Lehigh County Health & Medicine Spring 2021 - 21

L C M E D S O C .O R G

caused cataracts, macular swelling, hypotony,
and infections, and didn't cure the disease.

the eye (not an absolute number as was taught
years ago) is too high for the eye, and presses
on the delicate nerve fibers. This damages then
Fast forward to 2021, and things are signifi- kills them, resulting in loss of small spots in the
cantly different! We understand that Glaucoma side vision at first, then larger areas, and then,
is a disease of damage to the optic nerve, and lastly, complete blindness. The central vision
can happen at ANY eye pressure, even very remains unaffected until very late in the disease,
low pressure. It is a combination of poor so people don't notice anything is happening.
circulation, mechanical factors, heredity, and Then suddenly it's too late and, when they have
effects of medication and lifestyle. There are very few nerve fibers left, they go blind.
over 35 different types of Glaucoma, and I
am diagnosing and treating people in their 20s
If you think of each nerve fiber serving a
and 30s with lots of years to live and hoping pixel in a picture, you can understand why
to enjoy a lifetime of good vision. With early going from 13 megapixels to 8 megapixels
detection, treatment, and monitoring, they can would go unnoticed to a patient. Since we use
have good vision for a lifetime!
both eyes together, it is easy for the brain to fill
in small gaps and the picture to seem normal
So, what is Glaucoma? Glaucoma is a silent, even with moderate Glaucoma. Patients cannot
blinding, neurodegenerative disease of the optic tell something is wrong until quite late in the
nerve. It is not diagnosed at a single point in disease, like the 53-year-old woman who came
time, but is a timeline of slow, gradual loss of in to me because she had failed her driver's
nerve fibers. It affects over 3 million people in test-not because she couldn't see (she read
the United States, with over 120,000 people 20/20 with each eye), but because she had lost
blind from Glaucoma.
so much side vision that she didn't meet the
visual field requirements to drive. This was a
Yet over half the people with Glaucoma permanent loss and could not be improved with
don't even know they have it starting! Even if glasses, medicine or laser, and all we could do
you don't have a family history of Glaucoma, was to aggressively treat and try to save what
it could be happening to you, because your vision she had left.
family may be undiagnosed as well. Glaucoma
creates significant morbidity and decreases So, how do we screen pahealth-related quality of life, and the World tients for Glaucoma?
Health Organization lists it as the second cause
Checking intraocular pressure (IOP). Yet
of blindness worldwide.
half of all Glaucoma patients have low or
" normal " pressure. (Also, please note that " airIt is very important to be diagnosed early, puff " tonometry used at some offices is not
so that you can be treated very early! In early very accurate).
cases we can not only slow the progression
of the disease but may even be able to halt
Measurement of corneal thickness. Patients
it! Newer tests allow much earlier diagnosis, with thin corneas (after LASIK or PRK, or
and newer treatments are safe and tolerable high myopes) may have falsely low pressures,
so we can intervene earlier. Technology has so Glaucoma may be missed on screening.
improved, medicines have improved, so we
can get better results!
Most important: examination of the optic
nerve through pictures, exam, and several tests
Why is Glaucoma
including an OCT (ocular coherence tomograso insidious?
phy) and visual field test. Both structural and
We are born with 1.2 million nerve fibers in functional assessments are integral to patient care.
the optic nerve, and generally lose about 5000
nerve fibers a year due to natural aging. So, we How and When to treat
have a nice cushion to see well for our whole Glaucoma
life if nothing accelerates that loss. But with
Glaucoma isn't a single yes or no point, it's
Glaucoma the relative pressure of the fluid in a timeline of optic nerve damage. The earlier

glaucoma is detected and treated, the better it
is for prognosis and preservation of sight.
Newer medicines are safer and better tolerated than older treatments, making earlier
treatment easy and practical. Now SLT (selective
laser trabeculoplasty) is considered first line
treatment. SLT is a safe laser treatment that
is painless, repeatable, and doesn't depend on
patient compliance.
What are other risk
factors for Glaucoma?
Besides having a family history of Glaucoma
or any history of blindness, patients with vascular
and lung disease (e.g. asthma/COPD, migraines,
vasospasm, diabetes, cardiovascular disease), use
of steroids (even inhaled and nasal), or history
of ocular trauma are at increased risk. Hispanics
and Afro-Americans are known to have more
aggressive disease, so should be checked earlier.
Patients who are high myopes, or who have
had LASIK or PRK are associated with a falsely
low IOP measurement due to thinning of the
cornea, so often go undiagnosed. Doctors must
be suspicious of Glaucoma if they see changes
in the optic nerve on exam or testing.
Frequency of Testing
for Glaucoma
Because Glaucoma is asymptomatic till late in
the disease, we must rely on monitoring patients
via frequent tests and exams. The American
Glaucoma Society suggests four exams per year
(2 dilated, and two pressure checks), visual field
testing 1-3 times per year, and OCT twice a
year. If Glaucoma is uncontrolled, then even
more frequent tests are needed until control
is achieved. Treatment is individualized and
depends on test findings and patient compliance.
I treat everyone as I would want to be treated,
and as I have treated my family. My father and
my grandmother had Glaucoma, and they both
retained excellent visual fields for their entire
lives using this approach.
We are living longer and have access to better
technology and better treatments. So, Glaucoma
doesn't have to be the blinding thief in the night
anymore-catch and treat it early and your
vision can be saved!

SPRING 2021 | Lehigh County Health & Medicine 21


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Lehigh County Health & Medicine Spring 2021

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