Dr. Shachi Dwivedi
Ophthalmology (Eye Care)
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have had ocular hypertension for twelve years. I was diagnosed with IOP with no signs of nerve damage, and they prescribed me Xalatan. And I had Lasik surgery to correct myopia. After the surgery, I decided to check my eye pressure, which was high, and Xalatan did not work well because of the steroids, so I stopped the steroids and Xalatan. The doctor prescribed me a Cosopt eye drop, which worked well and allowed me to reduce my eye pressure. And yesterday, I consulted an eye specialist for a routine checkup. The nerve is fine, with no damage or signs of glaucoma, but my eye pressure in my left eye is 55 (when on Cosopt), while my right eye is 20. He double-checked, and it still read 55. I am concerned about what is causing this rapid increase in IOP. So I use Losec (to control stomach acid), Pantoprazole, or Actifast if necessary. What is causing this high IOP that I never had? What can I do to reduce it? Was there anything that day that caused my pressure to rise, only in one eye, rather than both?
Hello,
Welcome to icliniq.com.
I understand your concern.
I have reviewed your reports (attachment removed to protect the patient's identity). Firstly, you are saying that there is no optic nerve damage. But seeing your field test, there is a defect in the superotemporal quadrant. A field defect can only be detected after 30 percent of the neurons have been damaged. So the damage is evident in the left eye in the perimeter. That is why one eye has a sudden spike in IOP (Intraocular pressure). It can be due to multiple reasons. Or the most common reason could be pigment dispersion (a mechanical rubbing between two ocular structures) or acute angle closure. I would like to know when your IOP (Intraocular pressure) was recorded 55. Did you have any headache, nausea, vomiting, or blurred vision? And was the corneal thickness measured? Because you had LASIK (laser-assisted in situ keratomileusis) surgery, your corneal thickness differs from that of a normal person. So only after pachymetry (a simple, quick, and painless examination used to measure the thickness of the cornea) a correct IOP (Intraocular pressure) be determined. Also, was the IOP measured by non-contact technique, or was it a contact procedure? As for the drugs, Cosopt (Dorzolamide) eye drops are a combination therapy containing two drugs. Xalatan (Latanoprost) eye drop is single drug therapy. That is why Cosopt is effective in your case. Also, do you have hypertension? Increased blood pressure can lead to decreased aqueous outflow resulting in high IOP. Please respond to the questions mentioned above for better evaluation.
Patient's Query
Hi doctor,
Thank you for the reply.
Why would the doctor not mention it, not even about the superotemporal quadrant? Is this treatable or permanent? Do my results shows that I have glaucoma? When my IOP was recorded 55 I had no headache, nausea, vomiting, or blurred vision. And no, non of the symptoms appeared. The only thing I experienced was dry eyes and blurry vision due to astigmatism that I was diagnosed with a year ago.However, I get headaches frequently, perhaps once or twice a month, lasting up to three days. I get nauseous when it is intense, but I never vomit. Yes, the corneal thickness were measured. After the LASIK, they added 10+ to my result, which was 10 for right eyes and 45 for left eyes before it. Now that became 20 and 55 after 10+ was added. He used Goldmann applanation tonometry to get my IOP numbers on the blue light machine.
Hello,
Welcome back to icliniq.com.
I understand your concern.
Applanation is the correct method. But adding 10 to Lasik (laser eye surgery) is rough. Superotemporal quadrant in the upper outer corner of the eye. The damage done in glaucoma (a group of eye conditions that damage the optic nerve) is irreversible. But we can put you on medications that will prevent further damage of the same. Also, you are having frequent headaches with nausea because your IOP (Intraocular pressure) has been fluctuating, and when it goes over 40 mmHg, you have a headache. That also explains the nerve damage which is common in higher IOP (Intraocular pressure). I do not know why the doctor did not mention it. Maybe because the OCT (Optical coherence tomography) is grossly normal, but seeing the visual field's defect cannot be ignored. I suggest you follow a few things. Firstly, get an IOP (Intraocular pressure) checkup by diurnal variation. This means your IOP will be measured four times a day. This is important to notice if your intraocular pressure is always high or changes at certain times of the day. Secondly, get a pachymetry (a simple, quick, and painless examination used to measure the cornea's thickness) to measure your corneal thickness. I would also suggest a corneal topography because such high IOP can lead to post-LASIK ectasia (a condition related to keratoconus in which the cornea bulges forward at varying times following LASIK treatment). This might explain recent astigmatism (a common and generally treatable imperfection in the curvature of the eye that causes blurred distance and near vision) you developed. Finally, switch to eye drop Brimonidine or Apraclonidine twice daily with Travoprost at bedtime. Brimonidine is a neuroprotective eye drop that will help prevent further nerve damage. I still suspect you of glaucoma only because the optic nerve is fine.
Patient's Query
Hi doctor,
Thank you for the reply.
So, if these visual impairments impact me completely, would I be blind? But now, at 30 %, I can see perfectly and have no problems, except that my right eye is a little blurry or hazy. So, is the test for detecting sight loss the one in which you look at block dots and use a clicker? And you click when you see things flashing around it? If that is the case, I will have to repeat it because my eyes were dry that day, and the lens was a little blurry. And I informed the nurse and asked her if we needed to repeat it. She said it was fine. So, what are your thoughts? Also, does it affect my left eye because I sleep on my left side (lateral portion)? Also, when you mention medicines, do you mean select one and take it twice a day, or do you mean to take both twice a day? Also, are there any medications that cause red eyes? Is there another alternative to one that makes my eyes red and terrified all day? Finally, do you have any recommendations for any surgery that could eliminate IOP permanently? So, what can I do to cure it without relying solely on medications permanently?
Hello,
Welcome back to icliniq.com.
I understand your concern.
I intended to make you aware of the issue and not scare you as per your query. Just do not skip medications. There is also a surgical option. Trabeculectomy can be performed with or without a valve (at the surgeon's discretion) if medicines do not regulate your IOP (Intraocular pressure). Brimonidine and Apraclonidine eye drops can be used as an alternative. Brimonidine is preferred. Concerning the examination, you need to retake it. SITA (Swedish Interactive Thresholding Algorithm) Standard 30-2. This is the testing mode necessary for confirmation. However, please get a topography and pachymetry for post Ectasia after Lasik surgery. Please follow up with all these reports.
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Ophthalmology (Eye Care)
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