Eye Docs, PPG - when do you treat?

[masraum]

If you get someone with Pre-perimetric glaucoma, which I believe is thin optic nerve layers, but no loss of visual field or other issues, when do you start treatment? Do you start treatment right away to try to delay and slow the loss of vision or do you just keep a closer eye on things (no pun intended) and wait for other symptoms?

My wife was told today that she has PPG, and the Dr recommended drops with the explanation that eventually it will get bad enough to affect her vision, and starting the drops now will at least, delay and slow that progression.

We are google warriors and have read things on the 'Net that say "don't start treatment until you are actually being impacted" and other things that say "you will eventually be impacted, and once that starts, it can't be reversed so start treatment now to slow and delay things."

The missus is >60. Her mother has glaucoma, and her sister has been on drops for 2 years. Her mother's siblings aren't affected, but several (7?) of their children are. I suspect that probably pushes things more to the start treatment earlier side of things.

[2porscheguy]

It would appear that your wife has a very strong predilection towards developing POAG just based on her immediate family history so I would say best to start early here. Do you happen to know what her current IOP measures at now? Above 21 mmHG? What about her optic nerves...are they "markedly cupped"? How thin are her corneas?

Additionally, a visual field defect will not present itself until after a fairly substantial % of the optic nerve ganglions have already been affected. Once they are "dead" they won't come back no matter how aggressive the treatment so, again best to play it safe!

[recycled sixtie]

Now that Alex has answered as a professional this is what my mother experienced in the UK. I am sorry to hear about your wife's eyesight. I am not an eye prof!

Back about 15 years ago my mother was diagnosed with glaucoma. She took drops and had an operation in each eye. She passed away four years ago age 94. She never became totally blind but her last home was a home for the blind and she paid for this privately.

The most obvious deficiency was coming out of a restaurant with her. I had to take her arm and guide her out. Coming out of a dark restaurant and into bright sunlight her depth perception was poor especially when she had to descend steps. She seemed to be able to read quite well in her later years and she did like to read.

I go for yearly eye checkups and so far age 70 I am glaucoma free.

[masraum]

Originally Posted by 2porscheguy

It would appear that your wife has a very strong predilection towards developing POAG just based on her immediate family history so I would say best to start early here. Do you happen to know what her current IOP measures at now? Above 21 mmHG? What about her optic nerves...are they "markedly cupped"? How thin are her corneas?

Additionally, a visual field defect will not present itself until after a fairly substantial % of the optic nerve ganglions have already been affected. Once they are "dead" they won't come back no matter how aggressive the treatment so, again best to play it safe!

The missus says she's pretty sure the IOP was 19mmHg. She's not sure if they are cupped. She says that she has often been told that her optic nerve was unusually large, but she is now showing thin fibers. She's also not sure about the corneas.

She was curious what the purpose of the drops (Travatan) is. She thought the drops kept the pressure down, but it seems like her pressure isn't that high. Do the drops help the optic nerve or do something else?

Thanks for the info.

[2porscheguy]

It sounds like she has "low tension" or "normal tension" Glaucoma. Travatan is a prostaglandin analog which will increase the outflow of Aqueous Humour (the fluid inside the front of the eye) thereby decreasing the intra-ocular pressure (IOP). The aim is usually to reduce IOP by 25%. Travatan may take up to about a full month of use to realize the full therapeutic effect however.

The thin fibers you mention probably relates to the appearance of her optic nerves. Often one of the first signs we see in early low-tension glaucoma are thinning of the "rim of the optic nerve" which usually implies marked cupping of the nerve itself...sorry if I'm getting too technical here but clinically Glaucoma is often a multi-factorial disease which makes it difficult to arrive at a clear diagnosis. It's not black and white but a whole bunch of grey!

[recycled sixtie]

Then Alex at what point does a person have an eye operation for glaucoma?

[2porscheguy]

That's a good question RS!

In POAG (primary open angle Glaucoma) surgery is generally reserved for patients that don't respond well to meds alone....although this is changing as we speak, with the advent of newer surgical procedures being introduced.

In Closed or Narrow angle Glaucoma, surgery, which in this case is called a peripheral Iridotomy, is the immediate and often prophylactic treatment of choice.

[masraum]

2PG, thanks for the info.

So does it make sense to take the drops with normal or low tension glaucoma? Is the thought that lower pressure when it's not that high to begin with help slow or delay changes/degradation?

I understand that you can't really give a diagnosis over the 'net, but we are just trying to make sure that the Doc isn't just shotgunning treatment when there's not a good reason or it's not the right treatment.

[2porscheguy]

Steve, does your wife suffer from LOW blood pressure by any chance? This is a risk factor for normal or low tension Glaucoma.

[masraum]

Originally Posted by 2porscheguy

Steve, does your wife suffer from LOW blood pressure by any chance? This is a risk factor for normal or low tension Glaucoma.

no, she doesn't have low BP. She says when she was young she did, but these days it's normal unless she's anxious in which case it's quite high. It goes up pretty much any time she goes to the Dr or Dentist.

[2porscheguy]

Ah, "white coat syndrome"....I have that too! Off the top of my head I also know that fairly recent studies have shown there to be a possible link between sleep apnea and migraine headaches to normal tension Glaucoma....does she suffer from either of those conditions?

[masraum]

Her mom and sis have migraines, but so far her only headache is me.

No, not aware of either apnea or migraines.

I think she's just going to start taking the drops since there's a family history. She says "thank you for all of the information. It's been helpful."

[2porscheguy]

Ya I would just go with her Dr.'s recommendation. He/she obviously feels that with your wife's given family history and with some of the risk factors that she may possess as a result of clinical testing, it's best to play it safe and initiate treatment. It's potentially not a case of "if" but "when"! Glad to help out!