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FEDERAL EMPLOYEE'S
HEALTH AWARENESS FORUM
Glaucoma - A Patient's Concerns and Issues
My wife Mary was diagnosed with Glaucoma about 10 years ago at age 45. This section
of our Health Awareness Forum will follow Mary’s case from its inception in 1995 to
present day treatment. These articles document the many issues we encountered with
diagnosis and treatment over the years and the dire consequences of this disease. If
Glaucoma is not treated timely it can lead to blindness. Parts I through VI of this series
discuss Mary’s Glaucoma diagnosis, treatments and surgeries, and summary of our
findings. They also present treatment options and things to consider if you are
diagnosed with this disease.
Disclaimer
Readers are strongly cautioned to consult with a physician or other health-care professional
before using any information contained in this forum. No forum can substitute for professional
care or advice. Extreme caution is urged when using the information contained in the articles that
are posted on this site. The authors and publisher are not engaged in rendering medical services.
If medical problems appear or persist, the reader should consult with a qualified physician or
other health-care professional. Accordingly, the authors and publisher expressly disclaim any
liability, loss, damage, or injury caused by the contents posted on this health care forum.
Copyright by Dennis V. Damp. All rights reserved. No part of these articles may be
reproduced or transmitted in any form or by any means, electronic or mechanical.
Including photocopying, without the written permission from the author, except for
the inclusion of brief quoted excerpts or in reviews. Contact Bookhaven Press at
[email protected] or write to Bookhaven Press LLC, P.O. Box 1243, Moon
Township, PA 15108. Web sites may link to these pages and include a short review
without prior permission as long as they give full credit to this forum with the link.
TABLE OF CONTENTS
Glaucoma - A Day of Reckoning - Part I
(2)
A New Doctor and SLT Laser Treatments - Part II
(3)
Iridotomy & SLT Surgeries - Part III
(5)
Taking Control of the Situation - Part IV
(6)
The Beat Goes On---and On - Part V
(10)
Less Medicine – MORE benefit!!! Part VI (1/2/07)
(14)
The End Game – Off Meds & Pressure Managed Part VII (3/8/08)
(15)
Conclusions and Summary - Part VIII
(19)
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Glaucoma – The Day of Reckoning - Part 1
A Glaucoma Patient’s Perspective and Observations
Glaucoma is a disease that damages the optic nerve. This disease is often referred to as
the “silent thief” because many don’t know they have it until much of their peripheral
vision is lost. This is just one reason why you should schedule time for an annual eye
exam. The Optometrist not only checks your general vision they also check your
Intraocular Eye Pressure (IOP), look at the optic nerve with an Ophthalmoscopy, and
use a mirrored lens called a Gonioscopy to view the angle where the cornea and iris
meet. In most cases high IOP pressure damages the optic nerve over time.
I interviewed Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified Ophthalmologist and
Medical Director of the Florida Eye Center in October. He stated that, “glaucoma causes
the drains inside the eyes to clog up. The eye makes fluid internally and the pressure
can’t escape causing nerve damage and eye sight loss.” Doctors use drugs, laser, and
surgical procedures to improve the flow of the fluids in the eye and reduce pressure.
There are also cases of what is called low tension glaucoma where nerve damage
progresses even with very low IOPs. My wife was diagnosed with Primary Open Angel
Glaucoma (POAG), Narrow Angle Glaucoma, and two years ago she was diagnosed
with a rare optic nerve birth defect called Schisis. There are many sub classifications
within these groups. Many medical facilities and Internet web sites provide abundant
information on this disease including the University of Pittsburgh Medical Center, Florida
Eye Center, University of Maryland Medicine, and Glaucoma Associates of New York
web sites to name a few.
My wife went for a routine eye exam in 1995. She was experiencing what is called
“ocular Migraines,” strange visual disturbances usually lasting for short durations without
a headache. Her eye sight checked 20/20 however she had elevated IOPs of 20R/21L
millimeters of mercury (mmHg). Average IOP ranges from 14 to 20 mmHg. High IOP
readings are one of glaucoma’s three primary indicators. To make a Glaucoma
diagnosis the doctor measures the patient’s IOP with a Goldmann Tonometer, performs
a visual field test, and checks the condition of the optic nerve. High IOP in and of itself
doesn’t confirm a glaucoma diagnosis. Pressure readings are relative and effected by
many variables. More on this later.
Mary was referred to an Ophthalmologist and he measured her IOP at 26R (right eye)
and 27L (left eye) mmHg and ordered a visual field check. The visual field check showed
indications of optic nerve damage and the doctor prescribed Timoptic, a beta blocking
agent. Mary had allergic reactions to the drops and her IOP didn’t decrease so they
prescribed Trusopt which also caused severe allergic reactions.
Through the course of the first year to 16 months of treatment she was prescribed pretty
much all of the available drugs, sometimes two at a time, with little to no benefit and the
side effects such as red eyes, facial swelling, hives, rashes, cramping, respiratory
problems, and general eye irritation were severe. Her eyes were constantly irritated; she
suffered from upper respiratory problems, and had to avoid smoke of all types. It
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appeared that the more changes they made to her treatment the higher her IOP went
and after about 16 months her eye pressure was in the mid 30s in both eyes.
The doctor recommended and performed Argon Laser Trabeculoplasty (ALT) Laser
surgeries on both eyes about a year and a half after initial diagnosis and the pressure
fell to the low to mid 20s. This procedure burns holes in the trabecular meshwork to
improve eye drainage and reduce pressure. New procedures have pretty much
eliminated the use of the ALT for this purpose. Most doctors now use the newer and
much less invasive Selective Laser Trabeculoplasy SLT for this purpose. More on this
later.
NOTE
Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified
Ophthalmologist and Medical Director of the Florida Eye Center,
recommends the SLT treatment as the preferred first choice to
lower IOP. He believes, and my wife and I concur, that you should
do everything possible to avoid caustic drugs. All of the drugs
currently available for glaucoma have potentially serious side
effects. They didn’t have the SLT option when my wife was first
diagnosed.
She had to continue taking Xalatan drops, a prostaglandin with many side effects
including respiratory problems, etc. Her pressure fluctuated in the safe range until about
two years ago.
A New Doctor and SLT Laser Treatments - Part ll
A Glaucoma Patient’s Perspective and Observations
My wife and I learned a costly and valuable lesson. Don’t assume anything, research
your condition online, and get a second opinion. Anytime you are diagnosed with a
chronic disease, illness, prescribed medications, or recommended for surgery get a
second opinion. At the very least, research the procedure or medicine online. You are
potentially impacting the quality of your life every time you take medications or have
surgeries or out patient procedures. You need to verify that all diagnostic tests have
been done – under the right conditions – BEFORE proceeding and evaluate all other
treatment options. You also need to evaluate:
1. The effects life style changes can have on your IOP
2. IOP home monitoring options (Proview by Bausch and Lomb)
3. Vitamin and mineral supplements
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4. Whether or not you are simply ocular hypertensive (The OHTS Study)
5. The effects of stress, caffeine, and other substances have on your IOP readings
and much more.
6. Exercise
Look before you leap and you will not be sorry later.
We didn’t have enough information ten years ago or knowledge to ask her first doctors
critical questions or question the integrity of tests. The internet has changed all of this
and now you can research about anything online with success.
Several years ago we elected to go to another Ophthalmologist to explore new IOP
lowering techniques. Mary’s current doctor had been recommending invasive Filtering
Microsurgery Surgery since she had the ALT laser surgery in 1997. The surgeon
operates on the eye with a scalpel to create a new drainage structure. Patients typically
loose 10% or more of their vision immediately with this surgery and they are highly
susceptible to cataracts and other serious complications.
I was researching my wife’s condition online and discovered that many doctors were
having great success with the new Selective Laser Trabeculoplasty (SLT) laser
surgery. Mary’s doctor didn’t have the SLT Laser and could not do the surgery. This new
procedure stimulates the cells in the trabecular meshwork, located in the angle between
the cornea and the iris, to increase their fluid pumping action without damaging the
meshwork. Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified Ophthalmologist and
Medical Director of the Florida Eye Center offered this excellent analogy of how this
works. He stated that the SLT’s red laser light cleans out the blockage by agitating the
clogged material in the drainage system. “It’s like thumping dried mud until it breaks up
the clog into sand so the body can wash the debris out of the system.” The SLT can be
repeated and does not damage the meshwork unlike the ALT laser treatment that
physically burns holes in the meshwork. ALT surgeries can’t be repeated.
Her new doctor took extensive tests including nerve density, pachymetry cornea
thickness readings, and OTIScans (an ultrasound of the eye) that showed the complete
eye structure and can reveal conditions such as pupillary block and plateau iris
components. The test results caused Mary and I to question much of what had
transpired over the past 8 years. Her optic nerve was thick and healthy except for a
small birth defect in the right eye – Schisis, a rare optic nerve defect, her corneas were
thicker than normal which meant her actual eye pressure was lower than what the
Tonometer was reading in the doctor’s office. We learned about the Goldmann
Tonometer IOP adjustment factors from my optometrist by chance. The OTIS scan
proved that her angles were very narrow and needed immediate iridotomy surgeries to
avoid the possibility of angle closure. The doctor wouldn’t do the SLT surgery until Mary
had the iridotomy surgeries. Angle closure could cause the eye drainage to plug up
suddenly resulting in extensive eye damage if not treated.
Glaucoma is diagnosed through a minimum of three tests, optic nerve damage, visual
field tests, and lastly IOP. The tests that were mentioned in the previous paragraph
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showed that even after 10 years with the disease Mary’s optic nerve was in excellent
condition except for a small birth defect on the right eye. Schisis caused the visual field
test to show loss of sight in that area. All previous perimeter tests also showed eye sight
loss limited to that area except the first one that she took under stressful conditions.
My wife initially went to the doctor to explore SLT surgery options to lower her IOP and
was now scheduled for two iridotomy surgeries the following week. We both had
reservations about the surgery because my wife’s IOP was elevated to the mid 20s and
susceptible to spiking into the mid to high 30s. At the time we were not aware that
Mary’s IOP was actually lower due to her thicker corneas. Her actual IOP (after adjusting
them for cornea thickness) in her left eye was approximately 21 mmHg and her right eye
about 24 mmHg, not the 25R/25L that the Tonometer measured. Many doctor's don't
use the adjustment factors however I believe that all eye doctors do agree that thicker
corneas can tolerate higher GAT IOP pressure readings. Even this was higher than her
actual readings and I will fully explain why in Part 4 and 5 of this series. Secondly, Mary
felt that the debris from the laser surgery, the minute pieces of tissue that remain after
the laser burned holes through the Iris to relieve the pressure and open the angles,
would clog the drainage in the meshwork further. Her doctor wasn’t concerned about this
at the time.
Iridotomy & SLT Surgeries - Part lll
A Glaucoma Patient’s Perspective and Observations
Mary’s IOP pressures were in the mid 20s, actually lower due to her thick corneas, when
she went in for the Iridotomy laser surgeries. One hour after the surgery her IOP
elevated to the high 30s. What we had feared happened. Apparently, the debris from the
holes they burned in both irises were clogging the eye drainage canals. The doctors said
that Mary was one in 100, most after surgery experienced lower IOPs. They gave her
multiple drops of various IOP lowering drugs until the pressure decreased to the low 30s
and she was advised to come back in two weeks.
Two weeks later her IOP dropped to the mid 20s and she changed medicine to Xalatan
which she tolerates a little better. She returned to her original doctor for routine checks.
After about 9 months her IOP elevated and she went back on Lumigan, a stronger
prostaglandin. The doctor again recommended Filtering Surgery and Mary insisted on
going back to the new doctor to be evaluated for SLT laser surgery.
The new doctor agreed that the surgery could help lower her pressure and Mary insisted
that they only do the SLT procedure on her right eye first, the eye with the highest IOP.
She was apprehensive after what happened with the Iridotomy surgery earlier. The SLT
surgery was painless and only took a few minutes to complete.
The surgery went well and initially her IOP dropped to the mid to high teens, actually
lower because of her thick corneas. At the two week post op visit her IOP was in the
high teens and she was advised to return in two months. At the two month check her
IOP had increased to the mid 20s. Several medical specialists and doctors took her
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pressure and each obtained widely varying IOP readings from 23/25 to 29/29. The
doctor then prescribed a second eye drop, a Beta-Blocker called Timoptic, without
preservatives. Mary had allergic reactions to this drug when she was first diagnosed with
Glaucoma and she was scheduled for a follow-up visit 4 weeks later.
Note: We were concerned about wildly varying Goldmann Tonometer IOP readings at
the doctor's office. The staff and doctors would take as many as three IOP readings per
visit and the readings increased dramatically from the first to last check, sometimes by
as much as 9 to 12 mmHg in one eye. I questioned the Tonometer calibration, the
expertise of the persons taking the tests, the procedures used, and couldn't determine
why the readings varied so much. It's hard to put any faith in a test where the readings
varied from a low of 14mmHg to 26 mmHg in the same eye within 15 to 30 minutes
between readings. Later on, after Mary started using the Proview IOP monitor, she
confirmed that her IOP readings were relatively steady and varied + or - 1 mmHg at the
most throughout the day.
I noticed one common denominator for all of these tests. The numbing drop they use
prior to taking IOP readings. The standard drug used for this is called Fluress. Could my
wife have an allergic reaction to this medication? She is allergic to the majority of
glaucoma drugs. I asked the doctor about this and he pretty much discounted it. Fluress
must be refrigerated before it is used and then after it is opened it only has a shelf life of
30 days. I sent a letter to the doctor asking him if the Fluress was outdated or
contaminated or were they using the generic brand of Fluress. The generic brands may
use Timeorsal as a preservative that causes a number of allergic reactions. I would like
to locate more information on this subject. If anyone has information or located research
that shows similar characteristics send an email message to [email protected].
There were just too many inconsistencies in what we were experiencing and Mary and I
knew for a long time now that something just wasn’t right. I know that medicine isn’t an
exact science. However, there were too many contradictions and questions that we
could not get answers to.
Taking Control of the Situation - Part lV
A Glaucoma Patient’s Perspective and Observations
Proview IOP Home Monitoring and the Ocular Hypertensive Treatment Study
Nothing seemed to be making sense with my wife’s treatment. It appeared that eye
drops increased her pressure, especially when she was placed on multiple drugs.
Surgeries that were designed to improve her IOP didn’t. Every time we went in for
checks her IOP fluctuated dramatically. Different doctors and specialist would get wildly
varying IOPs within 10 minutes of each other. We got the prescription filled but Mary
refused to take it. She wanted to wait a while to think things over. I searched the internet
for days to locate clues as to why this was happening.
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We started to ask questions, e-mailed the doctor our concerns, called the doctor’s staff
and technicians to question procedures, equipment calibration, etc. We discovered that
many factors effect IOP readings including stress, vitamin and mineral supplements,
exercise, caffeine, systemic blood pressure, menopause, and life style issues.
Prior to Mary going to her follow-up visit we sent the doctor a three page letter describing
our concerns after doing considerable research and purchasing a Proview IOP home
monitor. Mary and I thought that her IOP pressure was staying elevated all of the time.
Fortunately, Bausch and Lomb manufactures a home IOP pressure measuring device
called the “Proview” and we purchased one direct from www.drugstore.com, local
pharmacies didn’t carry it. You don’t need a prescription for this device and it only cost
$69.00 plus shipping. The doctor that frequently suggested Filter Surgery often
questioned what Mary’s pressure was on the days she wasn’t at the doctor’s office. He
was concerned that it may be going even higher. Now we could check it at home. You
can visit the Bausch and Lomb web site at http://bausch.com to review information on
this excellent device. You can also view a video on the Proview monitor online.
When my wife first went to the eye doctor 10 years ago her IOP readings were 20R/21L
(unadjusted). The average IOP ranges between 14 – 20 mmHg. Here is the kicker. We
discovered that my wife has thicker corneas than most. When we purchased the
Proview Monitor my local Optometrist checked my wife’s IOP on her Goldmann
Tonometer so that we could verify the Proview’s accuracy and establish offset factors for
home readings. She advised Mary to have a cornea thickness Pachymetry test. Thicker
corneas give high false IOP readings on the Goldmann Tonometer pressure test set. I
called my wife’s second doctor and his staff confirmed from previous tests that her
corneas were R 561 microns and L 592 microns thick which equates to an adjustment
factor of -1 mmHg in her right eye and -4 mmHG in her left eye off of the Goldman
Tonometer readings. Mary’s actual IOP (adjusted by the Duke University's IOP
Correctional values Chart) was now only reading 22/22, in the low 20s after using the
correction factors. This was confirmed on our optometrist’s Tonometer and our Proview
monitor.
Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified
Ophthalmologist and Medical Director of the Florida Eye
Center states that, “if a patient has not had a Pachymetry
cornea thickness reading nobody knows if they have a
diagnosis of glaucoma or not.” This is a very important test.
Further research uncovered information on Ocular Hypertension at the Pacific Cataract
and Laser Institute’s web site, a condition that warrants monitoring but not necessarily
aggressive treatment. We were unaware that this condition existed and the symptoms of
Ocular Hypertension fit my wife to the tee. A case study referenced on this site
presented the following clinical observations for Ocular hypertension:
·
High intraocular pressure (IOPs Over 21 mmHg)
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·
Normal ocular nerve head
·
Normal visual field
·
No response to glaucoma medications
When my wife was first referred to the Ophthalmologist ten years ago her actual IOP
was only 19R/17L (adjusted) and would not have been referred for further evaluation.
This is a double edge sword. If she would not have been referred, her narrow angle
glaucoma may not have been diagnosed with serious consequences. On the other hand,
if she hadn’t been diagnosed in her mid 40s she would have avoided the medications
that have caused her considerable hardship these past 10 years. We both believe that
her erratic eye pressure is impacted by many factors other than Glaucoma and we
believe the medications at times actually cause higher IOP readings.
Many doctors don’t adjust their Goldmann Tonometer’s (GAT) readings for cornea
thickness and we have debated this point on several visits. The Duke University Eye
Center publishes an IOP Correctional Value Chart that we use to calculate what we
believe is Mary's true IOP. The Goldmann Tonometer is calibrated for a cornea
thickness of 515 microns and the Goldmann Tonometer’s IOP readings are not accurate
for cornea thickness that varies from the calibrated standard. The Goldmann IOP
readings are adjusted from a -7 mmHg with corneal thickness of 645 microns to a +7
mmHg for corneal thickness of 445 microns. What a difference. I have read numerous
studies confirming that thicker corneas give false high Goldmann Tonometer readings.
Conversely, thinner corneas read much lower and this may be one of the reasons there
is such as thing as low tension Glaucoma. The GAT apparently can't accurately read low
tension patients pressure accurately either. Actually, we are finding that the Proview
Monitor is more accurate, has less of an adjustment factor, than the Goldmann
Tonometer. The Proview reads 2 mmHg lower in each eye and the Goldmann
Tonometer reads +1 mmHg higher in her right eye and +4 mmHg in her left eye. I
apparently have normal cornea thicknesses because my Proview IOP readings mirror
my Optometrist’s Goldmann Tonometer readings.
Side Note
After we purchased the Proview monitor we questioned why the
doctors hadn’t recommended this device to us years ago. Neither
doctor mentioned the availability of a home IOP monitor kit. We think
doctor’s may be concerned that patients will depend on this unit as
their sole IOP monitoring device or may not come in for important
recurrent checks if they use this device. We calibrated our Proview
with two Goldmann Tonometers from different offices and developed
a correction factor that is working well for Mary. It is also possible
that the Proview is fairly new and more studies are needed to
convince doctors of this excellent tools' worth.
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The more we researched and learned about Ocular Hypertension the more it made
sense. When my wife went in for her initial visual field test 10 years ago she went on the
day before Christmas and they were short staffed. She was nervous and uncomfortable
during the test and immediately questioned whether or not it would be accurate. She
also felt that the staff specialist was rushing her through the test probably because of the
holiday and we were the last ones in the waiting room. This first test indicated some
sight loss. However, all subsequent visual field checks showed loss of sight basically in
the area where the Schisis was diagnosed two years ago. The doctor confirmed that the
visual field test showed sight loss in that area so apparently her visual field checks had
been good all these years. Mary didn't have any of the diagnostic tests the first eight
years she was being treated that would have detected the Schisis, confirmed her optic
nerve density, or cornea thickness.
My wife has had reactions to all glaucoma medications and tolerates few. She did not
take the second eye drop her new doctor prescribed last visit due to her concern that her
pressure would increase as it did in the past when prescribed multiple medications.
The possibility exists that Mary’s pressure variations may be due to Ocular
Hypertension, stress, white coat blood pressure syndrome, possible negative reactions
to Fluress and other glaucoma medications, secondary issues with debris caused by the
two iridotomy surgeries, and Goldman Tonometer readings that weren’t adjusted for
cornea density.
Contradictions
1. Tests that Mary took last year indicated that her optic nerve thickness was good.
2. The perimeter tests were good except for the area where the Schisis is located. The
doctor compared the location of the Schisis and the visual field tests. Eye sight
loss was limited to the area around the Schisis and not nerve damage attributed
to glaucoma.
3. The three indicators for a diagnosis are nerve head damage, perimeter test results,
and lastly IOP. All are good except for variations in IOP. Mary’s erratic IOP may
be attributed to other factors.
4. The Proview IOP Monitor confirmed that her IOP does not vary more than + or – 1
mmHg morning to night and the longer she is away from the doctor’s visit the
more her IOP drops. It is now measuring 14R / 16L.
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The Beat Goes On.... and On............ and On.................. Part V
A Glaucoma Patient’s Perspective and Observations
The PASCAL DCT, Fluctuating IOP, and OCT Scans
Mary advised the doctor on her next visit that she didn't take the second medication that
she was prescribed. She was concerned that the medication would cause her IOP to
spike as it did in the past when on two medications. While at the office, Mary's IOP
pressure was measured three times and again with widely varying results. The first
check was R14/L14, the second check 5 minutes later was R20/L21 and the Doctor's
measurement 30 minutes later was R23/L26. We advised the doctor that Mary's IOP
was measuring R16/L18 (corrected) with her Proview monitor at home and only varying
+ or - 1 mmHg morning to night. Mary was suppose to have a series of tests taken that
day but because of all of the confusion they were rescheduled for a later date. We knew
that something wasn't right and discussed this with the doctor before leaving, again
expressing our concerns about the accuracy of the Goldmann Tonometer. The doctor
annotated in Mary's records that he would be the only one to measure her pressure on
her return visit.
That week I researched alternate IOP measuring devices and looked for cases online
that discussed wildly fluctuating Goldmann IOP measurements. Much to our surprise we
discovered that a new IOP measuring device called the Pascal Dynamic Contour
Tonometer (DCT) was available and had been since 2003 in the United States. The
device literature states, "Unlike applanation tonometers, which are influenced by corneal
thickness and other characteristics of the cornea and hence may produce misleading
estimates of IOP, a contour tonometer provides an accurate direct measurement of true
IOP which is independent of inter-individual variations in corneal properties." I
immediately checked for relevant case studies and found many that confirmed the units
diagnostic benefits over the Goldmann and other applanation tonometers. I searched for
doctors offices that were using the device and discovered that Mary's doctor had the
only one available in the Pittsburgh area. I emailed him and he agreed to use the Pascal
to check her IOP next visit.
The wildly fluctuating IOP still needed to be explained and I asked Dr. Elliot M. Kirstein,
OD, FAAO from Cincinnati, Ohio about my wife's IOP variations. Dr. Kirstein is the U.S.
Research Coordinator for the Ziemer Ophthalmic Systems, AG. He suggested what we
suspected for some time now and said, "changes like this are common with people who
tighten up temporarily causing the IOP to spike. When they relax and breath a little, it
drops. By the way, in the aforementioned case, the lower pressure would be the most
believable one." We now had confirmation from several sources on what we had been
saying for years. My wife's IOP is directly affected by her "White Coat Blood
Pressure." Anytime she gets near a doctor her blood pressure elevates substantially.
On the follow-up visit, Mary's doctor checked her eyes with the new PASCAL (DCT) unit,
the Goldmann Tonometer (GAT) and Mary took a Proview reading. The readings were
as follows:
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Tonometer
Right Eye IOP Left Eye IOP DCT Q R/L DCT OPA R/L Comments
GAT
21
23
DCT
21.7
24.9
Proview
16
17
2/1
4.2/4.5
Unadjusted
We calculate a new Proview correction factor for her doctor's GAT readings and another
taking into consideration Mary's thicker corneas. Basically, if you use a Proview IOP
Monitor at home I suggest having the doctor take your IOP readings. Take the Proview
reading just before the doctor takes the GAT reading. In the case above Mary's Proview
correction factors would be as follows:
Right Eye (Correction factor) (GAT) 21 - (Proview) 16 = 5
Left Eye (Correction Factor) (GAT) 23 - (Proview) 17 = 6
Now when Mary takes her readings we will add 5 to the right eye and 6 to the left eye
Proview readings to track the doctor's GAT (unadjusted) readings next visit.
We still believe that Mary's actual eye pressure is lower because of her thicker corneas
and due to the fact that at home her pressure reads lower. The Proview tracks the IOP
increase when she is in the doctor's office. In this case her IOP in the right eye would be
the GAT reading -1 or 20 and the left eye with a cornea thickness of 592 would be a 3.5 or 19.5. This seems to us to make more sense because the eyes are much more
balanced with the R 20/ L 19.5 reading. We use the Duke University Eye Center's IOP
Correctional Values Chart that is identical to the chart the article on the referenced web
site.
To calculate a Proview correction factor for Mary's thicker corneas
Right Eye (Correction factor for Cornea thickness of 561 microns)
(GAT) 21 - 1 = 20 - (Proview) 16 = 4
Left Eye (Correction Factor Cornea thickness of 592 microns)
(GAT) 23 - 3.5 = 19.5 - (Proview) 17 = 2.5
To compensate for cornea thickness Mary will add 4 to her right eye Proview reading
and 2.5 to the left eye Proview reading to track the doctor's GAT readings adjusted for
thicker corneas.
I believe a more accurate way to calculate the correction factor is to do a ratio that you
can use as a multiplier. For example. We know that the Proview reading of 16 in Mary's
right eye equals an adjusted GAT reading of 20. When you divide 20 by 16 you get a
multiplication factor of 1.25. This is another way to correct the Proview. When Mary's
right eye Proview pressure read 14 the next day at home her actual pressure would be
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14 x 1.25 or 17.5 mmHg. You can see there is a difference of .5 between using a
standard + 4 or the multiplication factor of 1.25. Her left eye multiplication factor would
be 19.5 divided by 17 or 1.15.
It would be beneficial if Bausch and Lomb developed a digital Proview monitor that you
could enter the correction factors in and then read the actual IOP direct. It could be
easily done with today's technology. It really doesn't matter which you use, the
multiplication factor or just add the points as described above. What matters is that you
can track your IOP at home!!! Quite a benefit and this alone was a tremendous relief for
my wife. IOP readings are relative at best and as you see in this series the readings
seldom repeat with the GAT and we have found GAT readings very erratic. All Mary and
I care about is that we can track with some certainty what's going on with her pressure at
home. With the Proview we know from experience that Mary is able to measure and
track her IOP fluctuations at home and the readings correlate to office visits if you
calculate in the correction factors. We are curious to see if the PASCAL DCT will be
more reliable and accurate.
Mary was then scheduled for a visual field test. The test showed no eye sight loss in the
left eye and only a very small amount of loss in the right eye where the schisis was
detected several years ago. The Medical Center's visual field test equipment
incorporates an internal error detection system that insures reliable results. If the patient
moves their eyes or field of vision from center during the checks the equipment detects
this and tracks the errors. If more than 4 errors are detected the test is invalid and must
be repeated. Actually, her doctor was insistent that the test was done right. Mary had to
repeat this test 4 times to obtain acceptable results.
The doctor explained that the test went well and we talked about our concerns.
Basically, we still feel Mary is primarily ocular hypertensive and she desired to get off
medications if at all possible. Previous OCT scans of the optic nerve were good except
in the area where the schisis is formed on the optic nerve in the right eye. The doctor
indicated that Mary had a very unusual case that hasn't been documented before and he
is going to do a paper on the subject that could help others with this disease. He
scheduled a battery of tests including a Spectral OCT, GDX, HRT and regular OCT laser
scan. Mary spent a total of 6 hours in the office completing the exams and the doctor
advised us that he was going to review the tests and get back to us. Mary was advised
to come back in six months. We knew from the minute he said to come back in 6 months
that he too was confident that Mary's apparent higher pressure was not the problem it
was originally thought to be. This is the first time in years that she hasn't been at the eye
doctor every two months or so.
The initial cursory review of the new tests along with the pressure readings, and visual
field tests, gave us hope for the first time in years that we were making progress and
getting answers. The doctor and his staff at the medical facility in Pittsburgh were very
thorough and professional during her visits.
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Less Medicine — More Benefit!!! - Part VI
A Glaucoma Patient’s Perspective and Observations
January 3, 2008
Mary visited the Doctor and completed numerous tests in 2006. She used the Proview
daily to monitor her IOP and we anticipated that her IOP would be in the mid to high
teens based on our established correction factors. Her IOP readings elevated above
what we had anticipated and we determined that the Proview Monitor doesn’t track GAT
IOP readings reliably in the mid 20s and above. We purchased a new Proview to
compare readings. The IOP readings were higher on the new Proview and we
established new corrections factors as discussed in previous articles.
In June Mary’s IOP readings were R18 / L23. Mary suffers numerous side effects from
Lumigan, the Prostaglandin drug that she takes. Mary decided to reduce her eye drops
to every other day to see what effect this would have on her IOP. The Doctor agreed and
scheduled a follow-up appointment in July. Mary has thicker corneas and can stand
higher IOP pressure. Her readings four week later only increased slightly and she
decided to maintain the every other day routine to reduce the side effects.
Her next appointment was scheduled for November and to our surprise her pressure
dropped considerably in both eyes. Our contention for years was that the medications
were causing problems and elevated IOP. Her IOP read R15 / L16 at the first IOP check
at noon. On the second check at 3:35 p.m., after her pupils were dilated for several OCT
scans and Perimeter checks, her pressure read R17 / L21. Pupil dilation causes IOP to
rise.
This was good news for all and Mary asked to switch to Xalatan. She thought that it
would have fewer side effects. She started taking the Xalatan everyday and found the
side effects worse than what she was experiencing previously with Lumigan. After three
weeks she went back to Lumigan every other day.
My wife’s condition is quite unusual. The doctor’s discovered Schisis in her right eye 3
years ago. The perimeter test only showed a slight problem with the right eye, one
quadrant, where the Schisis was present and there is a scar close to the macular just
above the Schisis. The perimeter checks over ten years show no change, only the same
eye sight loss in one small area where the scar is located. Mary has apparently had this
condition for many years, possibly since birth.
She was asked to participate in a UPMC glaucoma study and it was recently published.
The odd thing about her condition is that the Schisis, which is similar to edema or
swelling, was thought to be a birth defect and irreversible. To all of our surprise the
Schisis disappeared in the right eye. Unfortunately is reappeared in the left eye! My
online research discovered that Prostaglandin drugs can cause what is called Macular
Edema, a swelling under the Macular and asked the doctor if the prostaglandin
medications may have caused Schisis. He dismissed the assumption and is not sure
why this occurred.
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Our observations may hold the key. Mary’s right eye, prior to SLT surgery, always had
higher IOP than the left eye. It seems that the Schisis disappeared after the SLT surgery
was performed on Mary’s right eye only after the pressure reached the mid to high
teens. It took many months for the SLT to dramatically lower Mary’s IOP. Actually, her
pressure went up the first month and it took about a year for the pressure to reach the
mid teens. Considering that her IOP in the right eye before SLT surgery was in the high
20s and above, that’s a dramatic drop.
It appears that the higher pressure along with possibly the eye irritation caused by the
prostaglandin drugs may in combination create this edema or schisis and increased
pressure readings. Things seem to be coming together the more we experiment. For
example, after the SLT surgery and the pressure decreased the schisis disappeared!
Mary elected to take drops every other day and the pressure reduced more, about 4
mmHg in the right eye and 6 mmHg in the left eye. Coincidence or not, only time will tell.
Mary would like to get off glaucoma medications due to the many negative side effects
that make her life miserable at times. She is considering having an SLT on the left eye
next visit and hopefully stop medications in 3 to six months on a trial basis. If her
pressure can be maintained in the mid teens to low 20s, and with her thicker corneas
she may be fine without medications. The SLT has proven to be a valuable tool to
reduce IOP and it may have other benefits as well.
The End Game – Off Meds & Pressure Managed – Part VII
A Glaucoma Patient’s Perspective and Observations
March 8, 2008
The last update in early 2007, Part VII of this series, was a turning point for Mary. Her
IOP was in the high teens to low 20s and she was able to reduce her eye drops to every
other day with only a slight increase in Intraocular Eye Pressure (IOP). Her goal has
always been to get off medications altogether because of the many side effects that she
suffers from when taking Lumigan, or for that matter any of the many eye drops she has
been on over the past 12 years. I believe even the doctor was surprised that reducing
the eye drops to every other day didn’t dramatically increase her IOP. If you are
experiencing serious side effects to your glaucoma medications, you may be able to try
this under your doctor’s supervision and care. Don’t do this on your own, talk it over with
your physician first to make sure he agrees and monitors you throughout the test period.
Everyone’s case is different. Just because it worked for Mary doesn’t mean it will work
for everyone. Case in point, according to Doctor Schuman from the UPMC Eye Center,
the Selective Laser Trabeculoplasty (SLT) laser treatment that my wife has had three
times in the past 2 years to reduce her IOP, doesn’t work on 30% of glaucoma patients.
Fortunately for Mary she has had excellent results with the SLT.
In 2007 Mary achieved her goal, she is now off medications. We don’t know for how
long, it has been over 6 months so far and we are optimistic that she will be able to stay
off medications indefinitely or at least for the foreseeable future. Mary’s visual field tests,
OCT, and other diagnostic tests showed no significant changes since she went off
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medications. This is exceptional considering that her previous doctor told her she would
never be off medications and that she required scalpel surgery to lower her IOP. This
was the main reason Mary decided to seek a second opinion and consider SLT laser
surgery. Her previous doctor offered her few options and we both felt that her case was
unique as we discussed in earlier articles in this series. Be sure to read the conclusion,
part VIII of this series, where we suggest things that you need to discuss with your eye
doctor when you go in for your next visit. Had Mary taken these precautions when she
was first diagnosed, we believe the outcome would have been different and she possibly
would not have gone on medications to begin with.
Mary has been going to the UPMC Eye Center in Oakland, just outside of Pittsburgh PA,
for about 3 years now. She is under the care of Doctor Joel Schuman, the Eye Center’s
director and ophthalmology department chairman. He listened to our concerns and
worked with us throughout her treatment at UPMC. Mary and I insisted on being actively
involved with her treatment and some doctors are not quite as accommodating to this
approach.
Doctor Schuman asked Mary to participate in a study concerning her condition and the
results were published in The American Journal of Ophthalmology. The title of the
article is “Periopapillary Schisis in Glaucoma Patients With Narrow Angles and
Increased Intraocular Pressure.” At the time of the study only two patients were known to
have this condition. Mary was also interviewed by Pohla Smith for a Pittsburgh Post
Gazette article about the UPMC Eye Center, the article was published February 27,
2008.
Mary’s case did prove to be unusual as we anticipated and we believe that she is ocular
hypertense as described in previous articles, has narrow angles that were treated with
iridotomy surgeries, has a rare eye condition called schisis – diagnosed with the OCT
and other diagnostic tests, and suffers from white coat hypertension that causes her
blood pressure and IOP to spike dramatically whenever she gets near a doctor.
We have proven the white coat hypertension hypothesis numerous times where we
observed IOP increases of as much as 12 mmHg during one visit from the first to the
final IOP GAT pressure check. Even during her last visit on March 4, 2008 her IOP
during the first pressure check measured R 22 / L 19. The second check, an hour and a
half later, measured R 21 / L 29. Mary and I knew immediately that the higher IOP
readings were incorrect for a number of reasons. First, Doctor Schuman rechecked the
reading, making sure my wife breathed normally during the check, and her IOP reading
was R 23 / L 21, almost the same reading as earlier. Secondly, my wife can actually tell
me before a doctor’s visit if her IOP is normal, lower than usual, or high from physical
observations. When her pressure is low, in the high teens to low 20s she has a harder
time reading small print and when they test her vision she will miss a few of the letters
on the smallest scale. We believe this is caused from eye lens distortion. Just imagine a
beach ball that’s fully inflated, its outside surface is smooth, when you let the air escape,
the outside surface distorts. Her eyes feel different when her IOP is high as well and
she can read really small print with ease. The Proview IOP monitor that she uses at
home also gives her relative readings and an indication of whether or not her IOP is
high.
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During the year, Mary had two Selective Laser Trabeculoplasty (SLT) surgeries on her
left eye. She had an SLT in her right eye about two years ago. After the first surgery in
early 2007 she went off medications with her doctor’s consent to see if her IOP would
stay in the normal range. Her IOP increased over time from R 22 / L 22 uncorrected on
September 25th to the mid to high twenties in both eyes by December. The doctor
performed a second SLT on Mary’s left eye January 14, 2008 and her IOP dropped from
the mid twenties the day of the surgery to and IOP reading of 20 that day. On March 14th
her IOP was R 23 / L 19 without medications. The good thing about the SLT is that it can
be repeated frequently without damaging the meshwork like the ALT does.
Mary was able to get off medications due to the availability of Selective Laser
Trabeculoplasty (SLT) laser surgeries at the UPMC Eye Center. Doctor Schuman’s
profound understanding of Mary’s case, through extensive diagnostic testing that is only
available in our area at the UPMC Eye Center, and his awareness of the adverse side
effects she suffered while on medication was a major contributing factor as well. His
willingness to work with us and the fact that he took into consideration our perspective
and input for her treatment is commendable.
If you have glaucoma read the conclusion, Part VIII of this series before going back to
see your doctor. If your doctor has diagnosed you with glaucoma without extensive
diagnostic tests, go for a second opinion to a medical facility that offers them. If your
doctor doesn’t have the diagnostic testing mentioned in these articles, he should, at a
minimum, send you to a diagnostic facility in your area to have these tests before
prescribing medications and treatment. The tests include but are not limited to:





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Visual Field Testing (Checks visual field for blind spots)
Pachymetry cornea thickness tests (Thicker corneas can take higher pressure)
OTIScans (an ultrasound of the eye)
Optical Coherence Tomography (OCT) Retina Scanner
GDX (Measures the thickness of the nerve fiber layer around the Optic disc.)
Heidelberg Retinal Tomographer (HRT) MACULAR screening
In four months Mary goes back for a second checkup and for OCT and visual field tests.
Mary is relieved that she is off medications and is doing whatever she can to remain off
them indefinitely. Only time will tell. Thanks for following this case study. We intend to
update this series annually in the hopes that the information provided will help you better
understand and evaluate your personal situation. If you would like to comment on this
article email [email protected].
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Conclusions and Summary - Part VIII
A Glaucoma Patient’s Perspective and Observations
After considerable research and time invested we believe we now have a much better
handle on my wife’s case. Treatment involves a partnership where patient and doctor
can have meaningful dialog to get to the bottom of each case. I believe that too many
patients leave everything up to the physician, who is often distracted and overworked.
Sometimes you have to get their attention with facts, speculation, and just put the brakes
on so your case gets the attention it deserves. Things aren’t always what they seem and
what at first may appear insignificant takes on a while new dimension as time
progresses. I believe it is also helpful to maintain a journal for your treatment so you can
review it from time to time for clues.
We certainly don’t have all of the answers and we intend to work with Mary’s doctors
throughout her treatment. Overall, we believe that my wife may have initially been ocular
hypertensive. The initial visual field test was flawed due to time and circumstance.
Subsequent visual field tests may have been miss interpreted due to the Schisis on her
right optic nerve that was found through diagnostic tests taken last year. Various Scans
confirmed that she had a normal nerve head except for the Schisis. Apparently Mary did
have narrow angle glaucoma that was eventually treated with Iridotomy surgeries.
Mary was able to get off all medications in 2008 after working this past three years with
Doctor Schuman at the UPMC Eye Center in Pittsburgh, PA.
Note: I asked Doctor Mark Sibley, M.D.,F.A.C.S., Board Certified Ophthalmologist and
Medical Director of the Florida Eye Center what effect glaucoma eye drops have on a
patient that has gone through SLT surgery and how does a patient stop taking the drugs
if the SLT surgery was successful. He stated that once the drains are cleaned up
through SLT surgery, and the response to the SLT surgery is known, the patient can
immediately stop the medications if the drains are working properly as indicated by lower
acceptable pressure. He clarified this point by stating that the drains can only be cleaned
up to what they have the potential for. Furthermore, “if you give a person with open
drains Glaucoma medications the person with open drains has virtually no eye pressure
lowering because the drains are already open. When you successfully open the drains
with SLT surgery the drains take over and the eye drops become unnecessary,
dangerous, and an expense that can be stopped.”
I also asked Doctor Sibley if the side effects from eye drop drugs are reversible when the
drugs are stopped. Doctor Sibley said, “when you stop the medications the side effects
go away.”
Mary’s apparent erratic high pressure has caused the doctors the most concern. After
much research, self tests with the Proview monitor, and evaluation we believe that her
erratic IOP readings in the doctor’s office may have been an anomaly all along
predicated on other factors specifically:
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White coat hypertension and stress
My wife has what is referred to as white coat blood pressure. Anytime she goes
to a doctor’s office her blood pressure elevates significantly. She monitors her
blood pressure daily and it is normal except when she goes to the doctor’s office.
Research has indicated that IOP is positively related with systemic blood
pressure as noted in the Singapore Medical Journal. We check her IOP
immediately before going to the doctor’s office and it is elevated several points
from her normal readings. At the doctor’s office it increases more. Her IOP stays
elevated for several days after her visit until she calms down. Then it goes back
down to normal levels. We concurrently monitor her blood pressure and it
correlates with her IOP.
Note: We also suspect that Mary may have negative reactions to the drug
Fluress that is used to numb the eye prior to taking IOP readings.
Cornea thickness
Pachymetry test. Thicker corneas give high false IOP readings on the Goldmann
Tonometer pressure test set. Mary’s corneas measured R 561 and L 592 which
equates to IOP adjustments of -1 mmHg in her right eye and -4 mmHG in her left
eye from the Goldman readings. The Duke University Eye Center publishes an
IOP correctional values chart for the Goldmann Tonometer. I obtained a copy of
the chart from my optometrist.
Exercise
The University of Maryland states on their web site under patient articles that,
“Studies indicate that glaucoma patients who exercise regularly (at least three
times a week) can reduce IOP by an average of 20%. If they stop exercising for
more than two weeks, pressure increased again. In one study, those who walked
briskly four times a week for 40 minutes were able to go off their
medications.” The web site www.healingtheeye.com reports, “Areobic exercise
has been shown to reduce intraocular pressure by 4.6 mmHg when compared to
sedentary glaucoma patients.” My wife walks for 30 minutes most days on a
treadmill. This along with other things appear to be decreasing her pressure.
Caffeine
Healthnotes Newswire reported on June 27, 2002 that caffeine increases
intraocular pressure (IOP). The study measured an IOP increase of between 2 to
3 mmHg 60 minutes after drinking one 7 ounce cup of regular coffee containing
180 mg of caffeine. I found several articles on the effect of caffeine on IOP. Mary
has decreased her consumption of caffeinated pop and dark chocolate which
also has high levels of caffeine.
NOTE: There are reports that IOP measurements are effected by drinking
coffee, water, or alcohol before IOP readings.
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Excerpt from my retirement journal: Since retiring, I dramatically
increased my physical activities. However, it appeared that the more I
exercised the worse my arrhythmia became and I was having a hard time
sleeping. I couldn’t determine what was triggering the attacks.
One of the known triggers for this condition is caffeine and fortunately I
watched 20/20 last week when they featured decaffeinated coffee. Their
research uncovered that a third of the decaffeinated coffee purchased at
coffee shops across the county was not decaffeinated at all. Some cups
had as much as 90 milligrams of caffeine, about 80 mgs more that the
typical cup of decaf!!! Since retiring I stopped at Starbucks daily and when
my A-Fib started acting up I went to 100% decaf with no change in
condition. After the 20/20 show I stopped buying coffee all together and
low and behold the attacks stopped almost immediately. Live and learn,
not everything advertised is what it is cracked up to be.
Water intake
It is reported on the University of Maryland Medical web site
(http://www.umm.edu) that fluid intake in large amounts can cause eye pressure
increase. They report, “Drinking large amounts (a quart or more) of any liquid
within a short time, about half and hour, appears to increase pressure. Patients
with glaucoma should have plenty of fluids, but they should drink them in small
amounts over the course of a day.”
Smoking
Doctor Krondit at www.healingtheeye.com states, “Studies show that there is a
2.9 increase in the risk in developing glaucoma in smokers. While smoking, each
cigarette can raise the IOP by 5.0 mmHg or more. Nicotine has been shown to
reduce retinal blood flow by 16%.” Other studies recommend that glaucoma
patients avoid second hand smoke as well as it to can raise IOP.
NOTE: Mary is currently taking Lumigan, a Prostaglandin analogues. This drug
causes upper respiratory problems and she has to avoid smoke of all types
including smoke from frying foods. This drug also causes complications for
menopausal women.
Vitamin and mineral supplements
There are many studies on the effects of vitamins and mineral supplements. The
web site www.alternative-medicine-and-health.com suggest the following
supplements:
Vitamin A: 10,000 I.U. per day
Vitamin C: 1,000 to 3,000 mg. daily, in divided doses
Vitamin E: 400 I.U. daily
Chromium: 100 mcg. Of trivalent chromium 2 times daily
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Zinc: 50 mg a day
Fish oil: 1000 mg 3 times daily of MaxEPA
Rutin: 50 mg 3 times daily
NOTE: You can get Rutin from green tea. Meat and chicken is rich in Zinc, and
chromium is abundant in vegetables including broccoli. Mary has many allergies
and was hesitant to take these larger doses. She started taking a daily multiple
vitamin several months ago along with 200 I.U of vitamin E and 500 I.U of vitamin
C daily. Since stating this vitamin regime her IOP has dropped in both eyes. This
drop may not be fully attributed to the vitamin intake. She also exercises and has
made other life style changes that may have reduced her IOP.
Menopause
A study by the Singapore Medical Journal states, “In recent years, it has been
noted that intraocular pressure is a dynamic function and is subjected to many
influences both acutely and over the long term.” Menopause is a significant life
cycle that Mary and I believe impacts IOP and the glaucoma diagnosis
significantly. This is especially significant when a woman is prescribed a
Prostaglandin such as Lumigan or Xalatan. Further investigation should be made
into the efficacy of using these drug on premenopausal and menopausal woman.
Prostaglandins cause bleeding and uterus contractions in women. Menopause
causes significant hormone fluctuations that also may create IOP fluctuations of
and in itself.
Since many who are diagnosed with glaucoma are older we believe there has
been little research on this subject.
NOTE: If you are going through menopause be forewarned that prostaglandins can
prolong and magnify menopausal symptoms significantly.
Conclusions & Suggestions
There are many forms of Glaucoma and your treatment may be considerably
different from what my wife experienced. Everyone over 40 should have an annual
eye exam and be tested for Glaucoma and other eye diseases.
Patients need to be aware of the many factors that affect IOP before starting
treatment or agreeing to surgery. Mary and I recommend that before starting drugs
or having surgeries get a second opinion and ask your doctor these questions:
1. What type of Glaucoma do I have?
POAG - Primary Open Angle, Narrow Angle, or other type?
2. What are my cornea thicknesses?
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Do you adjust your Goldmann Tonometer IOP readings for cornea
thicknesses? If not, do you have a PASCAL DCT tonometer for IOP checks?
3. Is there optic nerve damage?
4. Do I need an OCT, GDX, or HRT Scan, or an OTIScan Ultrasound? The
OTIScan is an Ultrarsound of the eye that checks eye structure and for the
conditions such as pupillary block and plateau iris. The other low level laser scans
look at the optic nerve fibers and structure. I consider these tests necessary before
proceeding with treatment. This may seem a matter of fact. However, not all doctors
have access to the very expensive test equipment required to thoroughly evaluate
your eyes. Some doctors may be hesitant to refer you to other offices. Insist on a
referral if these tests can’t be performed at their office.
5. Our opinion is that prior to taking medications you should get a second opinion
and have at a minimum a "Visual Field Test" and the OCT or equivalent laser scan.
Many of the older visual field machines are not as accurate as the newer units. The
newer units have self checks built in that void the exam if the patient doesn't follow
instructions to a tee.
VISUAL FIELD TEST DISCUSSION - Since the visual field test is so critical to
diagnosis and treatment it is imperative that it be done correctly. The technician that
administers the test should stay with you throughout the entire exam to remind you to
stay focused on the center light and not to look for the lights. Basically, you look
straight ahead and when you first see the light in your peripheral vision you press a
button. This is repeated over and over again until they map the entire eye. Patients
tend to get concerned when they feel it is taking too long for the light to reappear so
they start to look for it and it flaws the test. Patients should be reminded that
everyone has a natural blind spot in each eye and at times it will take awhile for you
to see the light again. Actually, if the test doesn't map a blind spot the test was not
done properly.
5. If drugs are prescribed, ask the doctor if the SLT Laser Treatment would
accomplish the same thing? You want to avoid medications if at all possible.
6. If your pressure is higher than normal ask the doctor if you could be ocular
hypertensive? The "Ocular Hypertensive Treatment Study" OHTS includes many
helpful clues about this condition. You can uncover volumes of information by doing
a Google or Yahoo search on these key words.
NOTE: There is also a condition called "Low Tension Glaucoma" where optic nerve
damage occurs even with very low IOP readings.
SUGGESTION: Mary was always concerned that her IOP pressure was always high
until we purchased the PROVIEW Home Monitor. We discovered that her IOP
dropped substantially after leaving the doctor's office and remained relatively
constant + or - 1 digit on the Proview scale morning to night. The day of her office
visit the Proview readings would go up at much as 2 mmHg or higher. Many doctors
don't trust the Proview but if you calculate the correction factors as noted earlier they
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do provide a good relative measure of your daily IOP. Mary takes her Proview
readings up to three times a day and it only takes a minute to take each reading. The
unit looks like a short fat pencil.
7. If you are experiencing IOP fluctuations, erratic, or high IOP readings with the
Goldmann Tonometer, ask the Doctor to check your pressure with the PASCAL DCT
tonometer. If they don't have one locate a doctor in your area that has one and have
your IOP read on their unit. You will be able to compare the readings to your doctor's
GAT readings. The PASCAL unit takes into consideration the biomechanics of the
eye and their readings are not effected by cornea thickness. They also give you
readings for Ocular Pulse Amplitude and pulse rate. I believe these two additional
PASCAL readings help the doctor better understand your case, especially if you are
nervous and suffer from White Coat Hypertension like my wife does. The PASCAL is
fairly new. However, the research I have read was highly favorable and many now
believe it will become the new "GOLD STANDARD" for IOP readings.
8. Start a journal coincident with your first doctor's visit and keep it updated. Explore
the diagnosis and condition online and locate as much information as possible to
help you understand your condition and to help your doctors treat you. Tell your
doctors all of your medical concerns no matter how insignificant you may think it is
and certainly let them know if you are going through menopause, have allergies, or
have other problems.
We will continue to post updates to this journal as we progress from this point on and
hope that you have found this information helpful. If you would like to comment on
this article or its contents you can send an email message to [email protected].
Either my wife or I will respond and if your information will be helpful to others we will
post it on this forum.
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