeculoplasty can be used in peoples whose Argon trabeculoplasty has worn off and it can be repeated as needed.

Narrow Angle Glaucoma

Narrow Angle Glaucoma Treatment | Philadelphia | MarltonIn narrow angle glaucoma, access to the drainage sieve is impeded, usually by the iris (colored part of eye as blue eyes or brown eyes) when it dilates or opens to let more light in under circumstances of darkness, fight or flight, or excitement. Narrow angles are seen in people who are born with short eyes and tend to be farsighted, seeing more easily in the distance than at near. Everyone's natural lens enlarges throughout life, adding layers like an onion. As the enlarging lens pushes the iris forward, it overlaps the entrance to the drainage sieve in people with short eyes. When the pupil dilates, it is as though the iris were a thin sheet of paper dropping over a drain opening.

The iris suddenly plugs the entire fluid drainage mechanism, causing a painful and sudden loss of vision. It is in this situation that pressure can rise rapidly, causing pain, a red eye, brow ache and sometimes nausea, and can result in devastating visual loss in a short time (acute angle closure glaucoma). In people with narrow angles, the problem is best prevented by making a small hole in the iris with the YAG laser (iridectomy). If an acute angle closure glaucoma attack occurs, medications must be used first in order to be able to perform the laser iridectomy. Sometimes people need eyedrops to maintain a safe low pressure even after the necessary laser iridectomy.

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Lasers For The Treatment Of Glaucoma

We at Nevyas Eye Associates use the new frequency doubled YAG laser which targets just the pigmented cells of the drainage sieve for open angle glaucoma and the YAG laser for the treatment of narrow angle glaucoma.

Laser treatment of the eye is mostly painless. After instillation of anesthetic eyedrops to numb the eye, a special contact lens with a thick fluid in it is placed on the eye. The patient then either feels a series of "pops" in the eye with the YAG laser or sees a series of bright lights with the frequency doubled Argon laser in selective laser trabeculoplasty. Afterward, the fluid-filled laser lens is removed and the excess thick fluid is washed out. The treated eye will be slightly blurred from medications for about a day, but most people resume normal activities immediately, including driving. Usually, steroid drops are used in the laser treated eye for a few days after the treatment.

Occasionally, an iridectomy for narrow angle glaucoma cannot be completed at a single sitting because liberated debris blocks the doctor's view, and needs to be finished another day. Once an opening is made, it is effective immediately. After laser trabeculoplasty for open angle glaucoma, it takes about one month for the effect to be measurable.

If the pressure in the eye cannot be kept low enough with drops and laser to prevent progressive damage, surgery may become necessary. Usually an alternative pathway for the drainage of circulating fluid is created by removing a small piece of the inner half of the white sclera in a small area as well as the adjacent small piece of iris, and the outer half of that piece of sclera is loosely sewn back into place so the fluid can get out from under the loosely sewn flap. The conjunctival edges (clear tissue over the white sclera) are then resewn together tightly. Thus, the fluid leaves the inside of the eye through a new pathway, under and within the tissue around the eyeball, but it stays under the outer layer and does not become part of the tears.  This operation is called “Trabeculectomy.”

Sometimes, an antimetabolite medication such as Mitomycin-C (MMC) or 5 Fluorouracil (5FU) is used at surgery to try to keep the edges of the scleral flap and conjunctiva from healing together completely and stopping the flow. These compounds enhance the pressure lowering effect of the procedure.

If the trabeculectomy scars down and the eye pressure rises, inserting a special plastic or metal shunt drainage device may become necessary to drain fluid out farther back in the eye.  Sometimes a shunt device is used for the initial surgery.

Some people in whom no high pressure is ever found still develop glaucoma-like damage to their optic nerve (normal tension glaucoma or low tension glaucoma). We look for treatable causes such as inadequate blood flow to the head because of blood vessel problems, diabetes, problems with thickness and clotting of blood as well as rare brain problems. Usually no treatable cause is found, and either that eye is vulnerable at ordinary pressures or the pressure is spiking high at other times in the 24-hour period. Such eyes are helped somewhat by lowering the eye pressure. In people with very thin corneas, the eye pressure is actually higher than measured, and in people with very thick corneas, the eye pressure is actually lower than measured. We measure the thickness of the cornea of all glaucoma suspects in order to obtain a precise measurement of the actual pressure. 

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Glaucoma Diagnosis

Glaucoma Treatment | Philadelphia | MarltonThe diagnosis of open angle glaucoma is made by combining the results of examination of the eye and special tests. Eye examination includes the study of the front and back surface of the cornea (clear window), the estimation of the amount of space between the cornea and the lens of the eye (anterior chamber depth) and evaluation of the size of the angle between the cornea and the iris with a special lens. After dilation of the pupil, the optic nerve is examined for evidence of damage. The eye pressures are measured with a tonometer before and after dilation.

Special tests include the Optical Coherence Tomography (OCT), Heidelberg Retinal Tomograph (HRT), GDx nerve fiber layer analysis, visual fields, and optic nerve head photos.

Nerve fiber layer analysis measures the thickness of the retina's nerve fiber layer just before it becomes the optic nerve carrying visual messages back to the rest of the brain. Nerve fiber layer thinning is one of the earliest signs of glaucoma, and thus this new instrument is the most sensitive way to diagnose glaucoma at its earliest and most treatable stages.

The retinal tomograph (HRT) measures the amount and proportion of healthy tissue in the optic nerve head and is used to help diagnose early stages of glaucoma and to signal change in glaucoma patients at the earliest stage so far.

Visual field testing measures the sensitivity of one's side or peripheral vision, the area usually affected the earliest in glaucoma. This is done by shining lights of varying dimness from different directions while the patient looks straight ahead at a central dot. The visual fields and nerve fiber layer analysis are repeated at six to twelve month intervals looking for progression signifying the need to begin or increase glaucoma treatment.

Optic nerve head photos enable us to keep a visual record of the appearance of the face of the optic nerve, so that when we examine the eyes we can compare what we see with the previous appearance and treat if progressive damage is seen.

Who Gets Glaucoma?

Risk factors for glaucoma:

Family history Previous eye surgery
African descent
Myopia
Diabetes
Nearsightedness
35-40 and older
Previous eye injury
Farsightedness
Previous eye inflammation/infection
Arthritis
Steroid use, oral or inhaled
High blood pressure

If You Have No Risk Factors for Glaucoma*
If You Have Risk Factors for Glaucoma*
Under 45 Years old:
Examination recommended Every 4 years
Examination recommended every 2 years
45 years & older:
Recommended Every 2 years
Recommended every year

If you are diagnosed with glaucoma, your doctor will set a treatment cycle based upon your medical needs.

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Because there are no symptoms associated with glaucoma, regular eye examinations by an eye doctor are critical. There is no eye pain, eye redness or vision reduction. Vision loss occurs very late in the disease process. However, if the disease is monitored closely, patients seldom go blind. Thus, it is essential in making a diagnosis of glaucoma that the intraocular pressure, in conjunction with the appearance of the optic nerve and its fibers and visual field testing, is evaluated.

What does Pre-Glaucoma Mean?
Two findings at examination are associated with increased likelihood of development of glaucoma over time.

  1. Some people have no detectable optic nerve damage or visual field loss but have elevation of intraocular pressures. These people are called ocular hypertensives.
  2. Some people have enlarged nerves and/or elevation of intraocular pressures without detectable visual field damage. These people, as well as ocular hypertensives, are called "glaucoma suspects."

In the past, the intraocular pressure was considered a reliable way of detecting glaucoma. Intraocular pressures vary at different times of the day. Some optic nerves are not damaged at higher-than-normal intraocular pressure while other optic nerves are damaged by relatively lower-than-normal intraocular pressures. Thus, it is essential in making a diagnosis of glaucoma that the intraocular pressure, in conjunction with the appearance of the optic nerve and visual field testing, be evaluated.

Does exercise lower intraocular pressure?

Maintaining a normal blood pressure is important in minimizing damage in glaucoma, and an aerobic exercise program is an important part of blood pressure control. However, in certain types of rarer glaucoma, such as pigmentary glaucoma, liberation of large amounts of pigment during jogging may clog the trabecular meshwork drainage sieve, causing the intraocular pressure to rise significantly.

Does marijuana help glaucoma?

Marijuana can reduce intraocular pressure, but the dose for glaucoma would cause brain and liver damage, so it is not used for glaucoma treatment.

What are the possible side effects of the various eyedrops used in the treatment of glaucoma?

Any eyedrops may cause stinging and red eyes in some people.

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Beta Blockers (timolol, betaxolol,  carteolol)

may make asthma worse, slow pulse, increase blood lipids, occasionally worsen congestive heart failure. May cause hair loss, depression, decreased sex drive.
Betaxolol is somewhat less of a problem in asthma, and carteolol slows the pulse less and increases blood lipids less.

Prostaglandins (Xalatan, Travatan)

may cause darkening of iris and eyelash color, eyelash lengthening, runny nose and cough.

Sympathomimetics (brimonidine, Iopidine, dipivefrin)

may cause increased heart rate, increased blood pressure, red eyes, conjunctival inflammation. Increase of rate of allergy development.  Brimonidine may cause excess fatigue (as well as all of the above).

Carbonic Anhydrase Inhibitors (Trusopt and Azopt eyedrops, acetazolamide (Diamox) and methazolamide (Neptazane) tablets.

Both drops and pills may cause tingling of the hands and feet, appetite loss, metallic taste and mild sedation.  Cross reaction with sulfa allergy is occasionally seen.  Tablets may rarely cause kidney stones and anemia

Muscarinics (pilocarpine, echothiophate)
can cause increased nearsightedness and brow ache.


The Nevyas Eye Associates Glaucoma Services

Like diabetes, open angle glaucoma is a disease which can be controlled but not cured. Early diagnosis, close followup care, and lifetime monitoring are key in maintaining good vision. Using eyedrops becomes as normal a habit as brushing one's teeth, and people continue to lead normal active lives with glaucoma.

Nevyas Eye Associates ophthalmologists are trained to treat glaucoma. In many cases, the treatment can be successfully achieved with eyedrops and or laser. In more advanced cases, surgical operations must be performed.  Most medical and laser glaucoma treatment is performed by Drs. Joann Yaskin Nevyas, Mitchell Stein and Vipin Goyal.  Filtration surgery for glaucoma is performed by Dr. Herbert Nevyas.  Most filtration surgery is now performed by trabeculectomy using the new Ex-PRESS™ microscopic stainless steel shunt.

Contact us to learn more on Glaucoma

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Nevyas Eye Associates has a team of board certified ophthalmologists serving Philadelphia, Marlton, Haddonfield, Cherry Hill, Bala Cynwyd, West Manayunk, Center City, Rittenhouse Square, Northeast Philadelphia Airport, NE Philadelphia Airport, Pennypack, Ashton-Woodenbridge, Ashton-Wooden Bridge, and the surrounding area.
www.nevyas.com
Main Office/ Surgery Center: Nevyas Eye Associates | Two Bala Plaza 333 E. City Avenue, Bala Cynwyd, PA 19004 | Tel: (610) 668-2777
Northeast Philadelphia Office: Nevyas Eye Associates | Central Square 2465 Grant Avenue, Philadelphia, PA 19114 | Tel: (215) 673-2020
New Jersey Office: Nevyas Eye Associates | Greentree Executive Campus 1001 Lincoln Drive West - Suite E, Marlton, NJ 08053 | Tel: (856) 985-9797
 
 
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