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Dr. Rick
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 7745
Experience:  Ophthalmology since 1994 with Retina sub-specialty interest
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Im an artist, painting and drawing so my eyes have a special

Customer Question

I'm an artist, painting and drawing so my eyes have a special significance for me. Two months ago had a cataract surgery on the left eye. I did not have great vision immediately after surgery; I have progressed from a dense white fog but no objects were recognizable to the present where overall field is the same general brightness as the right eye, and (as a frame of common reference) I can read "Speed Limit" - not merely the numbers "45." The visual spectrum seems very complete. In short I'm improving at a slow but steady rate. In discussing what I believe may be opaque humor (largely because of how it has appeared, then totally went away on several occasions prior to this surgery...AND the fact that it seems to be retreating now) - in attempting to discuss this possibility, my surgeon stated that the reason I can't see very well out of the left eye is because of damage from glaucoma. Prior to surgery my pressure was stablized to around 16, went up briefly w/surgery and returned to 17 currently. I may need the Trabeculectomy suggested; BUT I feel that if the question of why my vision is blurred in that eye is not explored now, it never will be. I'm told that I have very little eyesight left, at the same time remark on how well the left eye SEES. No traditional dimming of vision, fade to black-merely a blurring which has come and gone before. I just want to know if my surgeon suffers from a kind of tunnel vision caused by the expectations of his speciality.

Submitted: 11 months ago.
Category: Eye
Expert:  Dr. Rick replied 11 months ago.
Hi. I'm Dr. Rick and I have two decades of ophthalmology experience. I'm online and happy to answer your question today.

Do you know what your cup/disk ratio is in this eye?

What was your visual field testing results?

How long have you had glaucoma issues?

What medications for glaucoma and other issues do you take?

Do you have any other medical problems?

Do you know what your eye pressure was when it was high?

Have you ever been told you have low tension glaucoma?

Other than drops,have you had any other therapy/treatment for your glaucoma?

Are both eyes affected?


This is not an answer, but an Information Request. I need this information to answer your question. Please reply, so I can answer your question. I look forward to helping you.
Customer: replied 11 months ago.
I answered these questions. got a message of "trouble" on the page, asked to 'refresh' DID you get a reply? Or do I have to do it all over again?
Expert:  Dr. Rick replied 11 months ago.
Jeff,

Yes, I'm getting that message a lot today. There seems to be some difficulties with the internet connection. I can only get online in spurts....

I'm sorry, but none of your replies to my questions came through. Could you please re-enter them.

Sorry about the technical glitches the internet seems to be having today :(

Customer: replied 11 months ago.
cup to disk - unknown, will try to get info from online patient charting, but so far will not let me sign on.

visual field results - well this is what the report is basid upon...a white field onto which small shimmering, banded squares are projected. My problem seems to be the overall cloudiness (which again is gradually breaking up/ clearing away) which leaves even less contrast than the test setup. I am fully aware of a grey curved area of early-on glaucoma damage; the size and area of it has not changed.

How long glaucoma - clearly defined as such five years.

Meds - Currently Combigan x 3 daily. Lotemax .5 Gel 1 drop day (it being my option I do it an hour or so before bed). Xalatan 1 drop at bedtime. I also take Diamox 500 SR x2 a day. I talked myself into this for its other benefits. Pressure after cataract surgery led to 5 hours in eye center chair with various combinations being administered. Finally I was given two tabs of Diamox which brought the pressure down 10 points over an hour. I discovered that my BP had ALSO suddenly normalized (from 190s/110 to 120s/80) requested to continue it; my GP concurred. Eye surgeon sees it as part of eye meds.

Med problems - 3 heart stents, but -0- deposits elsewhere.

Eye pressure when high. Five years ago I saw Anna Zeil on an emergency referral: OP measured 150. She medicated to reasonable levels. A year before that she told me I had "flashing scotomas, nothing to worry about." - such irony. Pressure was kept largely in teens until Cat surgery when it rose to 30, briefly

Low tension glaucoma? No
"Diagnosis: Primary open-angle glaucoma - Primary
Pseudoexfoliation glaucome - severe stage"
...A question here: if the cells are sloughing off the insides of the eye, where do they go? Perhaps contribute to overall haze?

Other treatment? SLT x2. Had expected it to be a regular part of my life until DR left Practice. Other partner seems happier with surgery.

Problem is only with left eye. Dire prediction that right will follow just has NOT worked out: no indication whatsoever.
Expert:  Dr. Rick replied 11 months ago.
Jeff,

Thank you for that extra information. I actually did research on pseudoexfoliation syndrome and the secondary glaucoma it can cause when I was a resident. As you already know, this is a very serious type of glaucoma and can be difficult to treat.

To directly answer your question, I do not believe that your vision loss is secondary to any sort of "humor opacity" such as clouding of the cornea, lens (yours was removed) or vitreous. Any such opacities would be instantly apparent to your ophthalmologist.

I feel, from what you have posted, that your visual problems are do to your glaucoma. I think that the pressure spike you experienced caused more damage to your optic nerve but, fortunately, your optic nerve is recovering somewhat and your sight is improving. I must tell you that you are fortunate that your vision is getting better as it is not common for a stressed/optic nerve to improve after any insult.

So. What is the take home message? From what you have posted, I agree with your surgeon: Your vision loss is due to severe damage to your optic nerve secondary to your glaucoma and the stresses of cataract surgery on your eye. It is good that some vision is returning over time but you should think of this as "bonus vision" that the majority of patients in your situation do not get.

Does this make sense to you.

I hope this information was helpful for you. But I do work for tips so I want to make sure you are happy with me before rating me. If you have another question on this or a related issue feel free to fire away. You may also receive an email survey after our chat, if you don’t feel that I have earned a “10” rating in all areas, please let me know what I can do to meet your expectations.

Thanks in advance,

Dr. Rick MD FACS
Customer: replied 11 months ago.
It is helpful but.... You speak of the stresses of cataract surgery as part of the visual loss. I'm thinking of the even greater stresses - including optic nerve anesthesia - of the proposed Trabeculectomy. Liability being what it is, I've ONLY had the possibilities of disaster read to me, not even a "I've done X number of these surgeries with a success rate of ___%, or better a failure rate of ___%." At my age, I've long ago passed the age of being able to be rushed; so this decision making process being pushed so hard makes it all the more threatening. I have to wonder if the stresses of the surgery will in essence push me visually over the edge, if the IOP of 12 the surgeon wants is all that much better than the 16 I can get with drops. It really seems that every proceedure takes away a bit more; with the Trabeculectomy it seems a LOT more might vanish
Expert:  Dr. Rick replied 11 months ago.
Jeff,

Those are all very good thoughts and concerns. However, I must agree with the glaucoma surgeon: Lower pressure is better.

Unfortunately, we don't know any other way to treat glaucoma then to lower the eye pressure. Hopefully in the future we will have other treatment tools.

In cases like yours, a pressure of 16 may still be too high for the health of your optic nerve, hence the trabelectomy to bring it down lower then meds can do.

There is no need for you to rush into this decision. Take your time. It is important that you are comfortable with whatever decision you make. But, every day that your pressure is higher than your optic nerve can tolerate, you will loose nerve fibers and visual field/vision.

Does this make sense to you?

It's safe for you to press the positive feedback button now if you so desire. And, never fear, even after you press that button I don't go up in a puff of smoke -- I'll still be right here to continue helping you, but, as I do work for tips, I want to make sure you are happy before rating me.

Dr. Rick MD FACS
Dr. Rick, Board Certified MD
Category: Eye
Satisfied Customers: 7745
Experience: Ophthalmology since 1994 with Retina sub-specialty interest
Dr. Rick and 2 other Eye Specialists are ready to help you
Customer: replied 10 months ago.


Yes, I did rate you and appreciate your information. Interestingly enough the IOP of 12 that the surgeon stated to be the goal of the proposed surgery has been passed (now 11); so we now have a memo from my original clinic to the Trab surgeon asking if there is any reason to go forward with it. I'll mention that vision in the eye continues to slowly improve, now to the point I can read crossword puzzles (with reading glasses). The fundamental haze oh soooo slowly fades.


 


I am so glad you asked. With the prospect of the surgery and my wife'smost successful 1st cataract replacement, I had totally forgotten about adding money to my account. I had difficulty when I tried to previously and, frankly, would rather just send you a check. But I will take this time to make another attempt.

Expert:  Dr. Rick replied 10 months ago.
Jeff,

It looks like the positive feedback went through.

I hope that your IOP of 11 is low enough for your optic nerve to keep from getting any further damage. The only way to know for sure, of course, would be to continue to monitor your optic nerve morphology, nerve fiber layer anatomy and visual field tests....

Let me know if there is anything else I can do to help you in the future.

Have a good weekend.
Customer: replied 10 months ago.

Dr. Rick:
Thanks again for your comments/insight. The surgery went "perfectly," according to the surgeon. Can't ride my motorcycle for a month, bend over at all...all the prohibitions you are aware of. Now, I gave you all of the possibilities that would have allowed you to give me the scenerio I wanted; instead, you gave me the one I needed to face up to. A good deal all 'round!

Expert:  Dr. Rick replied 10 months ago.
Jeff,

I am glad I could be of assistance, if only to prod you to make the decision you needed, but didn't want to, make. :)

Take care and heal up fast so you can go on a fall color ride...

Dr. Rick

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