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Living with glaucoma

Coffee/Tea

Within the first hour after consumption, coffee and tea can lead to a moderate increase in the intraocular pressure, but this effect is so small that no glaucoma patient has ever had to abstain from drinking these beverages. Basically, the glaucoma patient should not restrict his fluid intake, but rather consumption should be distributed throughout the day. Glaucoma patients who drink a lot within a very short time - say, one litre in just a few minutes - will experience a short-term increase in the IOP. The recommendation is thus to drink adequate amounts of fluids, but not large quantities in a very short time.

Alcohol

A small amount of alcohol, especially wine, is well tolerated and even exerts a protective influence on the heart and circulation. A glaucoma patient can enjoy a drink, even daily, without having to worry about the consequences to his eyes. In cases of acute angle-closure glaucoma , a large quantity of strong alcohol can lower the IOP for a few hours. Administering alcohol as a "therapy" only makes sense, of course, if there is no other way to lower the pressure in an emergency situation.

 

Smoking is the most important preventable risk factor that threatens human health. Smoking leads to cancer as well as to arteriosclerosis. Several eye diseases (obstruction of retinal vessels, maculopathy, cataracts, etc.) are much more common in smokers and occur at an earlier age than in non-smokers. Older smokers also have a higher risk of developing increased intraocular pressure as compared to non-smokers, but there is no evidence that smoking is an independent (i.e. unrelated to the IOP) risk factor for glaucomatous damage.

Marijuana

Even though marijuana does decrease the intraocular pressure, its medical use has not yet been investigated to the extent that it can be recommended as a therapeutic drug. Very few controlled studies have been performed to date; the advantages and disadvantages of long-term treatment with this agent still need to be fundamentally weighed against each other.

 

Regular physical activity is just as important to the glaucoma patient as is proper relaxation and adequate amounts of sleep.

Physical activity tends to cause a decrease, rather than an increase, in the IOP. However, patients with pigmentary-dispersion glaucoma are sometimes the exception to this rule: they can experience a significant rise in the IOP following physical activity (see Glaucoma with Pigment Dispersion Syndrome) even a patient with this special form of glaucoma should be able to participate in sports. Preventative measures, such as a laser iridotomy or administering pilocarpine before exercise, can avert an IOP rise. Sports are also recommended for patients with very low systemic blood pressure to help stabilize the body's circulation.

Patients who already suffer from a visual field defect should be made aware of their condition. For example, these defects could result in a ball not being seen in time when playing tennis or an approaching danger going unnoticed when bike riding.

Scuba diving

When swimming or snorkeling in relatively shallow water, there are only minor changes in the IOP. Glaucoma patients who plan to scuba dive should first consult their ophthalmologist. Someone having advanced optic nerve damage should probably refrain from diving.

Saunas

Saunas can also be enjoyed without concern. The IOP reacts just the same in glaucoma patients as in healthy subjects: it decreases in the sauna and then returns to original levels within about an hour. However, there is no proof that saunas are beneficial in glaucoma.

Flying

The IOP measured by doctor is – as defined from a physics point of view – the difference between an absolute intraocular pressure and the current atmospheric pressure. A rapid decrease in the atmospheric pressure thus leads to a (relative) increase in the IOP. This normally poses no problem for a glaucoma patient on board a plane: there is an artificial atmospheric pressure inside the aircraft's cabin that compensates for most of the natural pressure drop experienced at high altitude. The eye adjusts relatively quickly to the new situation. A moderate decrease in atmospheric pressure will therefore not induce a significant rise in IOP.

Another aspect to consider is the quality of air inside the cabin with its somewhat lower concentration of oxygen at high altitude and, as a consequence, a lower availability of O2. But here again, cabin ventilation provides the passengers with an almost normal level of oxygen. Nevertheless, glaucoma patients with advanced circulatory problems who fly frequently should discuss this with their ophthalmologist.

Music

Playing a wind instrument may lead to a transient increase in the intraocular pressure. Glaucoma patients who play these instruments should discuss this with their ophthalmologist.

 

The contact lens wearer can be reassured that these little optical devices do not affect the intraocular pressure. Indeed, IOP-reducing drugs can be given in even smaller doses to contact-wearing glaucoma patients. This is because a part of the drug is stored in or beneath the contact lens, forming a depot that continually releases the medication. However, keep in mind that some IOP-lowering drugs can render the corneal surface less sensitive. This increases the likelihood that an accidental injury occurring during lens insertion could go unnoticed.

After years of wearing contacts, certain changes occur in the patient's conjunctiva. This means there is a higher risk for the eventual obstruction of a fistula should a glaucoma operation become necessary. The introduction of mitomycin C has reduced this risk. Some glaucoma drugs can increase the symptoms generally known as "dry eyes," a condition that makes wearing contact lenses more difficult.

In short: glaucoma patients can usually wear contact lenses, but should first consult their ophthalmologist.

 

On average, the IOP decreases during pregnancy. This (as well as the moderate increase after menopause) is an indication that sex hormones play a significant role in regulating the intraocular pressure. Since glaucoma is a chronic disease with a very slow progression, starting a therapy can often wait until after delivery. If there is already advanced glaucomatous damage or the IOP is extremely high, therapy during pregnancy is necessary and possible. The treating physician will know which IOP-lowering drugs are harmless for the mother and the fetus, and will choose the appropriate therapy.

 

Should I let the eye doctor know if I am, or am planning to become pregnant?

Yes. Many medicines are known to have adverse effects during pregnancy; others are known to be safe, but in a large number of cases there is no firm evidence to decide on risk or safety.

The most important thing, if you are pregnant or trying to conceive, is to consult your GP and eye specialist about the pressure lowering eye drops which you are taking. Your doctor will balance the potential benefits of medical treatment against any possible risks, so that you can decide on your treatment together. Your ophthalmologist may advise an alternative, as it is important that glaucoma treatment is not discontinued.

As drug molecules are comparatively small, they pass easily through the placenta from the mother into the baby's bloostream. However, the quantity of drug delivered in an eye drop is very small when compared with the amount in a tablet. Drug molecules also pass into breast milk, especially those which dissolve easily in fat. Drugs in breast milk may theoretically cause hypersensitivity in the baby even when concentrations are too low for a pharmacological effect.

The eye drops and tablets listed below may have effects on the developing baby during pregnancy or breast feeding and the use of any of these should be discussed with your doctor.

Beta Blockers pass into the breast milk but adverse effects on the baby are unlikely from normal eyedrop doses. The usual ones prescribed are Timoptol, Teoptic, Betagan, Betoptic. These are also available without preservative in single dose containers, as well as Metipranolol Minims and Nyogel.

Carbonic Anhydrase Inhibitors pass into the breast milk and may reduce the milk supply. They may be in the form of acetazolomide (Diamox) tablets or slow release capsules, or dichlorophenamide (Daranide) tablets. Eye drops of dorzolamide (Trusopt) are also available. Their side effects, due to a general absorption, appear to be very much less than when the tablet form is taken by mouth.

Brinzolamide (Azopt) should not be used during pregnancy unless clearly necessary. It is also strongly recommended that the use of Azopt is avoided when breastfeeding.

Sympathomimetics - Adrenalin (Eppy, Propine or Simplene): Theoretically these eye drops could cause an increased heart rate in the infant during breast feeding.

Miotics (Pilocarpine): There is no evidence of risk to the baby during pregnancy at the doses used for chronic glaucoma. The drug passes into breast milk but adverse effects on the baby are unlikely.

Prostaglandins - Xalatan (latanoprost), Xalacom (combination of latanoprost & timolol), Lumigan (bimatoprost) and Travatan (travaprost): None of these are to be used unless clearly necessary.

Alpha 2 Agonist - Brimonidine (Alphagan): The safety of use during pregnancy or breastfeeding has not been established in humans and this should only be used if the potential benefit justifies the potential risk to the foetus or infant. It is not known if Alphagan is excreted in human milk and therefore caution should be exercised since it has been found to be excreted in animal milk.

As a general rule, drug research cannot be carried out in women who are, or might be, pregnant or breast feeding and as a result, the drug manufacturers for legal reasons cannot recommend the use of drugs in such people.

 

The following information is applicable to the UK only, other countries may have different regulations and it is important to check with the authority concerned.

The Driver and Vehicle Licensing Agency (DVLA) is legally responsible for deciding whether a driver is medically fit enough to drive a vehicle. This includes the driver's visual ability. A driver must be able to have both good central visual acuity and adequate peripheral vision. Anyone suffering from glaucoma and who has a visual field defect in both eyes must, by law, inform the Drivers Medical Branch of the DVLA. If only one eye is affected and the other eye is perfectly normal it is not necessary to inform the DVLA. The DVLA will then contact the patient's eye specialist for an appropriate report. In addition, the DVLA will often arrange an examination of the patient's visual field at a local optician (optometrist). It is important to stress that it is up to the patient, and not any doctor or optician, to inform the DVLA.

The minimum standards for driving a Group 1 vehicle (ordinary private car) are set out below. Group 2 vehicles (heavy goods vehicles and passenger carrying vehicles) have more stringent standards, and patients who wish to drive these vehicles should seek the advice of the Drivers Medical Branch of the DVLA.

1) The driver should be able to read a standard number plate in good light at 20.5 metres with both eyes open with or without glasses. The newer licence plates introduced in September 2001 should be read at the slightly shorter distance of 20 metres, as they consist of smaller letters. Some drivers do better reading the number plate than they do reading the eye chart. As the requirement is with both eyes open, only one eye is necessary to drive a car legally. From 1st May 2012, there is also now a definite requirement to have a visual acuity (using spectacles or contact lenses) of at least 6/12 (0.5 decimal).

These are the only requirements for most people to drive a car. Those people with eye defects such as glaucoma must notify the DVLA of their defect and the following further standard applies to such drivers.

2) The driver should have a peripheral field of vision of 120 degrees on the horizontal meridian, with the additional requirement (introduced on 1st May 2012) that there must be a field of at least 50 degrees on either side of the centre. In addition, there should be no significant defect within 20 degrees of the central fixation point. This is measured on a machine called a perimeter and is usually done at the eye clinic or at a recognised opticians shop. This test, known as the Esterman Test must be done with both eyes open and can be performed with or without glasses. A Medical Adviser at the DVLA will look at the result of the test and a judgement will be made as to whether the driver is within the standard or not.

If the driving licence is revoked or withheld because of medical reasons, that driver has a statutory right to appeal to a magistrates court. This will be made clear in any communication from the DVLA. Before going ahead with any appeal, it would be wise to discuss the matter with an eye specialist or general practitioner to confirm whether there are good grounds for an appeal. Considerable expense is involved with appealing and if the case were lost, the claimant would have to bear the costs involved.

If a decision is made to go ahead with the appeal, the driver must let the DVLA know of his intention as soon as possible. Legal advice should be sought from a solicitor and the legal department of the DVLA would correspond with both the driver's solicitor and the driver. It is usual for the Medical Adviser at the DVLA who signed the original revocation of the licence to complete a statement and often to attend the magistrates court to support it.

Useful addresses:

Drivers Medical Branch
DVLA
Swansea
SA99 1TU

Also the DVLA website on http://www.dvla.gov.uk

Simon Keightley FRCS FRCOphth
Consultant Ophthalmic Surgeon

 

Will glasses help with glaucoma?

Glasses do not directly help glaucoma but may well be necessary anyway.

Do I have to get up in the night to take my glaucoma eye drops?

No. Having an undisturbed night is more important. If you have to take drops more than twice a day, put the drops in when you get up and when you go to bed and then space the other drops in between, during the day.

Do I need to put the drops in before I come to the clinic?

Yes. Always continue as usual unless requested otherwise. It helps the doctor to judge the effect of the treatment.

How important is it to put the drops in at exactly the time stated?

It is important to get into a routine and to put the drops in at around the same time each day, but the exact time is less important.

There are several ways to help yourself remember when to put your drops in:

  • A chart with tick boxes,
  • A box with compartments for the drop bottles,
  • A special timer can be set to ring several times each day as required. 

Does it matter if I put more drops into my eye than I should?

No, but try to keep it to the number prescribed. There is a small increased risk of general side effects if you use more drops than you should.

Is it safe to put in an extra drop just to make sure?

Yes, if you are not certain that the first drop went in, it is safe to put in another drop. In general, it is best to avoid putting in more than one drop.

What happens if I forget to take my drops when I go out?

Do not worry unduly if you forget on the odd occasion, but try to get into the habit of taking your drops with you wherever you go. If you have forgotten a drop, just put it in as soon as possible after the time it was due.

Where should I keep the drops and for how long?

Keep your drops in a cool place or in the door of the refrigerator, which is cool but not as cool as if they were put on one of the shelves. Do not place them in the freezer section.

The unopened bottle will have an expiry date. Once opened, drops will last about four weeks.

Most beta blocker drops are stable up to at least 25 degrees Celsius.

If I go on holiday and there is no fridge, where should I keep my drops?

Keep your drops in a cool place out of the light. An insulated pouch or cool wallet, available from the IGA, helps to keep the drops cool.

Can I do Yoga exercises?

Yes, except for exercises involving the head being lower than the body for an appreciable time e.g. headstands. This tends to increase eye pressure.

Can I play wind instruments?

Playing a wind instrument such as a trumpet increases the eye pressure, but the effect will depend on how much, and how often, you play.

It is best to ask your eye specialist if it would be suitable in your particular case.

Can strong sunlight affect primary open angle glaucoma?

No, but if eyes are sensitive to strong light, then sunglasses can be helpful.

Can I play games like football and tennis or go swimming?

Following a recent trabeculectomy operation, you should avoid exercise which may involve the risk of eye infection or a blow to the eye. It is sensible to wear eye protection for any sport in which injury to the eye is a possibility.

Drops are absorbed soon after insertion so that after a few minutes they cannot be 'washed out' by swimming. However, even normal eyes can be irritated by the chlorine in swimming pool water.

Can I drink alcohol? Should I have a particular diet?

Yes, you can take any drink, alcoholic or soft. There is no scientifically established evidence that any particular food or vitamin helps. You should maintain a normal and balanced diet.

Can I take other medicines at the same time as my glaucoma treatment?

Patients with angle closure or narrow angle types of glaucoma should seek advice before taking some types of tranquilliser or certain asthma and indigestion medicines. However, these are usually safe if you have had laser treatment (iridotomy) or surgery (peripheral iridectomy).

Steroid (cortisone-type) drops and tablets should be used with caution because they can increase the pressure in the eye. If you have had a glaucoma operation, steroid drops or tablets are safer.

Some other tablets may interact with glaucoma treatments. Always mention to your doctor that you are having glaucoma treatment and your doctor will advise you.

If I have an operation for my glaucoma, will I still need drops/tablets afterwards?

You will need steroid and antibiotic drops for a period of time after the surgery.

Steroid drops are sometimes continued long-term.

The operation usually makes further treatment with glaucoma drops unnecessary. In about 20 per cent of cases, it may be necessary to start glaucoma drops again, even if the surgery was initially successful.

Should I let my eye doctor know if I develop other medical conditions?

Yes. It may influence the treatment they prescribe you.

Please remember that eye drops are powerful medications and that they can interact with other treatments.

Why do I have to see the eye specialist or attend the glaucoma clinic regularly?

It is important to attend regularly, even if your glaucoma is stable. The purpose of your visits is to monitor the glaucoma (through optic nerve appearance, visual field and eye pressure tests) to ensure that the treatment is working.

Primary open angle glaucoma and conjunctivitis: does it matter if I develop an eye infection causing a red sticky eye (conjunctivitis)?

Usually, this responds rapidly to treatment with antibiotic drops or ointment and presents no problems. However, if the eye has had a drainage operation (trabeculectomy), it should be taken more seriously because infection may spread along the new drainage channel formed by the operation and cause inflammation inside the eye.

An ophthalmologist's opinion is indicated without delay so that intensive treatment can be commenced, if necessary, at an early stage.

THIS IS MOST IMPORTANT

 

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