Lasers, Medications and Surgery

Chat Highlights
Lasers, Medications, and Surgery
October 25, 2000
Norma Devine, Editor

On Wednesday, October 25, 2000, Dr. Rick Wilson, a glaucoma specialist at Wills, and the glaucoma chat group discussed “Lasers, Medications, and Surgery.”

Moderator: Doctor, before we start discussing the topic, what can you tell us about optic nerve regeneration?

Dr. Wilson: The company that is closest to developing this technology has been able to re-grow a severed spinal cord in the rat. The technology is based on stem cell research, so let your legislative representatives know that this is important to you if you want to see anything in the next five years or so.

Moderator: Thank you. Who wants to ask the first question about medicine, laser and surgery?

P: When is laser preferred over medicine?

Dr. Wilson: The laser is preferred over medicine usually when the medicines are intolerable to the patient or are ineffective. Usually I will try three or so medicines, and if I’m not having much luck, and the patient is a good candidate, then I will try laser.

P: I’ve read that laser is good for only one to five years, in most cases. Does it ever work for long periods, like 20 years? I’m looking for a way to get off medications. I have open-angle glaucoma.

Dr. Wilson: Usually one to five years.

P: Why is it that some people can’t have the laser and have to go straight to a trabeculectomy. It seems as if there are more side effects with a trabeculectomy than with laser surgery.

Dr. Wilson: The argon laser trabeculoplasty (ALT) works best in folks over 65, in those with normally open angles, and with pigment trapped in the trabecular meshwork. The brown or black color of the pigment absorbs the laser.

P: If a medicine stopped working and the patient stopped using it for a while, then restarted it, would that make it effective again?

Dr. Wilson: Just for a short time.

P: What is corneal edema?

Moderator: The swelling of the cornea. It can be transient, but usually is long-lasting, depending upon the cause. Usually corneal edema gives a blurry look to the vision and a bumpy, uneven look to the cornea.

P: Can these blister-like things be over the white part?

Dr. Wilson: No, just the clear part.

P: Does Fuchs’ cause the cornea to blur?

Dr. Wilson: Yes.

P: What is the cause of corneal edema?

Dr. Wilson: A drop-off in the number of cells lining the cornea.

P: My doctor says my pressure must come down or more surgery is the next step. I’m now on Cosopt, pilocarpine, and Timoptic. Could you tell me something about Rescula and Betatox?

Dr. Wilson: If you are on Cosopt two times per day, additional Timoptic just adds side effects without additional pressure-lowering help. Rescula is Xalatan light, a prostaglandin analogue that is not as effective as Xalatan, but has fewer side-effects.

P: If Timoptic will not lower my pressure anymore when I am taking Cosopt three times a day, would you advise stopping Timoptic?

Dr. Wilson: Cosopt over three times per day is probably not doing anything more than two times a day unless you have a beet-red eye.

P: I was started on Alphagan and now that I am reducing my prednisone (for arthritis) my eyes are itchy, but I don’t have a skin reaction. Should I be concerned?

Dr. Wilson: Yes, if your eyes become uncomfortable and slightly pink, you may well have an allergy to Alphagan. About 12% or more of patients are allergic to Alphagan.

P: I’m taking Xalatan and Alphagan, because my pressure shot up and the peripheral field shows deterioration. What’s probably next, a third medicine or some kind of surgery?

Dr. Wilson: A third medicine.

P: I’m using Xalatan and Azopt after laser surgery for exfoliating glaucoma. My concern is that these drugs will damage the eyeball, making the inevitable trabeculectomy less successful.

Dr. Wilson: That is probably true. However, the changes in the conjunctiva are relatively mild. I would continue the medicines.

P: How long after a trab does it take before the vision is not too blurry to read?

Dr. Wilson: The time until return to good vision is quite variable. Often a change in glasses is required.

P: For how many years is a trab effective?

Dr. Wilson: It used to be said that a trabeculectomy lasted eight years on average. With the use of antifibrotic agents, that span may be quite a bit longer for many people.

P: Have you ever seen a Rieger’s syndrome or Axenfeld Riegers patient? I’m at a loss about what to do next. My daughter is 18, she has had double Molento shunts, trabs, YAG laser, 5- Fu, and I don’t even know what else has been done.

Dr. Wilson: I have a very large children’s glaucoma practice, so I see them often. Yes, Reiger’s syndrome is a difficult glaucoma to control, but no more difficult that many of our other kinds of glaucoma.

P: What do you do when you’re on every medicine, no laser has worked and surgeries have failed?

Dr. Wilson: There is always a different type of surgery to try next.

P: What is the best eye drop for normal-tension glaucoma for someone with low blood pressure (90/60)?

Dr. Wilson: Probably dorzolamide (Trusopt), Azopt, or Xalatan.

Moderator: Are drops always the first line of defense?

Dr. Wilson: In the U.S., drops usually are used first for open-angle glaucoma. In patients with narrow and occludable angles, the laser is the first line of defense.

P: In Great Britain, at what age (how young) do they do surgery rather than drops?

Dr. Wilson: They often try a drop first and then turn to surgery, but may skip the drop. No age limit I know of.

P: My doctor is too interested in Lasik procedures. I will seek a specialist in another city.

P: My doctor is a glaucoma specialist, but he’s opening a Lasik clinic on the side.

P: One of the top glaucoma docs in this town has done the same thing.

P: That’s were the money is.

Dr. Wilson: Yes, unfortunately, glaucoma specialists are about the lowest paid of the ophthalmologists, so some are turning to Lasik to help support their glaucoma work.

Moderator: What would you consider a full glaucoma evaluation?

Dr. Wilson: Examination of the pupils, eye motility, lids and lashes, conjunctiva, cornea, anterior chamber depth and inflammation, iris, lens, nerve, retina and angle.

P: What are side effects of Trusopt and Azopt?

Dr. Wilson: Usually, just local allergy, although a systemic allergy is possible.

P: Do people experience pain with open-angle glaucoma? If so, what kind of pain is it? Is it inside the eye, near the eyebrow, or cheekbone, etc?

Dr. Wilson: Usually, there are no symptoms with open-angle glaucoma. Symptoms may be from dry eye, the drops, etc.

P: If my pressure stays high and my field in three weeks is worse, should I consider surgery or wait?

Dr. Wilson: Without seeing you, I cannot treat you over the internet except to educate you on glaucoma and its treatments.

Moderator: Imagine if you could evaluate our eyes over the net?

Dr. Wilson: I do evaluate consults sent in by other doctors with images over the net or in real-time over two ISDL lines.

Dr. Wilson: Time to roll. I’ve been gone for five days. Next week, let me talk more about the new things I saw at the American Academy of Ophthalmology meeting.

P: My computer has been acting up tonight and I I’ve had trouble following the messages on screen. I look forward to reading the chat highlights.

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About the Author:

The Glaucoma Service Foundation’s mission is to preserve or enhance the health of all people with glaucoma and to provide a model of medical care by supporting the educational and research efforts of the physicians on the Wills Eye Institute Glaucoma Service, the largest glaucoma diagnosis and treatment center in the country.
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