Glaucoma Doctors Answer Questions from Patients

The EyeFAQ series of videos are produced by Glaucoma Research Foundation (GRF) to answer frequently asked questions about glaucoma. Leading glaucoma specialists answer questions from patients about medication side effects, whether working long hours at a computer makes glaucoma worse, the meaning of “a glaucoma suspect,” and how to prevent infection after a trabeculectomy procedure.

This October 2020 EyeFAQ Roundup features Andrew Iwach, MD from the Glaucoma Center of San Francisco, Davinder Grover, MD, MPH from the Glaucoma Associates of Texas, and Mark Werner, MD from Delray Eye Associates in Delray Beach, Florida. All three are members of the GRF Ambassadors, a national leadership group of eye doctors dedicated to improving access to education and information for all glaucoma patients.

Mark Werner, MD: Any eye drops can cause allergy, which may consist of itching, redness, and scaling around the eyelids. And this may sometimes develop after years of using a medication. The vehicle or preservative that medications are contained in may cause irritation and inflammation on the surface of the eye, which may worsen dry eye symptoms, and also may impact the success of future glaucoma operations. Beta blockers, including Timolol may affect breathing in patients with asthma and COPD, and may be used very cautiously in these patients, if at all. And may also reduce heart rate and blood pressure.

Alpha agonists, including brimonidine or Alphagan, may cause young children to stop breathing and are contraindicated in this population. Older adults may experience fatigue with this medication.

Prostaglandins such as latanoprost could cause redness in and around the eyes, permanent eye color darkening, eyelash growth, and in patients susceptible to inflammation, inflammation may sometimes worse than what these medications. A newer medication, Rhopressa, may be associated with redness as well, and also corneal deposits.

The effects of many eye drops on the developing fetus may be unclear. So if you’re a pregnant or may become pregnant, please discuss this with your doctor, as some of medications may be safer than others. Finally, if you develop any new side effects, especially after recently starting a medication, discuss these symptoms with your doctor, as many medications have both known and unknown side effects.

Davinder Grover, MD, MPH: This pandemic has just changed so many things for so many of us. And what a lot of us find ourselves doing now is doing what we are doing right now, which is at a computer, staring at a screen. And we’re doing that a lot more than we were doing pre-COVID. And some of us find ourselves at home for 8,10,12 hours a day staring at a monitor. And a lot of my patients come to me and they’re worried that possibly using their eyes too much could potentially lead to harm, or damage, and they’re worrying that it has the potential of worsening their glaucoma. And the good news is that’s not true, which is good so as far as we understand, using your eyes, does not make your glaucoma worse.

What you’ll notice though is that in patients that have glaucoma or other eye diseases, when we’re staring at a screen or doing anything that requires a lot of our attention, we don’t blink as often. So, you know, when I’m operating and there’s a key moment in surgery my eyes are wide open and then after that moment sometimes I’ll blink and let my eyes rest a moment.

When you’re really focused you don’t blink as often. And so when we’re at a computer and reading a lot, whether it’s a computer or not, even when reading a book, or a newspaper, or magazine, we don’t blink as often. And when you don’t blink as often your eyes dry out. And when your eyes dry, you get this pressure sensation and that can be misunderstood by some people.

A lot of my patients say, “Oh my goodness, my eyes, I feel this pressure, my pressure is up, it’s my glaucoma.” And you get worried, obviously glaucoma is a very scary disease. And anything that happens to your eyes, when you have glaucoma it can set off some concern.

But what I usually tell my patients to do is, now that we are working at a computer a lot, it’s very important to stay hydrated. Not soda, not diet soda, not tea, not coffee, but good old-fashioned water. Ok? So making sure you’re drinking a lot of water, and then also when you’re at a computer making sure you’re cognizant of taking some blinks every now and then. You can also use some artificial tears [eye drops].

Andrew Iwach, MD: What it really means is you don’t have glaucoma right now, but you’re at higher risk for developing the disease compared to others. And that may be related to the [eye] pressure or it may be related to your family history of glaucoma, it may be related to how your optic nerve looks. And so, what we like to do at that point is not invest in what we call therapeutics, doing something, we often invest in diagnostics. That is understanding your eye and carefully monitoring all these parameters. If things are stable we may be able to at least delay or sometimes even avoid the need for treatment.

So what should you do in the meantime? Well stay healthy. Make sure you get a physical, make sure that you’re being looked at to make sure your high blood pressure, diabetes, cholesterol is being looked at. If you’re smoking please stop. And if you don’t smoke, don’t start. Look at general health things. Exercise is a good idea. Nutrition, great idea. General health tips that help the rest of your body, help your eye.

Make sure to have the regular follow up with your eye doctor. That is absolutely critical. If you have been identified at a higher risk for glaucoma, you are a ‘moving target.’ Things change. So as long as you get checked on a regular basis, if a change is detected then we’ll step in, and maybe start you on a [medication] eye drop or maybe do a laser treatment.

Davinder Grover, MD, MPH: There are certain things you need to be aware of. There is a risk, a lifelong risk for an infection. And that’s because there’s an external drainage from the inside of the eye to the outside of the eye. And the actual numbers are about 1% per year. But there are certain things that have been modified with our technique, how we make our incision, what kind of anti-scarring medication we use and how that anti-scarring medication is applied that have now minimized the potential risk for infection.

But although we’ve minimized it, it’s still a real risk that all patients that have undergone a trabeculectomy or any subconjunctival filtration procedure, such as a gel stent, need to be aware of. And so if you have a what’s called a bleb, and that’s the area where the fluid is flowing from inside of the eye to the outside of the eye underneath the skin. It’s called a bleb and you’ll hear your doctor say that on occasion. And if you have a bleb, then you need to be aware of the potential for an infection.

So unlike your neighbor that has never had a glaucoma surgery, if their eye’s red, you can kind of chalk it off to some irritation or maybe a pink eye or something. But if you have a bleb and you have a pink eye or an eye that’s irritated or tearing, you need to see your ophthalmologist because that could be the first sign of an infection.

If it gets worse, then the eye can get more red, more irritated, more tearing, more sensitive to light, and then you can have a drop in vision. All those are signs that things are getting worse. So what I tell my patients is you need to be aware of your eye, understand that because of this surgery, you’re at our lifelong risk for infection. And if you have any tearing or redness or pain, you need to call your ophthalmologist immediately.

Certain activities you should use caution with once you have had these kinds of surgeries. I would strongly discourage my patients from scuba diving, from swimming in a pool or a pond and opening your eyes underwater. Sometimes you can swim still, but use goggles that may not have that suction, but maybe the foam seal. Again, everybody has a different style. So make sure you run this by your ophthalmologist or your glaucoma specialist before you take these. But I’m very conservative with my patients when it comes to protecting them from infection.

And I strongly discourage them from having any kind of activity where they are at risk for any kind of bacteria or dirt in the eye. So dusty environments being outside around a lot of dirt and dust, swimming in a pond, opening your eyes underwater. All those things you need to be extremely careful of as well as contact lens wearing. I usually don’t like my patients to wear contact lenses after having a trabeculectomy or even having a bleb.

Posted on November 17, 2020. Reviewed October 21, 2021.