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General | Cataract | Glaucoma & Macular Degeneration | Ocular Surface Disease & Eyelids | Retina | Miscellaneous


Glaucoma
Glaucoma Exam & Diagnostics
Macular Degeneration (Dry & Wet)
Macular Degeneration Treatment
Macular Degeneration Vitamins





Glaucoma—The Basics

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Glaucoma is a disease of the optic nerve, which transmits the images you see from the eye to the brain. The optic nerve is made up of many individual nerve fibers (like an electric cable with its numerous wires). Glaucoma damages nerve fibers, which can eventually cause blind spots and vision loss.

Glaucoma has to do with the pressure inside the eye, known as intraocular pressure (IOP).  The intraocular pressure is not significantly influenced by blood pressure, which is a common misperception.  When the aqueous humor (a clear liquid that normally flows in and out of the eye) cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve and lead to vision loss.



Normal cup/disc ratio (<0.5)

Enlarged (glaucomatous) cup (0.8)

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The most common form of glaucoma is primary open-angle glaucoma (POAG), in which the aqueous fluid is blocked from flowing out of the eye at a normal rate through the tiny drainage system (trabecular meshwork). Most people who develop primary open-angle glaucoma notice no symptoms until their vision is already impaired.

POAG:                                     

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Ocular hypertension is often a forerunner to actual open-angle glaucoma. When intraocular pressure is above normal, the risk of developing glaucoma increases. Several risk factors will affect whether you will develop glaucoma, including the level of IOP, family history, and corneal thickness. If your risk is high, Dr. Haas may recommend treatment to lower your IOP to prevent future damage.

In angle-closure glaucoma, the iris (the colored part of the eye) may completely close off the drainage angle, abruptly blocking the flow of aqueous fluid and leading to a sudden increased IOP or optic nerve damage. In acute angle-closure glaucoma there is a sudden increase in IOP due to the buildup of aqueous fluid. This condition is considered an emergency because optic nerve damage and vision loss can occur within hours of the problem. Symptoms can include nausea, vomiting, seeing halos around lights, and eye pain.

Angle Closure:              

 

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Even some people with “normal” IOP can experience vision loss from glaucoma. This condition is called normal-tension glaucoma. In this type of glaucoma, the optic nerve is damaged even though the IOP is considered normal. Normal-tension glaucoma is not well understood, but lowering IOP has been shown to slow progression of this form of glaucoma.

Childhood glaucoma,
which starts in infancy, childhood, or adolescence, is rare. Like primary open-angle glaucoma, there are few, if any, symptoms in the early stage. Blindness can result if it is left untreated. Like most types of glaucoma, childhood glaucoma may run in families. Signs of this disease include:

  • clouding of the cornea (the clear front part of the eye);
  • tearing; and
  • an enlarged eye.

Dr. Haas may tell you that you are at risk for glaucoma if you have one or more risk factors, including having an elevated IOP, a family history of glaucoma, certain optic nerve conditions, are of a particular ethnic background, or are of advanced age. Regular examinations are important if you are at risk for this condition.

The goal of glaucoma treatment is to lower your eye pressure to prevent or slow further vision loss. Dr. Haas will recommend treatment if the risk of vision loss is high. Treatment often consists of eyedrops but can include laser treatment or surgery to create a new drain in the eye. Glaucoma is a chronic disease that can be controlled but not cured. Ongoing monitoring (every three to six months) is needed to watch for changes. Ask us if you have any questions about glaucoma or your treatment.


Glaucoma: People of African and Hispanic Ancestry Are at Higher Risk

If you are of African or Hispanic ancestry and especially if you have a known family member with glaucoma, you are at a higher risk for vision loss from this eye disease.
Glaucoma is a disease of the optic nerve, which transmits the images you see from the eye to the brain. The optic nerve is made up of numerous nerve fibers (like an electric cable made up of many wires). Glaucoma damages nerve fibers, which can cause blind spots and loss of vision.

Glaucoma has to do with the pressure inside the eye, or intraocular pressure (IOP). When the aqueous humor (the clear liquid that normally flows in and out of the eye) cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve.

Primary open-angle glaucoma
is the leading cause of blindness among people of African ancestry, occurring at a rate four times higher than among Caucasian patients. It also occurs about 10 years earlier among people of African ancestry than among Caucasians and develops more rapidly. Studies show that in the United States, African Americans between the ages of 45 and 64 are approximately 15 times more likely to go blind from glaucoma than Caucasians with glaucoma in the same age group. Primary open-angle glaucoma is also the leading cause of blindness among people of Hispanic (and especially Mexican) ancestry, occurring at a rate approaching that of people of African ancestry.

It is not clear why people of African ancestry have higher rates of glaucoma and subsequent blindness than Caucasians. One factor may be that they are more susceptible to developing elevated IOP earlier in life, which is thought to contribute to optic nerve damage and eventual vision loss. Another reason may be that they are less likely than Caucasians to have early eye examinations that might detect and treat glaucoma. This also may be a factor in the increased rate of glaucoma among Hispanics.

Glaucoma causes no symptoms early in its course; you will not experience pain or vision changes while it is developing. The best way to protect yourself and your family members against vision loss from glaucoma is by being aware of your higher risk of developing this disease and by having regular eye examinations for glaucoma at appropriate intervals.

Recommended intervals for a comprehensive eye evaluation in people of African ancestry are as follows:

  • 20 to 29 years of age: every 3 to 5 years;
  • 30 to 64 years of age: every 2 to 4 years;
  • 65 years and older: every 1 to 2 years.

It is also recommended that people of Hispanic ancestry have regular, comprehensive eye evaluations. This is especially important after age 60.
If you are diagnosed with glaucoma, please make sure to tell your family members and urge them to have an eye exam for glaucoma.

Here are some resources for more information on glaucoma:

The Glaucoma Foundation
80 Maiden Lane, Suite 1206
New York, NY 10038
Phone: 800.GLAUCOMA (452.8266)
www.glaucoma-foundation.org

The National Eye Institute
2020 Vision Place
Bethesda, MD 20892-3655
Phone: 301.496.5248
www.nei.nih.gov

Prevent Blindness America
Phone: 800.331.2020
www.preventblindness.org
The American Academy of Ophthalmology
P.O. Box 7424
San Francisco, CA 94120-7424
www.aao.org

Glaucoma Evaluation

Because it has no noticeable symptoms, glaucoma is a difficult disease to detect without regular, complete eye exams.
During a glaucoma evaluation, Dr. Haas may perform the following tests:

  • Tonometry. This measures the pressure in your eyes (intraocular pressure, or IOP) using a technique called tonometry. Tonometry measures your IOP by determining how your cornea responds when an instrument (it used to be a painful puff of air) presses on the surface of your eye. Eyedrops are used to numb the surface of your eye for this test.

Slit-lamp tonometer:



Handheld tonometer:

  • Pachymetry. Pachymetry measures the thickness of your cornea, or the front, clear part of the eye.  Corneal thicknesses vary greatly from person to person, and this test allows us to determine the thickness of your individual corneas.  This measurement will allow Dr. Haas to better know the accuracy of your intraocular pressure measurements, which are highly dependent on the individual corneal thickness.                                

Handheld pachymeter:               

  • Gonioscopy. This test inspects your eye’s drainage angle—the area where fluid drains out of your eye. During gonioscopy, you sit in a chair facing the microscope used to look inside your eye. You will place your chin on a chin rest and your forehead against a support bar while looking straight ahead. Anesthetic drops are placed for numbing, and the gonio-lens is put lightly on the front of your eye and a narrow beam of light is directed into your eye while Dr. Haas looks through the slit lamp at the drainage angle.                                               

Gonio-lens:                                   

  • Ophthalmoscopy. With this test, Dr. Haas can evaluate whether or not there is any optic nerve damage by looking at the back of the eye (called the fundus). There are two types of ophthalmoscopy: direct and indirect. With direct ophthalmoscopy, Dr. Haas uses a small flashlight-like instrument with several lenses that magnifies the eye up to about 15 times. This type of ophthalmoscopy is most commonly done during a routine physical examination. With indirect ophthalmoscopy, Dr. Haas wears a headband with a light attached and uses a small handheld lens to look inside your eye. Indirect ophthalmoscopy allows a better view of the fundus, even if your natural lens is clouded by cataracts.
  • Visual field test. The peripheral (side) vision of each eye is tested with visual field testing, or perimetry. For this test, you sit at a bowl-shaped instrument called a perimeter. While you stare at the center of the bowl, lights flash. Each time you see a flash, you press a button. A computer records your response to each flash. This test shows if you have any areas of vision loss. Loss of peripheral vision is often an early sign of glaucoma.         
  • Photography. Sometimes photographs or other computerized images are taken of the optic nerve to inspect the nerve more closely for damage from elevated pressure in the eye.
  • Special imaging. Different scanners may be used to better determine the configuration of the optic nerve head or retinal nerve fiber layer.

Each of these evaluation tools is an important way to monitor your vision to help ensure that glaucoma does not rob you of your sight. Some of these tests will not be necessary for everyone. Dr. Haas will discuss which tests are best for you. Some tests may need to be repeated on a regular basis to monitor any changes in your vision caused by glaucoma.

 

OCT (Optical Coherent Tomography) for Nerve-Fiber-Layer Analysis

Early in the disease process of glaucoma, individual nerve fibers in the eye’s optic nerve are lost, causing an associated pattern of nerve-fiber-layer thinning. This problem can later translate into loss of tissue at the optic nerve head, resulting in visual field defects and, ultimately, loss of vision.

New techniques have been devised to help measure the thickness of the nerve fiber layer, helping Dr. Haas diagnose glaucoma earlier and monitor progression of the disease.  One technique used to measure the nerve fiber layer is called optical coherence tomography (OCT). A low-level laser is used to provide cross-sectional views of the retina and optic nerve, and measures variations in thickness to the 1/1000 of a millimeter!  This imaging technique can help provide an objective measurement of the nerve fiber layer, enhancing the ability of Dr. Haas to effectively diagnose and monitor glaucoma and various retinal problems.

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OCT:
 

Optic Disc Photographs

Photographic images of the optic disc are also essential for monitoring glaucoma.

Glaucoma damage is seen clinically as loss of the nerve fiber layer and an associated thinning of tissue at the optic nerve head. With this damage, Dr. Haas looks for “cupping” of the optic nerve. Stereoscopic disc photos of the optic nerve are helpful in providing baseline information about the optic nerve’s condition for future comparison. These photographs are taken in our office using a special camera that can create a stereo image.

Optic disc photography is invaluable because the baseline photos can be used for future comparison. This will help identify signs of glaucoma progression.  Also, should you ever move out of the area, these pictures can be sent to any other physician’s office at any time in the future allowing continuity of your personalized eye care. 
Despite many new imaging techniques for glaucoma, disc photos and a careful clinical examination are still the standard of care for glaucoma.

Fundus and Optic Nerve (stereo) Camera:


Visual Field Testing

Because it has no noticeable symptoms, glaucoma is a difficult disease to detect without regular, complete eye exams.

One particular test, called a visual field test (or perimetry test), measures all areas of your eyesight, including your side, or peripheral, vision. A visual field test can help find certain patterns of vision loss and is a key way to check for glaucoma. It is very useful in finding early changes in vision caused by nerve damage from glaucoma.

To take this painless test, you sit at a bowl-shaped instrument called a perimeter. While you stare at the center of the bowl, lights flash. Each time you see a flash you press a button. A computer records the location of each flash and whether you pressed the button when the light flashed in that location. At the end of the test, a printout shows if there are areas of your field of vision where you did not see the flashes of light. This test shows if you have any areas of vision loss. Loss of peripheral vision is often an early sign of glaucoma. Regular perimetry tests are an important technique for learning how, if at all, your vision is changing over time. It can also be used to see if treatment for glaucoma is preventing further vision loss.

Visual Field Machine:               



Visual Field loss (glaucoma) in the right eye:   

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Dr. Haas will use your clinical exam findings along with these various diagnostic studies to assure you are receiving the best care for your glaucoma and glaucoma screenings.  Haas Vision Center has all of the instruments listed above, and you can feel comfortable in knowing that your care is top-notch with the utilization of the latest technologies to guide your treatment.



Age-Related Macular Degeneration (AMD or ARMD)

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Age-related macular degeneration (AMD or ARMD) is one of the most common causes of poor vision after age 60. ARMD is a deterioration or breakdown of the macula. The macula is a small area at the center of the retina in the back of the eye that allows us to see fine details clearly and perform activities such as reading and driving.
The visual symptoms of ARMD involve loss of central vision. While peripheral (side) vision is unaffected, with ARMD, one loses the sharp, straight-ahead vision necessary for driving, reading, recognizing faces, and looking at detail.

Although the specific cause is unknown, ARMD seems to be part of aging. While age is the most significant risk factor for developing ARMD, heredity, blue eyes, high blood pressure, cardiovascular disease, and smoking have also been identified as risk factors. ARMD accounts for 90% of new cases of legal blindness in the United States.

Nine out of 10 people who have ARMD have atrophic or “dry” ARMD, which results in thinning of the macula. Frequently deposits called drusen may develop as seen in the picture below.  Dry ARMD takes many years to develop. A specific vitamin regimen has been shown to slow progression of dry ARMD.  If you are a smoker, however, you need to modify these vitamins slightly as the high percentage of beta-carotene (vitamin A) in these compounds could potentially increase your risk of death due to lung cancer.

Dry ARMD with drusen:          

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Exudative or “wet” ARMD is less common (occurring in one out of 10 people with ARMD) but is more serious. In the wet form of ARMD, abnormal blood vessels may grow in a layer beneath the retina, leaking fluid and blood and creating distortion or a large blind spot in the center of your vision. This change can happen rapidly.  Researchers have found that a chemical called vascular endothelial growth factor, or VEGF, is critical in causing abnormal blood vessels to grow under the retina. Scientists have developed several new drugs that can block the trouble-causing VEGF. These are referred to as “anti-VEGF” drugs, and they help block abnormal blood vessels, slow their leakage, and help reduce vision loss.

Treatment with the anti-VEGF drug is usually performed by injecting the medicine with a very fine needle into the back of your eye.  Usually, patients receive multiple anti-VEGF injections over the course of many months. There is a small risk of complications with anti-VEGF treatment, usually resulting from the injection itself. However, for most people, the benefits of this treatment outweigh the small risk of complications.

Anti-VEGF medications are a step forward in the treatment of wet ARMD because they target the underlying cause of abnormal blood vessel growth. Unfortunately we do not yet have a cure.  This treatment offers new hope to those affected with wet ARMD. Although not every patient benefits from anti-VEGF treatment, a large majority of patients achieve stabilized vision, and a significant percentage can improve to some degree.

Promising ARMD research is being done on many fronts. In the meantime, high-intensity reading lamps, magnifiers, and other low vision aids help people with ARMD make the most of their remaining vision.

Wet ARMD with central scarring:      

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Anti-VEGF Treatment for Wet Macular Degeneration

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Anti-VEGF treatment is a way to slow vision loss in people who have a condition known as “wet” age-related macular degeneration (ARMD).

The two anti-VEGF medicines commonly used today for treatment are Avastin (bevacizumab) and Lucentis (ranibizumab), both made by Genentech.  Currently, there is no evidence of superiority of one of these medicines over another, although there is a huge cost difference.  Avastin costs around $50 per dose while Lucentis is over $2,000 per dose.  It is expected that people with wet ARMD will need a minimum of three treatments, though it is not uncommon to have 10 or more depending on how well your eye is responding to treatment.

In early 2008, plans were announced for enrollment of participants in the two-year Comparison of Age-Related Macular Degeneration Treatments Trials (CATT), sponsored by the National Eye Institute at about 45 study sites to help determine if Avastin or Lucentis is superior, or if they have the same equivalency.  The outcome of this trial will hopefully be known in 2011, and could have a major cost impact on our current healthcare.  This affects everyone, as there is a huge difference in cost when your copay per treatment is around $40 vs. $400 or more.

Macular Degeneration and Nutritional Supplements

Age-related macular degeneration (ARMD) is a disease caused by damage or breakdown of the macula, the small part of the eye’s retina that is responsible for our central vision. This condition affects both distance and close vision and can make some activities (like threading a needle or reading) very difficult or impossible. Macular degeneration is the leading cause of severe vision loss in people over 65.

Although the exact causes of ARMD are not fully understood, a recent scientific study shows that antioxidant vitamins and zinc may reduce the effects of ARMD in some people with the disease. These are known as eye vitamins or AREDS vitamins (Age Related Eye Disease Study). 

Among people at high risk for late-stage macular degeneration (those with intermediate ARMD in both eyes or advanced ARMD in one eye), a dietary supplement of vitamins C, E, and beta-carotene, along with zinc, lowered the risk of the disease progressing to advanced stages by about 20% over a 5 year period. However, the supplements did not appear to benefit people with minimal ARMD or those with no evidence of macular degeneration.

Light may affect the eye by stimulating oxygen, leading to the production of highly reactive and damaging compounds called free radicals. Antioxidant vitamins (vitamins C and E and beta-carotene) may work against this activated oxygen and help slow the progression of macular degeneration.

Zinc, one of the most common minerals in the body, is very concentrated in the eye, particularly in the retina and macula. Zinc is necessary for the action of over 100 enzymes, including chemical reactions in the retina. Studies show that some older people have low levels of zinc in their blood. Because zinc is important for the health of the macula, supplements of zinc in the diet may slow down the process of macular degeneration.

The levels of antioxidants and zinc shown to be effective in slowing the progression of ARMD cannot be obtained through your diet alone. These vitamins and minerals are recommended in specific daily amounts as supplements to a healthy, well-balanced diet.

It is very important to remember that vitamin supplements are not a cure for ARMD, nor will they restore vision you may have already lost from the disease. Also, if you are a smoker, you need to take a smoking-specific formula, as the standard formula has high doses of beta carotene (Vitamin A) which can increase the risk of death from lung cancer in smokers. 

Specific amounts of certain supplements do play a key role in helping some people at high risk for advanced ARMD to maintain their vision. You should speak with Dr. Haas to determine if you are at risk for developing advanced ARMD and to learn if supplements are recommended for you.

Smoking is also a big risk factor for ARMD.  If you are a smoker and have ARMD, it is possible that quitting smoking will have a more profound impact on your ocular health than any vitamin supplements you can take, and Dr. Haas recommends that you quit.

 


 




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