GLAUCOMA

THE

GUIDEBOOK

Okeke_Guidebook_Int_3pgs.indd 1 10/4/22 3:33 PM

 A J O H N S H O P K I N S P R E S S H E A LT H B O O K

Okeke_Guidebook_Int_3pgs.indd 2 10/4/22 3:33 PM

 THE GLAUCOMA
GUIDEBOOK

Expert Advice on
Maintaining Healthy Vision

Constance Okeke, MD, MSCE

JOHNS HOPKINS UNIVERSIT Y PRESS

BALTIMORE

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 Note to the Reader: This book is not meant to substitute for medical care, and treatment
should not be based solely on its contents. Instead, treatment must be developed in a dia-
logue between the individual and their physician. The book has been written to help with
that dialogue.
Drug Dosage: The author and publisher have made reasonable efforts to determine that the
selection of drugs discussed in this text conform to the practices of the general medical com-
munity. The medications described do not necessarily have specific approval by the US Food
and Drug Administration for use in the diseases for which they are recommended. In view of
ongoing research, changes in governmental regulation, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert of
each drug for any change in indications and dosage and for warnings and precautions. This is
particularly important when the recommended agent is a new and/or infrequently used drug.

© 2023 Constance Okeke

All rights reserved. Published 2023
Printed in Canada on acid-free paper
246897531

Johns Hopkins University Press

2715 North Charles Street
Baltimore, Maryland 21218
[Link]

Library of Congress Cataloging-in-Publication Data

Names: Okeke, Constance, author.
Title: The glaucoma guidebook : expert advice on maintaining healthy vision / Constance
Okeke, MD, MSCE
Description: Baltimore : Johns Hopkins University Press, [2023] | Series: A Johns Hopkins
Press health book | Includes bibliographical references and index. | Summary: “Dr. Okeke
provides a concise guide for readers about glaucoma—an eye disorder that leads to optic
nerve damage, vision loss, and blindness. She explains key terms used by doctors to talk
about testing and treatment options and provides guidance for readers on how they can take
care of their vision as well as their overall health”— Provided by publisher.
Identifiers: LCCN 2022017746 | ISBN 9781421445816 (hardcover) | ISBN
9781421445823 (paperback) | ISBN 9781421445830 (ebook)
Subjects: LCSH: Glaucoma—Popular works. | Glaucoma—Treatment—Popular works.
Classification: LCC RE871 .O34 2023 | DDC 617.7/41--dc23/eng/20220601
LC record available at [Link]

A catalog record for this book is available from the British Library.

Special discounts are available for bulk purchases of this book.

For more information, please contact Special Sales at specialsales@[Link].

Okeke_Guidebook_Int_3pgs.indd 4 10/4/22 3:33 PM

 DISCLAIMER

The mission of the author is to protect the sight and independence of people
with glaucoma through education. To this end, the author provides infor-
mation on glaucoma and glaucoma-related issues. The author works to
ensure that the information contained in this book is current, accurate, and
useful. Information contained in the book is based on professional advice
and expert opinion. This information, however, should not be considered
medical guidance or professional advice. The author, her representatives, and
any other parties involved in the preparation or publication of this book are
not responsible for errors or omissions in the information provided or any
actions resulting from the use of such information. Readers are encouraged
to confirm the information contained within this book with other reliable
sources and to direct any questions concerning their personal health to a
licensed eye doctor or other appropriate health care professional.

COPYRIGHT AND REPRINTS

The individual pages provided in this book are copyrighted by Constance

Okeke. This information is for personal use only. Permission to otherwise
reprint, copy, electronically reproduce, or utilize any document within this
book, in part or in whole, is expressly prohibited unless prior written con-
sent is obtained from Constance Okeke.
To request written permission, please email iglaucomapatient@[Link].
The compilation of information and materials in this book, including
design, graphics, and information, is copyrighted by Constance Okeke. The
unauthorized alteration of the content of this book is expressly prohibited.
The author and her representatives shall not be responsible for any claims,
actions, or damages which may arise as a result of the unauthorized alter-
ation of this book.

FEEDBACK

The author is proud to be a resource on glaucoma and glaucoma-related

issues. Let us know what you think about the book. We appreciate your
comments and ideas. To send us comments about this book or to request
information about our other products, please contact iglaucomapatient@
[Link].

Okeke_Guidebook_Int_3pgs.indd 5 10/4/22 3:33 PM

 PROCEEDS BENEFITS

Congratulations!
You are part of the fight against glaucoma blindness.
By purchasing this book, you have just financially contributed to increas-
ing glaucoma awareness, increasing support for glaucoma research, and
increasing opportunities for glaucoma surgical care for those in financial
need.
The author is donating some of the proceeds of this book’s royalties to
support the work of the Glaucoma Research Foundation and the American
Glaucoma Society’s AGS Cares Program. Read more about these organiza-
tions and their efforts in the “Philanthropy” section.
Sharing means caring. Spread the word about this book and save sight!

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 To my husband, Richard,
and my children, Izu, Ify, and Obi,
who support me with love and patience in every effort I make

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 Contents

FOREWORD, BY THOMAS M. BRUNNER xi

PREFACE xiii

CONTRIBUTING EDITORS xv

Introduction 1

1. Understanding Glaucoma 3

What Does Glaucoma Look Like? Part 1 5

What Is Glaucoma? 9
What Does Glaucoma Look Like? Part 2 17
What Are the Types of Glaucoma? 23
How Is Glaucoma Diagnosed? 28
How Is Glaucoma Treated? 34
Who Is at Risk for Glaucoma? 41
Recommendations for Eye Exams 46
What Is the Impact of Glaucoma? 47

2. 12 Expert Tips to Prevent Blindness 49

Tip 1. Don’t Ignore the Signs 49

Tip 2. Do the “Cover Your Eyes So You Can See” Test 51
Tip 3. Accept the Disease, Don’t Accept Defeat 53

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 x Contents

Tip 4. Conquer Your Fears: Don’t Despair, Have Hope 54

Tip 5. Take Glaucoma Seriously 57
Tip 6. Partnering with Your Doctor 57
Tip 7. Know What Is Expected 60
Tip 8. Keep Your Medical Records 63
Tip 9. Talk to Your Family 64
Tip 10. Be Honest with Yourself 66
Tip 11. Know the Risks Associated with Glaucoma and Cataracts 67
Tip 12. Manage Your Glaucoma and Dry Eyes 70

3. Keeping It Real: Real Patients, Real Advice 75

Conclusion 89

ACKNOWLEDGMENTS 91

RESOURCES 93
Guide to Putting in Eye Drops Correctly 95
Caregiver’s Guide 96
Additional Resources for Glaucoma Caregivers 101
Guide to Finding a Glaucoma Specialist 102
Additional Resources for Glaucoma Patients 105

REFERENCES 109

PHILANTHROPY 113

INDEX 115

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 Foreword

In this book, Dr. Constance Okeke concludes with the words, “Knowl-
edge is power.” I’d like to begin with those same words. With knowl-
edge, fear is eliminated. Dr. Okeke’s 12 expert tips help us to under-
stand and take control of our health and glaucoma.
As someone involved with glaucoma for almost 50 years, I’ve been
fortunate to know many of the leading glaucoma specialists around the
world and to read many books and articles that help glaucoma patients
manage their disease. Dr. Okeke’s approach is unique. She keeps her
book focused on two themes: understanding and responsibility. The
Glaucoma Guidebook is an easy book to read and is reassuring through
its simple and direct language.
It was at an annual American Glaucoma Society meeting in San
Diego where Dr. Okeke and I first met. She was an invited speaker and
gave a dynamic and well-received presentation that I still remember.
Following the session, I made my way quickly to the front of the room
to meet this new speaker with the important message about encourag-
ing glaucoma patients to speak to their family members regarding their
increased risk of glaucoma. We had a wonderful conversation and have
become friends and colleagues in our mutual efforts to help glauco-
ma patients preserve their vision through education and research. Dr.
Okeke is also an innovator and educator, utilizing the latest technology
for the best outcomes for her patients and sharing her experience with
other glaucoma specialists through her blogs and training courses.
Robert Shaffer, MD, one of the early glaucoma specialists and a
founder of the Glaucoma Research Foundation, taught his glaucoma

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 xii Foreword

fellows that it was important to treat the whole patient and not just
their glaucoma. As president and CEO of the Glaucoma Research
Foundation, I encourage readers to enjoy and learn from Dr. Okeke’s
guidebook and to take control of their health and glaucoma. Working
with their doctors, glaucoma patients can preserve a lifetime of healthy
vision.
Knowledge truly is power.

Thomas M. Brunner, BSEE, MBA

President and CEO
Glaucoma Research Foundation

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 Preface

As we talk about understanding glaucoma, there will be some discus-

sion and use of medical terms. You are in the right place. These medical
descriptions are written to help you understand a complex eye disease
in simple terms, with pictures to guide that understanding. Again, you
are in the right place. By the end of the book, your knowledge and
understanding of glaucoma will blossom, and you will gain confidence
as you talk to your doctors, family, and friends about glaucoma with
your newfound knowledge. Happy reading!

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 Contributing Editors

Eydie Miller-Ellis, MD
Director of Glaucoma
Professor of Ophthalmology
Scheie Eye Institute
University of Pennsylvania

Samantha Dewundara, MD
Glaucoma Specialist
Virginia Eye Consultants
Assistant Professor of Ophthalmology
Eastern Virginia Medical School

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 GLAUCOMA
THE

GUIDEBOOK

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 Introduction

Dear Reader,
As a glaucoma specialist, I have words of advice that I’d like to give
to every glaucoma patient—words of advice that I’ve gathered over the
years and feel that each patient should know to better take control of
their disease.
Glaucoma is an eye condition that, if left untreated, may lead to
blindness. That blindness is irreversible. We know that 50% of the
people who have glaucoma are not aware that they actually have the
disease, and we know that people who are aware that they have the dis-
ease still struggle with trying to live with glaucoma and take care of it.
Imagine that you lost your vision today. What would you miss most?
I want you to take a moment to write it down. Would it be that you
would miss looking at the faces of your family members and the mem-
ories that you recall having with them? Would it be clear sights that
you’ve seen, particularly if you’ve traveled around the world and viewed
certain beautiful images? Or maybe it would be your independence,
being able to take care of yourself, and walking without fear of stum-
bling or falling. These are things that could actually be lost if your glau-
coma is left untreated.

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 2 The Glaucoma Guidebook

If you have been recently diagnosed with glaucoma, or if you are

struggling to manage your glaucoma, this is the book for you. In these
pages, you will find some important tips from me—a glaucoma spe-
cialist and educator for more than two decades—to you, the glaucoma
patient. These tips will help you cope with your diagnosis and treat-
ment and equip you with knowledge to take charge of this serious but
treatable eye condition.

All the best,

Constance Okeke, MD, MSCE

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 1

Understanding Glaucoma

Before we begin to discuss what glaucoma is, I would first like to share
with you what the disease looks like. In pictures that try to convey
what someone with glaucoma sees, you may be shown an image of
normal vision, where the person can visualize everything in the envi-
ronment (fig. 1.1). Then you’ll see a picture of abnormal vision (fig.
1.2), which demonstrates that with glaucoma, there is generally a sig-
nificant amount of vision lost. This image represents what the world
may look like if you have glaucoma, but it is not the same for everyone
with the disease.
Glaucoma comes in many different stages, and in its earliest form,
people still see and function well. In fact, I’ve had glaucoma patients
who have looked at pictures on my clinic wall, similar to the abnormal
one here, and then said, “Oh, I must not have glaucoma, because my
vision doesn’t look like that.” Those patients did have glaucoma, but
at a different stage than that of the picture. Unfortunately, this type of
thinking is common and can lead to misunderstandings. I’m here to
tell you that glaucoma can be very sneaky, subtle, and misleading. In
the next section, I will share with you what I believe is a more realistic
description of what glaucoma can look like.

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 4 The Glaucoma Guidebook

Figure 1.1. Normal vision.

Figure 1.2. The same image viewed by a person with glaucoma.

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 Understanding Glaucoma 5

What Does Glaucoma Look Like? Part 1

A person can have advanced glaucoma and still have 20/20 vision, but
their peripheral, or side vision, can be severely affected. This concept of
what glaucoma looks like may seem confusing. Let me give you an idea
of what glaucoma looks like through two viewpoints.

Viewpoint 1: The Brain Tries to Fuse Both Eye Images

The brain wants you to see your best. It will take the image from each
eye individually and then fuse the two together to create the fullest pic-
ture. By doing this, it can be easy for you to miss a growing visual deficit
in one eye, because the other eye helps pick up the slack. Glaucoma can
affect each eye differently. A person can have glaucoma in one eye but
not at all in the other eye. On the flip side, a person can have glaucoma
in both eyes, but the disease can be worse in one eye compared with the
other. Doing the “Cover Your Eyes So You Can See” test can be a great
way to pick up on this. See Tip 2 (in chapter 2) for more details.
By looking at the pictures on the next three pages, you can get a
better sense of what I mean. These pictures show the viewpoint of a
person driving, looking through the front windshield.

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 6 The Glaucoma Guidebook

Figure 1.3. A driver’s viewpoint with a normal visual field (lower left corner),
indicating no vision loss.

In the first picture (fig. 1.3), the driver has early-stage glaucoma,
with a healthy, full field of vision. The lower left-hand corner contains
a diagram for a visual field that is normal. (A visual field is a type of
instrument used to measure visual function.) In this setting, the driver
can easily see the ball and the two children running after it. Normally,
this visual image would allow the driver to see the danger ahead and
stop immediately to avoid hitting the children.
I want you to take another look at the picture, noticing a few things
in particular:

• The yellow ball in the middle of the street.

• Two kids running after the ball.

• A red car (partial view) in front of kids.

• Tall buildings on both sides of the street.

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 Understanding Glaucoma 7

Figure 1.4. A driver’s viewpoint with a visual field (lower left corner) indicating
moderate vision loss due to glaucoma.

In the second picture (fig. 1.4), the viewpoint is the same. Now,
however, the driver has moderate-stage glaucoma, with a visual field
deficit that affects the field of vision. Can you see where the difference
is between the first and second images?
Look again for the yellow ball, the two kids running after it, and
the red car near the kids. Notice how the images of the children are
gone, except for the top of the head of the boy. Also notice the blurred
image of the red car. Glaucoma does not always cause absolute defects
that look like stark black blind spots. Some defects are often relative
and subtle, like a graying out of the area. With both eyes open, the brain
allows the images to fuse to make up for where there is loss, so the overall
image still looks okay.

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 8 The Glaucoma Guidebook

Figure 1.5. A driver’s viewpoint with a visual field (lower left corner) indicating
advanced vision loss due to glaucoma.

In the third picture (fig. 1.5), the driver is now at an advanced stage of
glaucoma, although still seeing a clear central image, possibly even with
20/20 vision. The peripheral field, however, is very blurred. Notice, yet
again, how the blur is not an absolutely black blind spot. The images are
grayed out. Remember the red car? Completely gone now. Remember
the buildings on both sides of the street? Now the left-side buildings
are gone.
At end-stage glaucoma, your central vision can also be damaged. This
is what treatment aims to prevent. We will get to the second viewpoint
of what glaucoma looks like after we explain what glaucoma is.

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 Understanding Glaucoma 9

What Is Glaucoma?

Glaucoma is an eye disease that causes damage to a structure in the eye,

called the optic nerve (fig. 1.6).

Figure 1.6. Eye anatomy.

This optic nerve is an essential part of the visual pathway. You can
think of the optic nerve as a lamp’s cable cord and the lamp as the eye.
Without the cord, the lamp won’t work. If enough damage is done to
the optic nerve, it will lead to vision loss. Ultimately, these changes are
permanent and can lead to complete blindness if not treated.

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 10 The Glaucoma Guidebook

Normal Optic Nerve

To understand glaucoma, it is important to know what a normal optic

nerve (fig. 1.7) looks like and how it normally works.

Figure 1.7. A doctor’s view of a

normal-appearing optic nerve.

When an eye doctor looks into the back of the eye to evaluate it for
glaucoma, he or she will look at the optic nerve. The optic nerve typ-
ically looks round, like a donut (fig. 1.8). The disc rim of the “donut”
should be thick. This is an indication that the nerve is healthy, with a
robust amount of optic nerve tissue. The central area has a “hole” that
we call the cup, and this area should be fairly small in size for a normal
optic nerve.

Figure 1.8. Left: A normal nerve. Right: A donut.

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 Understanding Glaucoma 11

When we are born, the optic nerve is created with a finite amount of
nerve cells that make up the disc rim. An average person has about 1.2
to 1.5 million cells. As we age, a small amount of those optic nerve cells
will slowly die off. This is normal and expected, because we are typically
born with many more nerve cells than we need to last us for a lifetime
of good vision.
What happens in glaucoma, however, is that there is a faster rate of
loss of those optic nerve cells. If this is left untreated, the loss will begin
to cause a permanent decrease of vision, which can significantly impact
one’s quality of life and ability to function.

Structural Damage in Glaucoma

When nerve cells are lost, the rim of the optic nerve begins to look
thin, and the central cup begins to look larger. We call these findings
cupping of the optic nerve (fig. 1.9). We use a term called cup-to-disc
ratio when we describe optic nerve cupping. The closer the number
is to 0.1, the healthier the nerve; the closer the number is to 1.0, the
more diseased the nerve. Findings of increased cupping are of concern
because it means there is damage to the nerve tissue. This is disturbing
news because nerve tissue loss is permanent. Optic nerve tissue does not
grow back and we do not have methods to replenish it.

Figure 1.9. Progressive (left to right) optic nerve damage.

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 12 The Glaucoma Guidebook

Functional Damage in Glaucoma

So, what does it mean if you have cupping of the optic nerve? Do you
still have normal vision? If you have cupping, there is loss of nerve
tissue. Yet you can continue to have normal vision in the early stages
of glaucoma. This is why we need to screen further for glaucoma and
perform a visual field test (fig. 1.10). This test is essentially a map of
your visual function. It tells the doctor what you can and cannot see.
It can often help determine if glaucoma is present, the stage of the
disease, and how aggressive we need to be with treatment. This is a
test that should be repeated regularly (typically at least once a year) to
determine if the glaucoma is stable or not. If the visual field progres-
sively gets darker, this can mean that the glaucoma is getting worse, or
is more advanced.
Later in this book, we will talk about glaucoma through a lamp anal-
ogy, where advancing glaucoma is like the brightness of the lamp’s light
getting dimmer and dimmer. If the optic nerve gets damaged enough,

Figure 1.10. Normal (A) and abnormal (B) visual fields.

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 Understanding Glaucoma 13

at the end stage it is like pulling the cord of the lamp out of the wall
socket, with the light completely going out. If a person’s glaucoma gets
worse, then the doctor will typically get more aggressive with treat-
ments to lower the pressure in that eye, perhaps with the use of addi-
tional eye drops, light energy/laser treatment, or incisional glaucoma
surgery. These efforts help significantly slow the dimming process, so
one can continue to see and function.

What About Eye Pressure?

The body naturally makes a fluid inside the eye, called aqueous humor.
This fluid drains out of the eye through an internal drainage system.
The balance between fluid being made and fluid draining out gives the
eye a certain eye pressure. Normal eye pressure for a normal optic nerve
is 21 millimeters of mercury (mmHg) or less. When there is an imbal-
ance in this process, it could lead to elevated eye pressure. Elevated eye
pressure may put stress on the optic nerve and could damage it, causing
glaucoma to develop. It was once believed that you must have glaucoma
if you have elevated eye pressure. This is not entirely true, however. Not
every patient with mildly elevated eye pressure will develop glaucoma
when their nerve is healthy. We call these patients ocular hypertensives.
Although their eye pressure is high, their nerve status and visual field
status are still healthy.
Here is a weight-lifter analogy to help you better understand the
risk of elevated eye pressure; see figures 1.11 and 1.12. Depending on
how high the pressure is and what other risk factors are present (such
as status of the nerve, thickness of the cornea, and family history), a
doctor may decide to monitor the condition closely, without treatment
(fig. 1.13), versus treating the patient to prevent glaucoma develop-
ment by lowering the eye pressure.

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 14 The Glaucoma Guidebook

Figure 1.11. For a strong weight lifter—a Figure 1.12. A weak weight lifter—a
healthy optic nerve—the pressure of the damaged optic nerve—cannot
weight is nicely in balance. maintain their balance because the
pressure of the weight is too much
for them.

Figure 1.13. Applanation tonometry, a method used to measure eye pressure.

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 Understanding Glaucoma 15

What About When the Pressure Is Not High?

Glaucoma can occur at any pressure level—high, low, or normal. In
fact, at least half of the people with glaucoma have normal eye pressures.
The problem with glaucoma is really about the damage that occurs to
the structure of the nerve and the resulting loss of vision. We know that
part of what causes the optic nerve to become damaged is the effect that
baseline eye pressure has on the optic nerve. Baseline pressure is the eye
pressure at the time of a glaucoma diagnosis, before any treatment. If
the optic nerve is getting damaged, the eye pressure must come down
below the baseline pressure to help slow down the rate of damage. This
is the only way in which we know how to manage glaucoma, because
other factors are out of our control.

What Is Good Eye Pressure?

If you are diagnosed with glaucoma, you may hear the term target pres-
sure. This is a designated eye pressure that your doctor will determine
based on your clinical picture. This target pressure is an estimated pres-
sure; maintaining it should slow the rate of nerve damage significant-
ly. A target pressure can remain unchanged if the nerve structure and
visual function remain stable over time. If the nerve structure or func-
tion (or both) get worse, however, the target pressure may need to be
changed. Your treatment regimen will then be altered to reach a new,
lower target pressure.
Although there is currently no cure for glaucoma, we know that we
can manage the disease by decreasing the eye pressure from its baseline
measurement. If done adequately and consistently, this will help slow
down the progressive nature of the disease and can continue do so for
several years.

Glaucoma Is Sneaky
The major problem with glaucoma is that it typically lacks symptoms.
There are several forms of glaucoma. (See the section on “What Are the
Types of Glaucoma?” for more detail.) The two most common forms
are open-angle and angle-closure glaucoma.

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 16 The Glaucoma Guidebook

By far the majority of diagnosed glaucoma in the United States is

open-angle glaucoma. In the early stages of open-angle glaucoma, you
can’t tell if you have an eye disease. There isn’t a sudden symptom that
can alert you to get your eyes checked. The early signs are very subtle
and are often ignored. Unfortunately, once the symptoms become sig-
nificant and noticeable, there is irreversible damage.
Angle-closure glaucoma, compared with open-angle glaucoma, is
not diagnosed as frequently in the US, and it occurs more common-
ly in Asian populations. That being said, angle-closure glaucoma can
still occur in all races and is seen readily in the US. The symptoms of
angle-closure glaucoma are often not as silent as those for open-an-
gle glaucoma. Common symptoms could show up in the form of a
subtle headache or pressure around the eye, often mistaken for a sinus
headache. Further, a person with angle-closure glaucoma could have an
angle-closure attack, where one can experience sudden intense eye pres-
sure, pain, headache, decreased vision, and eye redness. This is a true
eye emergency, and you will need to seek immediate eye care. Perma-
nent vision loss can occur quickly in this setting, and treatment often
involves using an eye laser or a surgical procedure, in addition to med-
ical therapy.

Screening Is the Answer

When glaucoma is caught early, it is much easier to treat. This is why

getting screened for glaucoma is so vital. The chance of still having a
lifetime of good functional vision is high. When someone does have a
noticeable loss of vision, however, the damage at that point is usually
moderate to severe and cannot be corrected. In that situation, a doctor
can only try to preserve the remaining optic nerve tissue and vision.
There is hopeful research about glaucoma and the ability to regener-
ate nerve tissue outside of the body.1 Nonetheless, no available clinical
treatments exist to successfully regrow functional nerve tissue in the
eye—at least not yet. One nonprofit organization I collaborate with

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 Understanding Glaucoma 17

that is fighting for a cure for glaucoma is the Glaucoma Research Foun-
dation. You can visit their website and gain more information about
fighting for a cure at [Link].

What Does Glaucoma Look Like? Part 2

So now that you have a better understanding of what glaucoma is, let’s
look at another analogy, through the viewpoint of a lamp and light.

Viewpoint 2: The Optic Nerve Is Like a Lamp’s Cable Cord

Think of a lamp and how it works. The lamp, like the eye, is made up of
individual parts (such as the bulb, socket, neck, base, and shade). They
can all be working just fine, but if the cord of the lamp is not plugged
in, the lamp won’t light.
Similarly, think of the optic nerve as a cable cord between the eye
and the brain (fig. 1.14). Signals for vision are sent from the eye to the
brain through this optic nerve. If the cable is not functioning fully, the
visual ability of the eye will be affected. If the optic nerve is completely
damaged, it’s like an unplugged lamp. There can be complete loss of
vision, to the point of perceiving no light.

Figure 1.14. A lamp

analogy.

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 18 The Glaucoma Guidebook

Glaucoma is usually a slow process, not a sudden one. You could even
lose half of your nerve cells and not begin to notice your glaucoma. The
signs are often subtle until the late stages.
Look at the image below with the light bulb (fig. 1.15). At full 100%
brightness, this is like a normal healthy nerve. You have plenty of ex-
panded vision to see well and clearly.

Figure 1.15. An optic nerve (left) and light bulb (right) at 100% brightness.

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 Understanding Glaucoma 19

If you lost 50% of the nerve tissue, and thus brightness, you would
still have light that would enable you to function (fig. 1.16). Your field
of vision could very well still be normal. The majority of people at this
stage would not notice the change, because it would be gradual.

Figure 1.16. An optic nerve (left) and lightbulb (right) at 50% brightness.

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 20 The Glaucoma Guidebook

If you lost 70% of your nerve tissue and were down to 30% bright-
ness, you might begin to notice a problem (fig. 1.17). You could proba-
bly still function fairly well. Maybe it would take a bit more work to see
and accomplish what you were doing before, but you could still do it.
You could ignore the signs or attribute them to aging or to being tired.
Or you could decide to get checked to see if you need glasses and then
find out you have another problem.

Figure 1.17. An optic nerve (left) and light bulb (right) at 30% brightness.

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 Understanding Glaucoma 21

If you lost 85% of the nerve tissue and were down to 15% bright-
ness, you would definitely notice signs of a problem (fig. 1.18). This
condition will begin to take a toll on your ability to function. At this
stage, you have moderate to advanced glaucoma. Treatments are aimed
at helping you maintain function and are not a cure. Unfortunately, the
currently available treatments cannot completely stop the progression
of nerve cell loss. Also, at this later stage, the treatment efforts often
need to be more aggressive to have an impact.

Figure 1.18. An optic nerve (left) and light bulb (right) at 15% brightness.

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 22 The Glaucoma Guidebook

If you lost 95% to 99% of the nerve tissue, you would have reached
legal blindness (fig. 1.19).

Figure 1.19. An optic nerve (left) and light bulb (right) at 5% brightness.

I paint this picture not to scare you, but to try to educate you. When
you understand what glaucoma can do, you will see why it is crucial to
get screened early, and, if diagnosed, to follow up regularly with your
eye doctor to preserve your vision.
Also understand that glaucoma is a complex eye disease, and each
person with glaucoma may experience vision loss differently. Glaucoma
can affect certain areas of the optic nerve specifically (focal loss), or it
can affect many areas of the optic nerve generally (global loss). Because
of this variability, each person experiences what glaucoma looks like in
their own unique way.
What is similar, though, is that if glaucoma is left untreated, it can
cause diminished color vision, reduced contrast sensitivity (the ability
to tell subtle differences between finer and finer light levels versus full
dark), and difficulty with depth perception. It ultimately can lead to
complete blindness, a drastic result that we want to prevent through
education and action. Keep reading.

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 Understanding Glaucoma 23

What Are the Types of Glaucoma?

We have mentioned that glaucoma is a complex eye disease. As such,

there are several types of glaucoma. By far the most common types are
open-angle glaucoma and angle-closure glaucoma. The classification of
these types is based on the position of certain structures in the eye.

Open-Angle Glaucoma

Within the eye there is a structure called the ciliary body. This structure
continually creates fluid, or aqueous humor, that nourishes the inside of
the eye. Aqueous humor flows from the ciliary body around another
structure, called the iris, into a space called the anterior chamber. It then
flows out of the eye through a drainage system and gets absorbed into
other parts of the body.
The entry point of this drainage system is called the trabecular mesh-
work. When we examine the eye through a special instrument called a
gonioprism, this lens allows us to see a magnified view of the trabecular
meshwork and other structures around it. When these structures look
like they are in a normal position and one can see the trabecular mesh-
work well, we call this an open angle.
What occurs in open-angle glaucoma is that there is some type of
clog within the drainage system (fig. 1.20). This clog prevents the aque-
ous humor from draining well, despite the eye structures appearing
normal. It eventually causes an increase in eye pressure due to the back
up of fluid drainage. As the increased pressure pushes against the walls
of the eye, the pressure causes damage to the delicate fibers of the optic
nerve in a permanent way, and thus open-angle glaucoma begins.

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 24 The Glaucoma Guidebook

Lens

Iris

Fluid Open angle

flow
Trabecular meshwork
(drainage canals)
Ciliary body

Figure 1.20. Fluid pathway in open-angle glaucoma.

Angle-Closure Glaucoma

In angle-closure glaucoma, the aqueous humor being made from the

ciliary body flows in a different pathway to the drainage system, caus-
ing pressure behind the iris, which pushes it forward (fig. 1.21). This
forward position of the iris results in a blockage of the trabecular mesh-
work, which further prevents the aqueous humor from flowing out
through the trabecular meshwork. We can use a gonioprism to magnify
the area and identify angle closure.

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 Understanding Glaucoma 25

Lens

Iris

Closed angle

Trabecular meshwork
Fluid (drainage canals)
flow
Ciliary body

Figure 1.21. Fluid pathway in angle-closure glaucoma.

Glaucoma Is Like a Sink

To understand the difference between open-angle and angle-closure
glaucoma, picture a sink with a drain and a running faucet. As men-
tioned earlier, fluid is continuously made in the eye, which is like a
running faucet that is always turned on. There is an internal drainage
system in the eye that drains this fluid, like an unclogged, open sink
drain (fig. 1.22A). There is a balance between the fluid being made and
the fluid going out of the drain, creating normal pressure in the eye.
When a person suffers from open-angle glaucoma, it is like there is
a clog inside the drain (fig. 1.22B). The faucet continues to flow, but
the fluid can’t escape. In a sink, the fluid would eventually build up and
spill over the edge of the sink. In the eye, however, the fluid cannot
drain out, because it is a closed system. So when the fluid builds up, the
pressure increases. This puts stress on the optic nerve, causing damage
and, ultimately, worsened open-angle glaucoma.

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 26 The Glaucoma Guidebook

A B C

Figure 1.22. Glaucoma sink analogy for (A) a normal eye, (B) primary open-
angle glaucoma, and (C) angle-closure glaucoma.

In angle-closure glaucoma, though, the “clog” occurs toward the

opening of the drain. It acts as a stopper, preventing the fluid from
the faucet from even entering the drain (fig. 1.22C). Angle closure can
create extremely high pressure very rapidly. This is a medical emergency
that needs to be treated quickly, as severe, irreversible damage to the
optic nerve can happen fast.

Other Types of Glaucoma

There are several other types of glaucoma, but a complete discussion of

them is beyond the scope of this book. Here we will simply mention
them briefly.

Congenital Glaucoma
Congenital glaucoma affects babies and is a result of poor development
of the structures in the eye that allow proper fluid drainage. This con-
dition is uncommon. Symptoms can include excess tear production,
cloudy or grayish-looking eyes, and eyes that appear larger in size when
seen early in infancy. Treatments for this condition are often surgical.

Secondary Glaucoma
This type of glaucoma is a generalized term that can encompass many
subsets of glaucoma that are secondary causes of open-angle or angle-

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 Understanding Glaucoma 27

closure glaucoma. They can be caused by trauma to the eye, the use of
steroids or other medications that can elevate eye pressures, diabetes,
inflammation in the eye, the development of a mature cataract, or a
tumor. The issue each form of secondary glaucoma has in common is
elevated eye pressure, which has a damaging effect on the optic nerve.

Pigment Dispersion Glaucoma

Pigment dispersion glaucoma occurs when there is an extra release of
pigment particles from the colored structure in your eye, called the iris.
Since these particles have to escape out of the eye through the same
drainage system as the aqueous humor, over time the pigment particles
can clog the drain and cause eye pressure to rise.

Pseudoexfoliative Glaucoma
In this type of glaucoma, there is a genetic development of protein
material that collects in the eye and sloughs off in small pieces over
time. Those pieces can get stuck in the drainage system and eventually
cause a significant clog that creates elevated eye pressure.

Normal-Tension Glaucoma
Normal-tension glaucoma is a subset of open-angle glaucoma that
occurs in patients who have normal to low eye pressure. Damage begins
from an unknown problem that shows up as weakness within the optic
nerve structure. The nerve can easily be damaged, even with normal or
low eye pressure.

Traumatic Glaucoma
This type of glaucoma occurs when there is direct trauma or injury to
the eye. Damage to certain structures within the drainage system cause
a poor outflow of aqueous humor, and resulting elevation in eye pres-
sure can damage the optic nerve.

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 28 The Glaucoma Guidebook

Neovascular Glaucoma
Neovascular glaucoma is caused by a vascular problem within the eye
that is related to conditions like diabetes or high blood pressure. Here,
a signal is turned on in the eye, which creates additional blood vessels
that act like weeds, spreading haphazardly and wildly throughout the
eye. They can bleed easily, causing inflammation and scarring, which
can ultimately clog the drainage system. Eye pressure is then elevated,
causing damage to the optic nerve.

Uveitic Glaucoma
This type of glaucoma occurs as a result of inflammation within the
eye. The inflammatory cells can clog the drainage system or cause scar-
ring that obstructs it. The treatment for inflammation typically involves
steroids, which, in turn, could cause an elevation in eye pressure. The
source of the inflammation could be from trauma, a systemic or body
condition such as arthritis, or unknown causes.

Steroid-Induced Glaucoma
People with glaucoma commonly have elevated eye pressure related to
their use of steroids. That usage could be in the form of topical ste-
roid drops in the eye; inhaled steroids, such as from devices to treat
breathing problems; topical steroid ointments for skin conditions; ste-
roid injections, such as for damaged knee joints; or oral steroids. It is
important for those using steroids for chronic conditions or at high
doses to be checked for eye pressure elevation.

How Is Glaucoma Diagnosed?

Look closely at this picture of three eyes (fig. 1.23). Which of these eyes
has glaucoma?
Any or none of these eyes could have glaucoma. Your guess would be
as good as mine. The reality is that looking at someone’s eye from the
outside, you can’t tell that glaucoma lies within. This is why regular eye
screening is so important.

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 Understanding Glaucoma 29

Figure 1.23. Eyes that could potentially have glaucoma.

In order to diagnose someone with glaucoma, a thorough eye exam-

ination in a clinical setting is required. There are multiple tests per-
formed during an eye exam in order to decide whether glaucoma is
present.

Tests for Glaucoma

Vision Test
Checking the visual acuity of each eye measures how good your vision
is. This test is typically performed by looking off in the distance at a
chart that has various letters or shapes in different sizes (fig. 1.24). By
finding out how much of the chart you can read, the doctor can assess
how healthy your vision is in each eye. Perfect vision is considered to be
20/20—in other words, your eye can see what is expected for normal
healthy vision at a distance of 20 feet.

Figure 1.24. Looking at a vision chart.

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 30 The Glaucoma Guidebook

Slit-Lamp Exam
A slit lamp is a common tool used to evaluate the eye (fig. 1.25). It has a
microscope and special light that allows a doctor to examine your eye in
great detail. With special lenses, your doctor also has the ability to look
inside your eye and study various structures, such as the optic nerve and
retina, to check for any damage.

Figure 1.25. A patient being examined with a slit lamp.

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 Understanding Glaucoma 31

Eye Pressure
A process called tonometry measures eye pressure. This is typically per-
formed after a numbing drop has been placed in the eye. A machine is
then used to measure the eye pressure by gently touching the numbed
surface of your eye, called the cornea (fig. 1.26). There are several differ-
ent techniques and devices that can determine eye pressure.

Figure 1.26. Eye pressure being taken with a device called an applanation
tonometer.

Gonioscopy
Gonioscopy evaluates the structures in the eye, allowing your doctor to
assess your natural drainage system. After a numbing eye drop has been
placed in the eye, the procedure is performed with the help of a special
lens that makes gentle contact with the surface of your eye (fig. 1.27).
The area in the eye that the doctor examines is often referred to as the
angle, and this is used to define the type of glaucoma one has: either
open-angle or closed-angle (narrow) glaucoma.

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 32 The Glaucoma Guidebook

Figure 1.27. A patient’s eye being examined with gonioscopy.

Visual Field Test

A visual field test is also called perimetry. This is a test of your side,
or peripheral, vision and can tell the doctor if your vision has been
affected by glaucoma (fig. 1.28). If you have glaucoma, this test will be
repeated many times to evaluate if your glaucoma is stable. There is a
learning curve with the test, meaning that as you take repeated tests in
the future, you get better and more accurate each time. This can be a
frustrating test for some because it evaluates areas where you can see as
well as areas where you can’t, which can make it feel as if you are not
doing well while you complete the test. Just make sure that you are well
rested before taking the test and try to do your best.

Nerve Fiber Layer Analysis

There are various types of imaging tests of the optic nerve that can help
examine it in great detail. The most common is called OCT, or optical
coherence tomography. It can give a direct measure of the thickness of
the nerve fiber layer and, over time, help your doctor assess whether

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 Understanding Glaucoma 33

Figure 1.28. A patient taking a visual field test.

damage to the optic nerve is stable or progressively getting worse. In

figure 1.29, the green color indicates healthy nerve tissue, yellow indi-
cates borderline healthy nerve tissue, and red indicates severe damage.

S S
101 69

T N N T
75 63 39 48

I I
114 64

TS NS NS TS
120 83 53 64
(132) (102) (102) (132) Figure 1.29.
T N N G T
75 63 39 53 48 Optical
(72) (72) (72) (96) (72) coherence
TI NI NI TI
146 83 56 72 tomography
(133) (104) (104) (139)
diagnostic
Classification OD Classification OS tests: (A)
A Within Normal Limits B Outside Normal Limits normal; (B)
abnormal.

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 34 The Glaucoma Guidebook

Photographs of the Optic Nerve

A picture is worth a thousand words. Photographs of the optic nerve
allow your doctor to have a record of how the nerve looks at one point
in time, so it can be compared with future views of the nerve to assess
any changes (fig. 1.30). This test is often done when the eyes are dilated.

Figure 1.30. Optic nerve photographs taken at various stages of severity.

Test Results

After these tests are performed and the results are reviewed by your eye
doctor, a diagnosis of glaucoma, as well as a determination of the type
of glaucoma and its stage (mild, moderate, or severe), should be able
to be made. At times the presence of glaucoma is not definite, but sus-
pected. A patient in this scenario is then given a diagnosis of glaucoma
suspect. There may be no immediate treatment, but that person will
undergo continued observation and repeated tests. Let’s next talk about
the treatment options for glaucoma.

How Is Glaucoma Treated?

Whether the glaucoma is open angle or angle closure, and is mild, mod-
erate or severe, all treatment methods are aimed at the same goal: to

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 Understanding Glaucoma 35

lower the baseline eye pressure. Think of eye pressure like stress on the
optic nerve. If one can reduce the stress, this can protect the remaining
optic nerve tissue and prevent further damage, as well as a possible per-
manent loss of vision.
The three pillars of treatment for glaucoma are medications, light
energy (laser) treatment, and incisional surgery. Medications are still
the most commonly used treatment method for glaucoma, though
there has been a more recent shift to utilizing light energy or surgical
interventions earlier in the process. You may benefit from one type of
treatment or several in combination to manage your glaucoma over
your lifetime. The various treatment options will be presented to you,
and recommendations will be made by your doctor.

Medication

Medications for glaucoma can be taken in the form of eye drops (most
common), oral pills, through an IV (an intravenous route), or other
modes of sustained-release delivery. There are currently six classes of
glaucoma medications, with various generic and brand names. Each
class comes in the form of eye drops that have a specific bottle top color,
which helps to more easily communicate medication regimens between
doctor and patient. This is especially helpful due to some of the compli-
cated names of these drops or complex schedules of usage.
Each medication has potential side effects, which are important to
keep in mind when deciding which medication will be the best option
for the patient. Also, each medication has a specific mechanism of
action for how it lowers eye pressure, which can be additive when mul-
tiple medications are used in combination. Let’s go over the six different
glaucoma drug classes (fig. 1.31).

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 36 The Glaucoma Guidebook

Class—color of bottle top—Mechanism of Action—Most

Common Side Effects

Alpha Agonists—purple top—decreases the production of intraocular

fluid (aqueous humor) and increases the drainage of the fluid—
burning or stinging in the eye, drowsiness, dry mouth and nose,
headache, fatigue

Beta Blockers—yellow top—decreases the production of intraocular

fluid—burning or stinging in the eye, reduced pulse rate, lower blood
pressure, shortness of breath in people with asthma or breathing
disorders, depression, reduced libido

Carbonic Ahhydrase Inhibitors—orange top—decreases the

production of intraocular fluid—blurred vision, dry eyes, stinging,
burning in the eye (side effects of the oral pill in this class includes
fatigue, frequent urination, tingling in the hands and feet, upset
stomach, kidney stones)

Cholinergics—green top—increases the drainage of intraocular

fluid—dim vision, headache around the eyebrow, small pupil size

Prostaglandin Analogs—teal top—increases the drainage of

intraocular fluid—red eyes, eye color change in the iris, darkened
eyelid skin, eyelash growth, stinging, itching in the eye, dry eyes,
sunken eyes

Rho Kinase Inhibitors—white top—increases the drainage of

intraocular fluid—red eyes, stinging in the eye, pigmentation on the
cornea, small amounts of bleeding in the white of the eye

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 Understanding Glaucoma 37

1 2 3 4 5 6

Alpha Beta Carbonic Cholinergics Prostaglandin Rho Kinase

Agonists Blockers Anhydrase Analogs Inhibitors
Inhibitors

Figure 1.31. Six classes of eye drops and their bottle cap colors.

Of the medication classes listed above, only the carbonic anhydrase

inhibitors come in an oral pill form, which can also be given intrave-
nously.
Several classes of drops can come in a combined form in one bottle,
for more convenient use and greater potency.
Outside of medications in the form of drops, one class of drug—the
prostaglandin analogs—now comes in the form of a sustained-release
pellet that can be placed in the eye and help lower eye pressure for a
period of months to years.
We are hoping for additional methods of drugs being delivered to the
eye, which are in the testing phases now.
Look in the “Resources” section in the back of this book to learn how
to properly instill eye drops and how not to put them in.

Light Energy (Laser)

We have several different types of light energy treatments. They come

in the form of various lasers that can be applied to the eye and effec-
tively lower eye pressure. Which laser is utilized depends on the type
of glaucoma and the severity of the condition. These treatments use
different wavelengths of light and are aimed at various structures in the
eye. Some treatments use a numbing eye drop, with the patient sitting
upright in an office setting, while others take place in an operating
room, under sterile conditions and with sedation.

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 38 The Glaucoma Guidebook

Laser Peripheral Iridotomy (LPI)

This laser treatment is used for angle-closure glaucoma. It helps move
the obstruction in the drainage system by making a small hole in the
iris tissue with a heated laser, so fluid can flow in a different direction.
This change in direction helps open up the obstruction. LPI is typically
performed in an office setting, with the patient sitting upright, and uses
a topical eye drop for anesthesia.

Selective Laser Trabeculoplasty (SLT)

This laser treatment is used for open-angle glaucoma. It helps open the
pores of the drainage system within the trabecular meshwork by using
a cold laser (fig. 1.32). Because the surrounding tissues are left intact,
this procedure can safely be repeated multiple times. SLT is typically
performed in the office setting, with the patient sitting upright, and
uses a topical eye drop for anesthesia.

Figure 1.32. SLT light treatment.

Argon Laser Trabeculoplasty (ALT)

This laser treatment is used for open-angle glaucoma. It uses a heated
laser to help make the drainage system flow better within the trabecular
meshwork. The laser can cause scarring of the tissue within the drain-
age system, so this type of treatment can’t be repeated. ALT is typically
performed in an office setting, with the patient sitting upright, and uses
a topical eye drop for anesthesia.

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 Understanding Glaucoma 39

Laser Cyclophotocoagulation
This laser treatment is used for open-angle or angle-closure glauco-
ma. The laser’s energy is aimed at a structure called the ciliary body,
which makes fluid in the eye. The laser effectively reduces the amount
of fluid being created, thus reducing the amount of fluid that needs to
be drained, which in turn lowers eye pressure. There are several different
methods for how this treatment can be applied to the eye. It could be
performed in the procedure room of an office setting or in a sterile oper-
ating room, but more numbing of the eye than just drops is required.

Treatment Choices
Studies have shown that laser peripheral iridotomy for angle-closure
glaucoma, and selective laser trabeculoplasty for open-angle glaucoma,
can be effective first-line therapies.

Incisional Surgery

There are several different types of glaucoma surgery options that can
be performed for the various types and stages of glaucoma. A determi-
nation of which option is best for a patient can be made at the time of
the examination and depends on both the specific glaucoma condition
and the skill set and comfort level of the doctor performing the surgery.
Traditional glaucoma surgeries have been available for several decades
and are able to lower eye pressure effectively. The most commonly uti-
lized ones are trabeculectomy and a tube shunt. Though these surgeries
help lower eye pressure, they can also be associated with some compli-
cations that can affect one’s vision, and they have a longer healing time.
Nonetheless, they are the go-to procedures when glaucoma is more
advanced or refractory (meaning it is very difficult to control).

Trabeculectomy
Trabeculectomy is considered the gold standard for glaucoma surgery.
In this procedure, incisions are made in the eye to create a new pathway
for fluid to flow internally. A bleb is created as result of this procedure.

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 40 The Glaucoma Guidebook

This is a space for intraocular fluid to flow into that can allow the fluid
to be absorbed, thus lowering the overall pressure inside the eye. This
outpatient procedure is done in an operating room and can take 6 to 8
weeks to heal.

Tube Shunt
In a tube shunt procedure, a device is permanently placed in the eye
and acts as a new drainage system. The device can vary in shape and
size, but it typically sits along the wall of the eye in an area that is cov-
ered by the eyelid. As fluid flows into the tube, it is shunted away to
another place internally where it can be absorbed. This reduces overall
eye pressure. This outpatient procedure is done in an operating room
and can take 6 to 8 weeks to heal.
If you have had a traditional glaucoma procedure, know that there
can be risks of infection even years or decades after the surgery has been
done. You should alert your doctor if you develop a painful red eye.

MIGS
Minimally invasive glaucoma surgery, or MIGS, is a more recent class
of glaucoma surgery. It was developed in order to find solutions to effec-
tively lower eye pressure while reducing some of the risks involved with
traditional glaucoma surgery. Though these procedures can reduce eye
pressure, they typically are not able to lower them to the level obtained
through traditional glaucoma surgeries, so they are often utilized in
patients who have mild to moderate glaucoma.

Treatment Choices
These surgical procedures have various mechanisms for how they work,
but collectively their goal is to enhance the eye’s natural drainage system
by clearing away clogged material or using an implanted device within
the natural drain to create a stable pathway for intraocular fluid to flow
better. Better flow means lower eye pressure. Often these procedures
can benefit patients by also reducing the number of eye drops that are

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 Understanding Glaucoma 41

needed to help control their glaucoma. Any of these procedures can be

done at the same time as cataract surgery, and some can be performed
alone. MIGS are outpatient procedure that are done in an operating
room and can typically take 4 to 6 weeks to heal.

Who Is at Risk for Glaucoma?

Not everyone will develop glaucoma, but anyone can be at risk. It can
occur at any age, for any gender, and in any ethnicity. There are, how-
ever, risk factors that make certain people more susceptible to glauco-
ma than others. Some risk factors are easily discernible by an average
person, while others are found through an actual eye exam. Because
the list is extensive, we will discuss just some of the most common and
important risk factors.

Increasing Age

The risk of glaucoma increases with age. This

is because we naturally lose optic nerve tissue
as we age. The older you are, the higher the
chance that this loss of optic nerve tissue
can negatively affect your vision. We can use
a jar of marbles as an analogy to illustrate
this concept. When we are born, we have a
jar full of marbles (fig. 1.33). Each day, we
lose about 1 marble. As we get older, the jar
gets less full, and we continue to lose mar-
bles at a higher rate. Older people without
glaucoma may lose 5 marbles a day. Their jar
is half full. They don’t have vision loss yet,
but we should monitor them closely anyway
and begin treatment to slow down the rate Figure 1.33. A jar of marbles
of marble loss if they are losing marbles at representing an optic nerve.

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 42 The Glaucoma Guidebook

Figure 1.34. Jars of marbles representing a normal optic nerve (left) and a
weakening optic nerve (right).

a much higher rate than normal. Even more elderly people with glau-
coma may lose 10 marbles a day. Their jar is only one-fourth full (fig.
1.34). This puts them at a greater risk of vision loss. We should monitor
them even more closely and treat them more aggressively.

Family History

If you have glaucoma, anyone who is a blood relative has an increased

risk for developing glaucoma. This is especially true for your immedi-
ate family, including your siblings, parents, and children. The rate of
glaucoma can be up to nine times higher among individuals with a sibling
who has glaucoma. See Tip 9 (in chapter 2) for further discussion on
this topic.

Ethnicity

There are certain ethnicities that are more predisposed to various types
of glaucoma.

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 Understanding Glaucoma 43

African or Caribbean Descent

According to many population-based studies, more African Americans
have glaucoma, compared with Caucasians. Blindness from glaucoma
is 6 to 8 times more common in African Americans than Caucasians.2
And African Americans are 15 times more likely to be visually impaired
from glaucoma than Caucasians.3 Worldwide, one of the continents at
highest risk for blindness from glaucoma is Africa.

Asian Descent
Angle-closure glaucoma is more common in people of Asian descent.
People with acute angle-closure glaucoma can have it show up as pain,
sensitivity to light, redness in the eyes, and sudden blurred vision. This
is a more aggressive form of glaucoma. It makes up less than 10% of the
glaucoma diagnosed in the US, but it is much more commonly seen in
Asian countries. Angle-closure glaucoma accounts for 90% of all cases
of blindness from glaucoma in China.
Another type of glaucoma is called normal-tension glaucoma, where
damage to the optic nerve happens when eye pressures are normal or
even low. This form of glaucoma seems to occur more commonly in
Japanese populations.4

Hispanic Descent
Glaucoma is also more common in Hispanic populations, especially
in those with predominantly European ancestry. A population-based
study showed the overall prevalence of open-angle glaucoma among
Hispanics to be nearly 5%, similar to that for those of African descent.5
This and other studies also indicate that as Hispanics age, the incidence
of glaucoma increases exponentially for those over the age of 60.6

Scandinavian Descent
Pseudoexfoliative glaucoma tends to occur more commonly in people
of Scandinavian descent. This type of glaucoma is associated with the
production of a certain type of protein that collects in various parts of
the body. In the eye, it can be seen as a fluffy white material that col-

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 44 The Glaucoma Guidebook

lects on the iris and the lens (fig. 1.35). It can cause an aggressive type
of glaucoma and makes cataract removal during surgery more difficult.

Figure 1.35. Pseudoexfoliative glaucoma.

Overall Susceptibility
Please note that though some ethnicities may be more predisposed to
certain types of glaucoma, this doesn’t mean that they cannot get other
types of glaucoma. Each type of glaucoma can affect any race, gender,
or nationality.

Trauma

An injury to the eye or the structure around the eye can increase the risk
of glaucoma, although glaucoma as a result of trauma usually occurs
only in the injured eye. It may be present immediately after the injury,
or it can take several months or even years to develop. Not all people
with a history of an eye injury will develop glaucoma. It does put you
at a higher risk, however, and should prompt the need for an eye exam
soon after the trauma occurs.

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 Understanding Glaucoma 45

Use of Steroids

Steroids are a class of drugs used to treat inflammation in the body.

These are different from the anabolic steroids that athletes might use.
Steroids can be prescribed in many forms, such as in eye drops, oral
pills, injections, an inhaled treatment, and a topical cream. Steroids are
used for a variety of reasons. Taking steroids may lead to elevated eye
pressure and eventual glaucoma. It is very important to schedule regular
follow-up exams with your eye doctor to check your eye pressure if you
are using steroid eye drops or steroids for other parts of the body for a
longer period of time.

Myopia, or Nearsightedness

If you are nearsighted, you typically can see well up close but can’t
see distant objects clearly. This is called myopia. It commonly occurs
when the eyeball is too long, so light is focused too far in front of
the information-processing center of the eye. Population-based studies
show that the risk of glaucoma is higher with an increasing degree of
nearsightedness.7,8 This means that the longer your eyeball is, the higher
the chance that you will have damage to your optic nerve, and the more
likely it is that you will have glaucoma.

Blood Pressure

High blood pressure does not have a direct relationship with an increase
in eye pressure, but there can be an indirect relationship, which could
have an impact on the development of glaucoma. If you have elevated
blood pressure, you should have regular eye screenings.
Low blood pressure can be a problem for glaucoma patients, because
it is important for the optic nerve to receive an adequate amount of
blood flow to be well nourished. Limited blood flow has been associat-
ed with optic nerve damage and is a risk factor for the development of
glaucoma.

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 46 The Glaucoma Guidebook

It is important to tell your eye doctor if you have high or low blood
pressure, particularly if you are taking medications for the condition.
Some blood pressure medications can affect your glaucoma treatment,
so be sure to share this information as well.

Recommendations for Eye Exams

For patients who do not have risk factors for glaucoma, the American
Academy of Ophthalmology recommends comprehensive eye exams
(table 1.1).

TABLE 1.1. AMERICAN ACADEMY OF OPHTHALMOLOGY EXAM

RECOMMENDATIONS FOR PEOPLE WITH NO GLAUCOMA RISK FACTORS

Under 40 years old every 5–10 years

40–54 years old every 2–4 years

55–64 years old every 1–3 years

65 years and older every 1–2 years

Source: Adapted from Preferred Practice Patterns: Comprehensive Adult Medical Eye
Evaluation, American Academy of Ophthalmology, 2022.

A comprehensive eye exam includes

• a detailed evaluation of your medical and eye history,

• a review of your medications,

• an eye health evaluation, including a dilated eye exam,

• measurement of your eye pressure,

• a test of your visual ability, and

• possibly additional tests, depending on the initial findings.

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 Understanding Glaucoma 47

As you get older, you should get comprehensive eye exams more
often. If you have additional risk factors for glaucoma (keep reading
to find out more about these), eye evaluation should begin even earlier
(table 1.2).

TABLE 1.2. AMERICAN ACADEMY OF OPHTHALMOLOGY EXAM

RECOMMENDATIONS FOR PEOPLE WITH GLAUCOMA RISK FACTORS

Under 40 years old every 1–2 years

40–54 years old every 1–3 years

55 years and older every 1–2 years

Source: Adapted from Preferred Practice Patterns: Comprehensive Adult Medical Eye
Evaluation, American Academy of Ophthalmology, 2015.

What Is the Impact of Glaucoma?

Worldwide, glaucoma is the leading cause of irreversible blindness.

Many people do not realize they have glaucoma because vision loss typ-
ically is subtle and unnoticeable until the disease is more advanced. In
the United States, up to 50% of the people who actually have glaucoma
right now do not realize they have it.9 That number reaches 90% on the
global scale. Worldwide, as of 2040, an estimated 80 million people will
have been diagnosed with glaucoma.10 In the US, more than 120,000
are blind from glaucoma, accounting for 9% to 12% of all cases of
blindness.11
As our aging population continues to grow, the number of people
with glaucoma will continue to rise. In the US right now, there are
about 3.5 million people with glaucoma, at a cost of approximately
$5.8 billion per year from more than 10 million physician visits annual-
ly.12 By 2050, that number will double, with an estimated 7.32 million
people having primary open-angle glaucoma.13

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 48 The Glaucoma Guidebook

Although the onset of glaucoma in our populations is on the rise (fig.

1.36), the good news is that the negative impacts of glaucoma in steal-
ing one’s vision can be lessened with awareness and by taking personal
action. In the next pages I will share some of my top tips that will arm
you with clear directions on how to preserve your sight.

WHITE BLACK HISPANIC OTHER

3,000,000

2,500,000

2,000,000

1,500,000

1,000,000

500,000

0
2015 2020 2025 2030 2035 2040 2045 2050

Figure 1.36. Projected glaucoma population by race and year.

Source: Courtesy of Prevent Blindness

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 2

12 Expert Tips to
Prevent Blindness

TIP 1. DON’T IGNORE THE SIGNS

It is true that in the early stages of glaucoma there are minimal, if any,
signs. I found that my own patients with moderate to advanced glauco-
ma, however, ignored many signs of vision changes several years prior
to seeing me. These signs were written off as “just my imagination” or
“just the process of getting older.” My advice to you is to become more
cognizant of any visual changes in your regular daily life. If these chang-
es occur, do yourself a favor and get your eyes checked. Time could be
of the essence.

Scenario #1: Love of Basketball

One of my patients was a skilled basketball player. As a point guard, he

prided himself on seeing everything that was happening on the court to
aid in his ability to pass. About 7 years prior to his glaucoma diagnosis,

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 50 The Glaucoma Guidebook

he began to notice that his accuracy in passing and receiving passes was
way off. Others noticed this as well. He thought aging was decreasing
his skill set. He eventually felt playing basketball was too much effort
and not as much fun, so he gave it up. Little did he know that the major
reason for this inaccuracy was his gradual peripheral vision loss from
glaucoma.

Scenario #2: Scared When Driving with a Child

Another one of my patients loved driving. He would have no prob-

lem driving long distances, or driving at night without glasses. About
5 years prior to his diagnosis, he realized that he had to look around a
whole lot more than he used to. It was getting harder to drive, because
he didn’t trust his vision as he once did. One rainy night, when he
had to pick up his child from basketball practice, he realized he could
not drive safely due to his poor vision (fig. 2.1). He was sweating the
whole way home, because he was afraid of putting his child in danger.
Even though he had known family members who were losing or had

Figure 2.1. Blurred vision in the rain.

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 12 Expert Tips to Prevent Blindness 51

lost vision from glaucoma, it still took what seemed like a near-death
experience for him to understand the importance of getting screened.
Other patients have told me that they bump into things more often
(for example, hitting the curb when driving or striking the car’s side
mirror because of faulty judgment). Some report that things just come
up on them quickly, whether while driving or being approached by a
person.
Don’t assume that these types of events are just the result of old age.
We have seen significant advances in technology today, and many dis-
eases are treatable and preventable. Don’t assume everything that hap-
pens visually is simply because you are getting older. Let someone look
at your eyes. Chances are, there is some level of treatment for improve-
ment, or to reduce the pace of worsening eyesight.

TIP 2. DO THE “COVER YOUR EYES SO YOU

CAN SEE” TEST

With both eyes open, our brain processes information from both eyes
to give us the best possible vision. When one eye cannot see well, the
other can compensate. I have seen countless times when patients have
a significant reduction of vision in one eye but, frankly, never noticed
it until someone asked them in a clinical exam to cover the good eye.
Because of this, a significant visual deficit can go unnoticed if a person
doesn’t check each eye individually.

Disclaimer: This is a test that is not specific for glaucoma. Any eye con-
dition that is vision-threatening can create a positive test. Moreover, if
your test is normal, this does not mean that you do not have glaucoma.
Only an eye care professional would be able to determine that. This test
is no substitute for an in-person eye examination, which is recommend-
ed for glaucoma screening. It is simply a useful tool to prompt an eye
exam that can further diagnose a problem.

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 52 The Glaucoma Guidebook

How to Do the Test

When you cover one eye and look out the uncovered eye, you can eval-
uate your vision in that particular eye (fig. 2.2).

1. Take time to notice both your central vision (clarity when looking
straight ahead) and peripheral vision (the ability to see what is to the
side of you without looking directly at it). If you have been prescribed
glasses or contact lenses, the test should be done with your corrective
eyewear in place.

2. Cover one eye and look out the uncovered eye. Can you still see
clearly?

3. Cover the opposite eye and look out the uncovered eye. Can you
still see clearly? How does it compare with the first eye?

Figure 2.2. A man covering one of his eyes to test his vision.

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 12 Expert Tips to Prevent Blindness 53

This test helps you discover if there are significant disparities between
the vision in each of your eyes. If you notice a significant difference
between how well you see in steps 2 and 3, you should contact an eye
care specialist promptly. This may save your vision. Try this test now!

TIP 3. ACCEPT THE DISEASE, DON’T ACCEPT DEFEAT

If you have been told you have glaucoma, the initial shock of the diag-
nosis can feel very unreal. This is understandable, especially if you are
still seeing well and functioning normally. It is very easy to want to feel
fine and, thus, go into a state of denial. This denial also can be present
when you are told you have a high risk for developing glaucoma, either
because of how your eyes look or because you have a blood relative
known to have the disease. If you stay in denial or are fearful of finding
out that glaucoma may truly be present in your eyes, this actually pre-
vents you from being your own advocate to protect the precious sight
you do have.
Remember, accepting that you have glaucoma does not mean that
you have to accept defeat in what seems like an incurable situation.
Don’t fall into feeling like a victim, because that mindset can make
it hard to empower yourself to take actions that can keep you seeing
better longer. Also, don’t be afraid to accept support or help from your
family (fig. 2.3).
Here are some ways to better manage a glaucoma diagnosis:

• Accept the disease. When you have been diagnosed with glaucoma
by a trusted doctor, your glaucoma doesn’t go away, and it won’t go
on pause, just because you’re not ready to accept it. Staying in denial
will not help slow down the disease. If you’re able to accept the dis-
ease now, you can actually take control of it and do something about
it. You have to be your own advocate.

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 54 The Glaucoma Guidebook

Figure 2.3. Accepting

family help.

• Accept the risk that you can lose vision from glaucoma, so you can
take the necessary action to keep seeing.

• When in doubt, get a second or even a third opinion from a glauco-

ma specialist. Look at the “Resources” section the back of this book
for a guide on how to find a glaucoma specialist.

• Accept that you have the power to control the best possible outcome
for your sight.

TIP 4. CONQUER YOUR FEARS: DON’T DESPAIR,

HAVE HOPE

Glaucoma is an eye disease that typically doesn’t have symptoms in its

early stages. It is called the “silent thief of sight” for this reason. There-
fore, it’s important to be screened early, when simpler treatment strat-
egies are most effective. This is especially true for those at highest risk.
Once you accept that you have glaucoma, you can be an advocate for
your vision. Remember the following pieces of advice:

1. Glaucoma can lead to blindness, but don’t despair! Most patients do

not go blind from glaucoma if they get treatment for it.

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 12 Expert Tips to Prevent Blindness 55

2. Treatment aimed at lowering eye pressure does work to prevent vision

loss. Find a doctor who you can trust (see Tip 6 on “Partnering with
Your Doctor”).

3. Conquer your fears. Glaucoma can be a disease where people feel

very alone and isolated, because they feel that the world does not
understand what they are seeing through their eyes. But you don’t
have to go through this alone. When you talk to other patients who
have glaucoma, you realize that you are not alone. You can gain
information on things others have done that have helped them, and
that you can do, too. You can also share your story and feel empowered
by helping someone else. Support groups could be found in places
as simple as the waiting area of your doctor’s office. I know many of
my patients with glaucoma talk to each other while waiting for their
eye exam, often finding support and encouragement by sharing their
stories with each other. To find other support groups that meet in
person, you can check with hospitals and eye care centers in your
area. Facebook and Yahoo have online groups for glaucoma who can
offer help. Also, don’t forget about sharing with your family. They can
often be a huge area for support if you open up to them on what you
are going through and need help with.

4. Have hope! We are in exciting times for glaucoma. Many new

medications, new ways of delivering medications, and new, less
invasive surgical techniques are coming out now. Have hope that
help is available now and that more is to come in the future (fig. 2.4).

5. If you currently have some visual impairment from glaucoma, I

strongly encouraged you to seek help through vision rehabilitation ser-
vices, which can maximize your health, quality of life, and indepen-
dence. This process begins with a referral to a low-vision optometric
specialist, followed by a visual efficiency and function evaluation,
and then specified care. During this exam, the specialist will find out
what your limitations are—that is, what specific activities you may be

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 56 The Glaucoma Guidebook

Figure 2.4. Hands holding a candle of hope.

having trouble with—so they can find tools to help. This could be as
simple as a magnifying glass. There are many different types of mag-
nifiers, and finding the best one for a specific task can make all the
difference in the world. The specialist can also offer suggestions and
advice on other topics, such as proper lighting, or the importance of
creating more contrast to see better in your home or the environment
you are in. Overall, the goal of treatment is to enable you to do all the
things you did before you lost vision, with help and the resources to
do them in a different—but effective—way.

To find additional helpful resources for you and your loved ones
related to the diagnosis of glaucoma, look at the “Resources” section in
the back of this book.

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 12 Expert Tips to Prevent Blindness 57

TIP 5. TAKE GLAUCOMA SERIOUSLY

Take your glaucoma diagnosis seriously. Although you may want to

take a break from the recommended treatment regimen or follow-ups,
glaucoma doesn’t take breaks. Glaucoma can be progressive, aggressive,
and relentless. It is vital that you:

• Follow your eye doctor’s recommendations.

~ If you have questions or concerns, speak
up and talk your doctor about them.

• Return for scheduled visits appropriately.

~If your appointment gets cancelled and is
not rescheduled, call and make a follow-
up appointment. You need to be seen
regularly.

• Take an active role in your disease.

~ Learn as much as you can to help you
live best with your glaucoma. Figure 2.5. A diagnosis of
glaucoma should be taken
• Visit the “Resources” section in the back of seriously.
this book to learn more.

When you do this, you are your best advocate to help prevent vision
loss.

TIP 6. PARTNERING WITH YOUR DOCTOR

Glaucoma is a chronic eye disease that, once diagnosed, will be lifelong.

In order to prevent vision loss, it needs to be treated. Though you play
a major role in advocating for your best vision, your eye doctor is your
partner in doing this effectively.

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 58 The Glaucoma Guidebook

Good glaucoma care should start with confidence in your doctor.

This is extremely important, because you will be receiving advice and
recommendations from your doctor that you should be able to take and
adhere to. If confidence is not there, you—as the patient—may not do
what is recommended, which could be detrimental to your vision.
This confidence often stems from good doctor-patient rapport,
where you feel like you are being listened to. Doctors should be able to
listen to your concerns and questions, so they can provide solutions to
those problems, as well as give you reassurance and a feeling that there
is a good plan in place to help your preserve your vision.
Effective strategies for working with your doctor include keeping
track of your appointments. Follow-up care is vital in maintaining con-
trol of glaucoma—that is, being able to assess if there is a problem
or if things are stable. As you prepare for your eye appointment, it’s
important to make a list of questions or concerns that came up during
the months since your previous doctor’s visit, and to consider whether
you need refills on your medications. Review this list when you are with
your doctor to get those questions or concerns answered and to obtain
any necessary prescriptions.
It’s also important to be very open and honest with your doctor. As a
patient, you want to please the doctor and make sure you do what you
are told. But we all know that life happens, and sometimes there are
issues related to the treatment that we, as doctors, need to know about
so we can come up with a better plan or solution for you. Maybe your
medications cause irritation in your eye or other symptoms that make
you not want to use your drops. Maybe the medication is so expensive
that you can’t afford it, so you don’t get it, or you try to stretch out the
timing of when you apply the drops, which is not an effective treatment
for you, either. Or maybe the treatment regimen is just too much, and
you are unable to keep up with it. All of these things are important for
your doctor to know about, so he or she can address these issues and
come up with possible solutions for them. Typically, there are multiple
other options that can be chosen.

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 12 Expert Tips to Prevent Blindness 59

It is important to understand what is going on with your eyes. We

know that all the medical words can sound confusing, or even like a for-
eign language. Your doctor should present you with information about
the condition of your eyes in simple terms, as well as clearly explain the
treatment options.
Remember, however, that it’s essential for you to ask questions. Some-
times you may wonder what is a good question to ask. Any question is
a good question when you are trying to learn more about how to take
care of your eyes.
Here are some common questions you should be able to ask and
then gain understanding from the answers:

• What is glaucoma?

• Do I or do I not have glaucoma?

~ If no (you don’t have glaucoma), what is my risk level for getting
glaucoma? How often should I return for re-examinations?
~ If yes (you do have glaucoma)
–What kind of glaucoma do I have?
–What stage of glaucoma is present in my eyes (mild, mod-
erate, or severe)?
–What is my eye pressure, and what target pressure is suit-
able for my eyes?
–At the end of every eye exam, find out if your eye pressure
is on target and whether your glaucoma is stable.
–If you take eye drops for treatment, you should know which
kind of drops to take for glaucoma, as well as their common
side effects.

These questions can change over the course of time as things prog-
ress.
Overall, you should know what you have to do to maintain and pre-

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 60 The Glaucoma Guidebook

Figure 2.6. A doctor in conversation with a patient.

serve your vision. It is important that you have relevant information

about your eyes from a qualified eye care specialist that you can trust
and partner with. Write down your questions, so you can go through
them one by one with your doctor. Always remember to ask questions
and never be afraid (fig. 2.6). The more you know, the more able you
are to maintain healthy eyes and preserve your vision.

TIP 7. KNOW WHAT IS EXPECTED

Initial Visits

When you are initially diagnosed with glaucoma, the state of your optic
nerve becomes a baseline for an eye doctor to follow over time. This

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 12 Expert Tips to Prevent Blindness 61

means that he or she will use the image(s) of your optic nerve and
compare them with any future ones, looking for any changes. Your eye
doctor will document the optic nerve structures by describing them
with words, drawing a picture, and probably taking a photograph. A
picture is worth a thousand words.
Some of the most common tests include:

• Vision

• Slit lamp exam

• Eye pressure

• Gonioscopy

• Visual field test

• Nerve fiber layer analysis

• Photographs of the optic nerve

Establishing these baseline tests will provide valuable information to

see if there is a change in the optic nerve over time.

Repeated Visits

Normally, patients return every 3 to 4 months for checkups. If your

glaucoma is mild or stable, you can return every 6 months to a year. If
you have recently had glaucoma surgery, however, or if your treatment
regimen is still being established, you may have to return sooner, within
days or weeks.

Repeated Tests

The baseline tests that you have at the initial visit are routinely repeated,
in order to look for progression in your glaucoma.

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 62 The Glaucoma Guidebook

When your eye doctor says that your eye pressure is under control,
do you have to come back?
yes!
You still need to have regular follow-up appointments to manage
your glaucoma. The disease doesn’t just go away, even if it is well treated.
This is true even if you have already had laser treatment or glaucoma
surgery.
why?
Glaucoma is a chronic condition that does not go away. With treat-
ment, glaucoma will either remain stable or get worse. Although there
is no cure for glaucoma, we do have excellent treatment options that
can help stabilize the disease.

Changes in Treatment

Glaucoma can get worse, even when the eye pressure stays well con-
trolled. This could occur for a number of reasons. Sometimes, if the
eye drops are not used as prescribed, eye pressure can rise and cause
damage to the optic nerve. For example, some patients may only use
drops the day before their exam. Their eye pressure may look good
that day. When they don’t use their drops regularly, however, their eye
pressure will rise, and their optic nerve will be damaged. On the flip
side, it could be that the treatment regimen is being followed, but the
glaucoma has changed and become more aggressive.
In cases where eye pressure is not controlled, it could be that the eye
drops that have been used for some time are not working as well any-
more. In those who have had laser treatment for glaucoma, the results
from some types of lasers are known to wear off over time. In cases
where glaucoma is treated with surgery, early or late scarring can occur.
This can cause the procedure to fail, with or without apparent symp-
toms. These scenarios are some of the reasons why glaucoma requires
monitoring to check for any changes.

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 12 Expert Tips to Prevent Blindness 63

Take Action

Glaucoma is a chronic disease that does not go away, so you will contin-
uously need to have follow-up care. If you miss an appointment, your
doctor’s office may call you to reschedule. If they don’t, you have to
take on the responsibility to call your doctor to reschedule that missed
appointment. You want to make sure your disease is well controlled.
You also need to make sure your eye drops and other medicines are in
order. If you run out of any drop or medicine for glaucoma, it’s impera-
tive that you call your doctor for a refill or a new prescription. Glauco-
ma is an aggressive disease, and we need aggressive measures to fight it.
This means we—doctors and patients—have to be informed and know
what to expect, so we can manage it the best way we can.

TIP 8. KEEP YOUR MEDICAL RECORDS

As I wrote in Tip 7, “A picture is worth a thousand words.” The same

is true for any kind of information about your optic nerve if you have
glaucoma. It is vital for you to be your own advocate. Make sure you
have copies of your medical records and copies of pictures of your optic
nerve, so you can share them as needed with your doctors.
A strong recommendation for you, especially if you travel from one
place to another or change doctors, is to gain personal access to your
medical records. You can do this by requesting your own personal copy.
The state of your optic nerve when you are first diagnosed with glau-
coma is the baseline for your eye doctors to follow over time. These
tests (such as visual field tests or optic nerve fiber layer imaging) are in
your medical record. It is more common nowadays to have access to
electronic patient portals, where your exam report and tests are acces-
sible. Paper copies, however, are also helpful. Especially try to keep the
records from when you were initially diagnosed, so you and your health
care providers can compare them over time with new results.

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 64 The Glaucoma Guidebook

Important Information for Your Medical Records

Here is a list of information that I recommend keeping with your med-

ical records:

• Baseline eye pressure at the time of diagnosis, before treatment

began.

• Baseline evaluation of the optic nerve (cup-to-disc ratio notation

and drawing).

• Any photographs of the optic nerve.

• First and last three visual field tests (if these aren’t all available, then
have the most recent ones on hand).

• Any nerve fiber layer imaging, such as OCT (see chapter 1).

• Any details on prior laser or surgical treatment for glaucoma.

In other words, it is imperative to get copies of both your old and

updated medical records. Many medical practices do a good job of
transferring your medical records. These records may not show up in
a timely fashion, however. This commonly happens. If you have a set
of your own personal records that you can supply on request, you will
have less frustration if other medical records do not arrive on time, and
you will have more control over your eye condition.

TIP 9. TALK TO YOUR FAMILY

Glaucoma Runs in Families

Glaucoma is a hereditary disease. This means that if you have glaucoma,

so could someone you love. Anyone who is your blood relative has an

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 12 Expert Tips to Prevent Blindness 65

increased risk of developing the disease as well. It is common for people

to be diagnosed with glaucoma and not know of any family history
associated with the disease. It is also possible, however, that you do have
a relative with glaucoma who doesn’t know yet that he or she has the
disease, or does know it but did not relay that information to you for
whatever reason.

Give the Gift of Sight

You can give the gift of sight to your family by letting them know you
have the disease. This should be followed by strong encouragement for
them to get their own eyes specifically checked for glaucoma. By shar-
ing your diagnosis with your family members, you are allowing them
to be proactive in preserving their vision. If you don’t tell them, you’re
actually doing them a disservice, because the earlier they find out if they
have glaucoma, the easier it is for them to treat it. If they have glauco-
ma, it is better to be diagnosed at an early stage, because early diagnosis
with glaucoma is the key to proper management of the disease.

Glaucoma Family Facts

• A family history of the

disease increases the risk
of glaucoma 4 to 9 times,
compared with those without
glaucoma in their family.13

• Siblings are at the highest

risk: approximately 10%
of siblings of patients with
glaucoma get glaucoma.14

• 1 in 8 relatives of people
Figure 2.7. Family hereditary risk for with glaucoma will also have
glaucoma. the disease.15

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 66 The Glaucoma Guidebook

So, at your next family gathering, make it a point to get everyone

together and let them know about glaucoma (fig. 2.7). Stress how
important it is for them to get their eyes checked to prevent vision loss
in their life. You can also recommend that they read this book!

TIP 10. BE HONEST WITH YOURSELF

For Those Diagnosed with Glaucoma

If you are actively being treated for glaucoma, it is important to be

honest with yourself. If you have been given a treatment regimen that
includes using daily eye drops to help lower your eye pressure, it is of
the utmost importance to keep up with that regimen. It is vital to put in
your eye drops every day. The effect of the eye drops can wear off after
so many hours, so forgetting your drops, or stretching out when you
apply your drops, or not using your drops when going to certain meet-
ings or events, can leave your eyes vulnerable to elevated eye pressure.
You won’t feel the eye pressure rise, but your optic nerve will feel it and
slowly continue to deteriorate without your awareness. You don’t want
to lose your eyesight, and we, as your eye care providers, don’t want that
to happen to you, either.
Also, please understand that we do understand your situation. You,
like many others, may have issues with your medication, such as:

“It costs too much.”

“It makes my eyes irritated.”

“It causes unpleasant side effects.”

“It is difficult to remember to put it in.”

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 12 Expert Tips to Prevent Blindness 67

All of these issues, and any others, are valid and should be discussed
with your doctor. Your doctor can change the regimen or address the
issue, so that things will work best for you. It is much better to bring
your concerns up for discussion than to be dishonest with yourself and
your doctor and say that everything is fine. Remember, it’s your vision
that is at stake.
The good news is that there are typically other kinds of eye drops or
other modes of therapy, such as light energy treatments with lasers and
minimally invasive glaucoma therapies, that can be used to help control
your glaucoma. Be real with yourself, and be open with your doctor. Let
him or her know how you are really doing with the treatment regimen,
so your doctor can come up with the best option for you.

For Those at Risk or a Glaucoma Suspect

You may have been told by a family member to get your eyes examined
for glaucoma. Maybe you have already been examined before and told
by a doctor that something in your eyes looks suspicious for glaucoma.
This means you are a glaucoma suspect (not in the criminal sense—
just in terms of your eye health!). Have you been hesitant to schedule
that appointment for the evaluation? Maybe you see just fine and don’t
understand why you should bother to get checked out.
Well, maybe you do have glaucoma, also known as the “I see just fine,
but I could go blind if I don’t get screened” eye disease. Enough said.
Go get checked. Your sight is on the line.

TIP 11. KNOW THE RISKS ASSOCIATED WITH

GLAUCOMA AND CATARACTS

Glaucoma is a disease that can develop at any age, but it is more common
with increasing age. Another eye condition that also increases with age
is cataracts (fig. 2.8). Although both conditions can lead to blindness,

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 68 The Glaucoma Guidebook

Figure 2.8. A mature cataract.

cataracts are curable, while glaucoma is not. A cataract is a condition in

which the lens in your eye becomes cloudy. It is like looking through a
fogged window. You cannot see well through a cloudy lens. Treatment
for cataracts involves replacing the bad lens with a good one, a simple
surgery. Glaucoma, on the other hand, results from damage to the optic
nerve. Vision loss in glaucoma is irreversible. That is why it is crucial to
screen for and treat glaucoma—to prevent further loss of vision.

Here’s the Good News

Don’t be discouraged when you hear that you have a visually signifi-
cant cataract in addition to your glaucoma. In fact, there is good news
for you! I have found that in some cases, the pressure-lowering effect
can be greater when cataract surgery is combined with glaucoma sur-
gery, compared with when glaucoma surgery alone is performed. This
means that there may be a way to reduce or eliminate glaucoma drops
if you are actively using them. There is a cutting-edge form of glauco-
ma surgery that has now been used for over a decade called minimally
invasive glaucoma surgery, or MIGS. The types of surgical techniques

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 12 Expert Tips to Prevent Blindness 69

used with MIGS allow a less invasive approach that is much faster and
safer, compared with traditional glaucoma surgical techniques, yet still
effective in lowering eye pressure. MIGS is easily coupled with cataract
surgery, going through the same small incision to enter the eye. Also,
the healing time for the combined surgery is very similar to that for just
cataract surgery alone.

You’re Not Alone

There are more than three million cataract surgeries performed every
year, according to the Centers for Medicare and Medicaid Services. In
about 20% of them, patients with cataracts also have glaucoma (known
as co-morbid cataract and glaucoma) and are actively taking eye drops.
If you have a visually significant cataract and take drops for your glau-
coma, you should ask your doctor about having combined MIGS and
cataract surgeries (fig. 2.9). This presents a wonderful opportunity for
many patients to conveniently have both procedures done at the same
time. Seeing better, and also having better controlled glaucoma with
fewer drops, equals a significantly enhanced quality of life!

Co-morbid
Cataract and Of the 3.5 million annual
Glaucoma cataract procedures
performed in the US, 20.5%
of patients have
co-morbid glaucoma and/or
ocular hypertension

>700,000 of co-morbid cases

Patients with Cataract

Patients with Cataract and Glaucoma

Figure 2.9. Cataract and glaucoma statistics.

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 70 The Glaucoma Guidebook

TIP 12. MANAGE YOUR GLAUCOMA AND DRY EYES

Dry eye syndrome is a condition in which a person doesn’t have enough

useful tears to lubricate and nourish the eye (fig. 2.10). Dry eye is a
common and often chronic problem, particularly in older adults.
Common dry eye symptoms include:

• Burning eyes

• Irritated eyes

• Tired eyes

• Stinging eyes

• Gritty eyes

• Blurred vision

Figure 2.10. An inflamed or irritated “dry” eye (right), versus a normal eye
(upper left).

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 12 Expert Tips to Prevent Blindness 71

• Red eyes

• Scratchy eyes

• Excess watering/tearing

Many factors can contribute to dry eyes, one of which is glaucoma

drops. Many glaucoma drops have preservatives in them that can irritate
the surface of the eye. This can create or exacerbate dry eye symptoms.
Treatments for dry eyes aim to restore or maintain the normal amount
of tears in the eye, both to minimize dryness and related discomfort
and to maintain eye health. It is common for glaucoma patients to have
mild redness in their eyes as a result of their glaucoma eye drops. Treat-
ing the eyes with the dry eye therapies described here can often reduce
redness in the eyes.

Ways to Combat Dry Eyes in Glaucoma

Even though glaucoma drops are used to prevent vision loss, you don’t
have to have dry, red, uncomfortable eyes. There are many options to
treat these dry eye symptoms. Some of the options can include the
following:

1. Switch the types of medication you use. There are different classes of
glaucoma medications and, typically, several different brands within
each class. It is not always clear which kind of drop will be best
tolerated by each individual patient. Some eye drops can be combined
into one bottle. Talk to your doctor to find the best tolerated and
most effective medication for you.

2. Try preservative-free drops. Another option is to switch to a

preservative-free form of glaucoma drops. There are several drops
now on the market that are preservative-free and still can lower eye
pressure and reduce symptoms of dry eye.

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 72 The Glaucoma Guidebook

3. Use glaucoma laser treatments. Using light energy, through a

laser procedure, is also an option. There are several laser procedure
options, typically performed in an office setting, depending on your
type of glaucoma. This form of treatment, in turn, has the potential
to reduce or eliminate the need for glaucoma drops and reduce dry
eye symptoms. A recent study called the LiGHT Trial showed that
a laser treatment called SLT was effective in reaching the target eye
pressure in 95% of nearly 400 patients for 3 years. None of them
required glaucoma surgery to lower eye pressure, compared with 11
patients who required surgery in the group receiving only eye drop
therapy.16 From this evidence, there has been a shift to considering
glaucoma laser treatments as the first therapy to try.

4. Ask about minimally invasive glaucoma surgery (MIGS). With the

advent of MIGS, options for glaucoma surgery are now offered ear-
lier. This can be helpful, especially when glaucoma is at an early or
moderate stage, eye drops are not tolerated, and laser treatment has
not been fully effective. The use of MIGS avoids the potential risks
involved with traditional glaucoma surgeries, such as a trabeculecto-
my or a tube shunt (see chapter 1). MIGS can effectively decrease eye
pressure, and many patients can reduce or fully stop their need for
glaucoma drops after a successful MIGS procedure.

If the best option, according to your doctor, is to stay on your current

glaucoma regimen, dry eye symptoms can still be treated in a number
of ways.

• Over-the-counter artificial tears. This is typically the first-line treat-

ment for dry eyes. Preservative-free artificial tear solutions are recom-
mended, because they don’t have additives that could further irritate
the eyes.

• Prescription dry eye medications. There are several classes of eye medi-
cations that can be used to help create more tear production, improve

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 12 Expert Tips to Prevent Blindness 73

the quality of the oils within your eyelids, or reduce inflammation

that can sometimes be the cause of the dry eye symptoms.

• Punctal plugs. To keep your natural tears in your eyes longer, silicone
or dissolvable gel-like plugs can be placed in your tear ducts, where
the tears normally drain. This creates a blockade, so more natural
tears wet your eye, helping reduce dry eye symptoms. Imagine that
the tears in your eye are like water in a leaky bottle. To maintain the
same amount of water in the bottle, you can either pour more water
in the bottle (use artificial tears) or plug the hole (use a punctal plug).

• Vitamin supplements. Omega-3 fatty acids are known to help

improve the quality of the oils within the eyelid glands. This, in turn,
can play a role in reducing tear film evaporation.

• Warm compresses. A washcloth moistened with hot water or a micro-

wave-heated eye mask can provide heat to help soften oils, open oil
glands within the eyelids, and aid in reducing dry eye symptoms.

• Lid scrubs. These cleaners can help decrease inflammation and

remove bacteria and debris from around the surfaces of the eyes.

• LipiFlow or iLux. These are in-office procedures that use a thermal

pulsation system to open and clear blocked oil glands. The procedure
allows the body to resume the natural production of oils needed for
tear film.

• BlephEx. This is another in-office procedure. It involves using a

handpiece with a gentle exfoliator tip to remove debris and film on
the eyelid margin, which can clog natural oil glands and prevent the
release of oils that coat the surface of the eye. This procedure can
decrease symptoms of dry eyes, such as itchy, scratchy eyelids and
eye redness.

As you can see, there are many options for dry eye treatments. You
can learn more about some of these dry eye treatment strategies on my

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 74 The Glaucoma Guidebook

iGlaucoma Patient channel on YouTube, at [Link] Ask

your doctor which treatment you should start with to help your eyes
feel better. Remember, just because you have glaucoma doesn’t mean
you should have dry, red, angry eyes.

Dry Eye Self-Care Treatments to Start Now

You can take the following steps, starting right now, to reduce symp-
toms of dry eyes:

1. Blink: Remember to blink regularly when watching television,

reading, or staring at a computer screen for long periods of time.
Lack of blinking will dry out the surface of the eye.

2. Follow the 20/20/20 rule: Every 20 minutes, look at least 20 feet

away for 20 seconds. This will help you avoid eyestrain and fatigue.

3. Add moisture: Increase the humidity in the air at work and at

home. Using a desktop humidifier or a room humidifier can help
provide moisture.

4. Use eyewear: Wear sunglasses outdoors, particularly those with

wraparound frames, to reduce exposure to drying winds and the sun.
This can also be helpful in the car when air or heat is blowing toward
your face.

5. Drink water: Stay hydrated by drinking plenty of water (8 to 10

glasses) each day.

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 3

Keeping It Real
Real Patients, Real Advice

Having glaucoma can feel very lonely at times because others around
you may have trouble understanding life as seen through your eyes, and
it can be difficult to explain. Part of the journey of living your best life
with glaucoma should include sharing experiences with others who also
have glaucoma. When you open up and reach out to others with this
disease, you will realize that, in fact, you are not alone, and that there
are many out there like you going through similar experiences. This
realization can put you at ease, give you encouragement, and even allow
you to learn something that can greatly benefit you and others.
Understanding this concept, and also knowing that some of you
reading this book may not yet have had the opportunity to reach out to
someone, I did it for you! I have asked some of my actual patients, who
I know are battling with glaucoma but living vibrantly, to share their
stories. They have various stages of glaucoma: from mild, to moderate,
to severe. I have enjoyed having the privilege to take care of them, and
they have each inspired me with their glaucoma journey, life challenges,
and triumphs. I thought it would be a great addition to this book of
advice from a glaucoma doctor’s perspective to include real stories and

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 76 The Glaucoma Guidebook

real advice from actual glaucoma patients. I hope the next few pages
will have a significant positive impact on helping you live the best life,
despite having glaucoma.

For Charmaign Vauters, glaucoma was a gradual process through which

she found herself with a loss of vision.

■ Looking back at before my glaucoma

diagnosis, I had only Saturday nights to
sit and watch Pandora on the big TV
in the sitting room. I started noticing
that the vision in one eye was not as
keen as the other, and I was doing more
of listening to the show than watching,
but even then I would try to rationalize
it with diet and exercises.
The glaucoma diagnosis was given to
me clearly and in all seriousness, but I
found it hard to place myself that day.
My glaucoma diagnosis made me
Charmaign Vauters, a glaucoma realize how valuable my eyes were to
patient of Dr. Constance Okeke. me; they were my superpower. Early

on as an organ donor, it was the organ

I specifically chose to donate one day. But now it felt like spring was
behind me, and I was entering autumn.
And so I took the diagnosis seriously, and even though I had never
had to take medications daily, I took up the responsibility of taking up
to 5 doses of eye drops per day to prepare for successful eye surgery.
Looking back, I should have gotten prescription glasses immediately
after the diagnosis; I felt the glasses added protection to my eyes. I even
made a proactive decision during the pandemic to wear eye protection
indoors in public spaces, and when I was asked why I wore a mask and
a shield, I would say, “My mask protects you, your mask protects me,
and my shield protects me.”

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 Keeping It Real 77

Through this stage in my life, I have learned three essential things

about glaucoma: if it is not diagnosed or treated, it will result in blind-
ness; secondly, the effect of glaucoma, which is loss of sight, is irrevers-
ible; and with proper diagnosis and treatment, eyesight can be saved
before damage is done.
My doctor, Constance Okeke, MD, is the best support resource. The
literary and visual resources she produces at her office, Virginia Eye
Consultants, are the best; I always refer to them in my pursuit to stay
educated and informed.
My best advice to anyone recently diagnosed with glaucoma is that
you educate yourself, no information is a waste, and seek out the best
professional medical treatment while taking extreme care to protect
your sight and eyes.
Establish an eye care regimen with a professional health expert expe-
rienced in the field and stay committed to your eye care. When I moved
to a new city, I thought about establishing care in my county, but I
realized that I was already enjoying the best medical care. These types
of important decisions will help you care for your eyes better. Basic
decisions like wearing sunglasses also help; before my diagnosis, I never
wore sunglasses, but now I always have them on me, wearing them
outdoors or indoors in public places. During the pandemic, I always
had my shield up.
Regarding medications, I started to lose count of how many times I
had taken my eye drops, so I got creative and playful about staying on
schedule, always thinking about the adverse effects of not taking my
medications.
My sight is my hidden treasure in plain sight, and I once set my
sights on taking “recreational” helicopter lessons after I retired. The
main attraction to this was the knowledge that this required specially
trained pilots. I was told that to operate a helicopter, each extremity
has a distinctly assigned task different from others—that is, each arm
and leg had to perform tasks wholly distinguished from others. It was
fascinating to me; I thought, as a senior, what a wonderful way to keep
the brain sharp. But the harsh reality is if you are losing your sight,

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 78 The Glaucoma Guidebook

whether you know it or not, there will be a day when you will be
exempt from doing what you love or aspire to do because your sight is
going or gone.
For my family, I told them about my diagnosis, and subsequently,
they took the initiative to schedule eye examinations; and I am proud
to say as a result, they can all quote their eye pressures. With constant
care, there has been an improvement in mine, too. ■

Arlene Kessell didn’t notice any changes in her vision before and after
she was diagnosed with glaucoma.

■ When my ophthalmologist informed

me of her diagnosis, I was taken aback,
shocked, stunned. The diagnosis had
to be a mistake, but it wasn’t. My ini-
tial [elevated] eye pressure was in the
mid-twenties, and that was a serious
cause for alarm. I would never have sus-
pected I suffered from glaucoma, as I
thought it occurred only in the elderly
. . . I was in my early forties. I noticed
absolutely no change in vision. After
the diagnosis, my situation was thor-
oughly explained to me, and I was over-
Arlene Kessell, a glaucoma whelmed, honestly frightened for the
patient of Dr. Constance Okeke. worst-case scenario: loss of sight. I recall

asking, “What do we do now? What’s

your plan?” My alarm was so intense, I
felt we had to hurry to make this vision thief disappear immediately,
but there is a catch, you see. This thief is a permanent guest who stays
for the rest of my life. I was anxious to begin treatment, to learn as
much as possible about this cursed disease (aren’t all diseases cursed?),
and follow my doctor’s advice perfectly.

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 Keeping It Real 79

My glaucoma has been my uninvited visitor for about twenty-five

years. If you imagine a pie, cut across it to create an upper and lower
half. My upper halves of this pie form my blind spot. I can see, I can
read, but I am somewhat aware I am missing half the picture. As a result
of this vision loss, I frequently and painfully hit my head and forehead.
When playing with my dogs in my tree-filled yard, I am forever hitting
tree limbs, branches, bird feeders hanging from branches. I hit my head
often on/in my car when loading the rear of the front seat area. I also
see nothing on the left side of my world. I have learned to adapt as well
as possible.
I have been a perfect glaucoma patient; I cannot afford not to be if I
want to maintain my vision, as much vision as possible.
If you are recently diagnosed with glaucoma, be concerned, very
concerned. The loss of vision is not noticeable to you; you are losing
peripheral vision and are not even aware of the loss. Use your drops!
Apply them correctly! Follow your doctor’s direction religiously!
I look forward to Dr. Okeke’s appointments because of the very
nature of glaucoma; I may not be aware of a change in my eye pressure
or a loss in my visual field, but my doctor can detect this during the
appointment. The best resource I have found is my ophthalmologist.
Ask questions!
My advice to family or caretakers of glaucoma sufferers is simple:
make sure drops are applied correctly—that is, at correct times of day,
in the correct eyes (occasionally, a drop is applied to one eye only); keep
all ophthalmology appoint[ment]s! Make sure all eye drop refills are
current!
The top three things the glaucoma patient must keep in mind are
(a) glaucoma can cause you to go blind; (b) a spike in your eye pressure
can still occur when you are flawlessly applying your eye drops; you will
feel helpless, [but] (c) be thankful for every day you can see. Trust your
doctor implicitly.
To someone who has recently been diagnosed with glaucoma, I
would say to listen to your ophthalmologist, be attentive, do not be

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 80 The Glaucoma Guidebook

hesitant to ask questions. Follow a regimen for your eye drops. Never
skip a dose! Again, trust your doctor implicitly.
As regards to families, make sure all family members have a glauco-
ma test annually. This is not to be taken lightly. Keep in mind that you
might believe you have no vision problems; however, that is the very
nature of this thief of sight! Glaucoma does run in families! But the
good news is it can be controlled and suppressed not to disrupt activi-
ties throughout one’s life. ■

Rosalind Quaye didn’t notice any signs that would have suggested she
had glaucoma.

■ There were absolutely no signs such

as pain, eye swelling, itching, or seeing
double. I only became aware of its silent
theft after my nearsighted mother told
me of her referral visit to an ophthal-
mologist and diagnosed glaucoma. My
mother reported the specialist inad-
equately informed her of the disease
but did discuss its hereditary aspect
and advised her [about] alerting family
Rosalind Quaye, a glaucoma members. She notified me several years
patient of Dr. Constance Okeke. later, at which time I wore corrective

eyewear due to pathological myopia.

As in any stage of myopia, I could
not see the distant fate of glaucoma-specific depreciated vision, which
I probably had then; no signs exhibited until later receiving specialist
findings, revealing advanced stage glaucoma. Glaucoma is a thief and
a robber! I felt violated and victimized, violated by a hereditary vision
stealer, victimized by its effectiveness and personal burden of complicity
attributed to inappropriate eye care decision-making.
I did not see it coming, and glaucoma, having no respect for vision’s

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 Keeping It Real 81

state, stole beyond suffering higher-degreed myopia (worse than 20/400

uncorrected vision). When detected in its advanced stage, glaucoma
had upgraded injury to my already damaged optic nerve by partner-
ing with other thieves and robbers, perpetrators such as life-threatening
diabetes, hypertension, and inflammation.
The diagnosis of the disease was clearly articulated, but a compre-
hensive synopsis of the disease was omitted. At first, I did not take the
diagnosis of glaucoma seriously due to a chronic addiction to distrust-
ing physicians. A personal inability to detect any vision change beyond
my 45-year comfortability with nearsightedness, crowned with years of
ignoring annual eye examinations, contributed to prideful behaviors.
Just seeing was enough for me. Quality of sight did not enter my
exceedingly large portfolio of “priority” things to do. A new pair of
glasses was a treat. I saw how to, without assistance: read the Holy Bible
and secular books; perform acts of maternal and neighborly love; travel
to and from gainful employment; navigate sidewalks and cross busy
streets; watch out for human predators and other creeping things; iden-
tify and run from danger; see and hail a cab; travel by ferry, bus, train;
satisfy legal and medical secretarial job duties.
During those years of ignorance, I thrived considerably as a young,
family-oriented, purpose-driven,vivacious, “indestructible” super single
mom! Able to defeat any Goliath, glaucoma was not a prioritized con-
cern; in fact, I just did not have time for a daily regimen of a time-
consuming 10 minutes for administering eye medications and keep-
ing scheduled follow-up appointments, with wait times exceeding three
hours.
I did not take the diagnosis of glaucoma seriously at all; I settled for
the grandeur vision correction afforded—enjoying a false sense of con-
fidence. Oblivious to an unseen vision future and an impending drasti-
cally altered quality of life, I remained in the dark, proudly declaring to
others, “An ounce of prevention is better than a pound of care!”
An attitudinal change has led to full compliance with keeping all
scheduled and emergent eye appointments and, respectively, diligent

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 82 The Glaucoma Guidebook

obedience to specialists’ advice. Personal experience with glaucoma,

staying informed on groundbreaking news, and applying readily avail-
able tips on the disease motivate information-sharing on personal
health and eye cares.
My advice on living well with glaucoma to someone recently diag-
nosed is to schedule taking your eye drops on a timely basis daily; alert
your care team of allergic reactions to any medication; ask family mem-
bers and friends to assist with transportation, cooking, and household
chores; develop healthy eating and a regular physical exercise regimen;
maintain good rapport with your glaucoma management team, keep-
ing all appointments and following their care instructions.
If you are family to someone who’s been diagnosed with glauco-
ma, be sober minded. Do not take your vision or the vision of others,
including family members and neighbors, for granted. Love them as
you love yourself and show this by communicating your experience
with glaucoma and how it can impact their sight, and taking immediate
bold, proactive steps toward obtaining professional consultation.
Additionally, I counsel all family members and neighbors to educate
themselves on glaucoma to develop sensitivities necessary for under-
standing behaviors or challenges of afflicted persons. Take advantage
of the portfolio of businesses, resources, and apps supporting the blind
and vision impaired.
Through my situation, I have learned glaucoma is an eye disease that
results from varying degrees of damage to the optic nerve, which leads
to permanent loss of vision. Vision loss is gradual, painless, prolonged,
and unbeknownst to the patient—necessitating keeping regular and
annual eye care appointments for early specialist detection and man-
agement intervention. Glaucoma, inherited or acquired, makes every-
one at risk for developing the disease; however, persons having a family
history of glaucoma are more susceptible.
If you’ve recently been diagnosed with the disease, I suggest that you
have faith in God! He can heal you, and His grace is sufficient to show
you His perfecting strength in your weakness. Give conscientious atten-

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 Keeping It Real 83

tion to measures of prevention, maintenance, and optimizing good

health and eye care. This same consideration must be given when one’s
sight becomes compromised by the presence of any eye disorder and
disease.
Glaucoma runs in families, so I emphasize that you do not delay
in seeking a professional ophthalmology consult. Be consistently and
fully compliant with specialist management instructions. Stay abreast
of current glaucoma-specific news and related medical issues. Proactive-
ly share your awareness and experience with others. Thank God for the
ability to do all of the above. ■

Roger Vann Smith was also interviewed about his experience with glau-
coma.

■ There was no sign whatsoever that

would have led me to believe I had any
eye disease, including glaucoma. . . .
At the time of my diagnosis, I did not
know such a disease existed. The pur-
pose of my initial professional medical
services visit to my then-ophthalmolo-
gist was to have an eye examination and
receive transition lenses.
The first thoughts I had were “Glau-
coma,” and “How it would bear upon
my professional service two-year con-
tract one way or another?” The diag-
nosis was given to me clearly, since
Roger Vann Smith, a glaucoma my elder sister is and was a practicing
patient of Dr. Constance Okeke. medical doctor in New York City, my

legal domicile; I knew to ask questions

regarding any gray area I required further comprehension on.
I took the diagnosis and prognosis seriously. Why? My doctor

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 84 The Glaucoma Guidebook

informed me that if the glaucoma was not successfully treated and con-
trolled, I would lose my eyesight. Furthermore, Dr. Kolsky informed
me he could not professionally advise me to be in Saudi [Arabia] unless
my glaucoma was medically controlled. Otherwise, I could lose vision
in at least one eye. Ergo, my ailment potentially had an economic bear-
ing on both my immediate family and me. Therefore, my employer
was immediately contacted, and my movement was placed on hold for
several months.
Glaucoma is said to be hereditary; I can’t change my genes to avoid
this disease. So I just follow the treatment procedures. So, my advice to
people diagnosed with glaucoma is to secure professional providers with
complete confidence in their professional services. Also, pressure your
federal legislators for more research and development with curing this
disease, and insurance coverage universally throughout this our nation
for everyone under an extended ongoing amendment of the Affordable
Care Act applied to all states, like Social Security.
Caring and concerned medical doctors such as Constance Okeke
and Martin P. Kolsky have been the best resources and support I’ve
had. My advice to families or caretakers of people with glaucoma is not
to take the matter lightly. While you have sight, protect it by following
the professionally advised procedures. If payment for services or medi-
cations is a problem, confidentially speak with a servicing physician for
assistance. Things can be done, possibly including taxation write-offs if
necessary and hardship medications from pharmaceutical entities doing
well financially [that] can afford some write-offs.
My diagnosis and the treatment of glaucoma have taught me to take
my medications as prescribed, keep to appointments, inform my physi-
cian of situation changes, and avoid depression through prayerful faith,
family, and love.
If you’ve recently been diagnosed with glaucoma, know that it’s a
brave new world. You can get over it by being positive. If you believe it
is a lemon, then make lemonade out of it. Otherwise, think of it as an
apple pie. Take a slice and enjoy the ride while doing everything you are

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 Keeping It Real 85

supposed to do medically. Where you can’t, then I suggest, as I have, to

consider asking for help with prayer.
Glaucoma runs in families, so should you be amid a family which
holds periodic reunion gatherings, recommend to the reunion planning
committee to invite, if possible, an ophthalmologist.
Many sufferers of glaucoma can live comfortably with it as long as
they control it and follow treatment procedures. One essential element
is having faith as opposed to fear. ■

June Hart talked about her experiences with glaucoma being added to
other eyesight issues.

■ In retrospect, I probably had some

symptoms. I was already struggling
because of my detached retina surgery
for that eye; I remember having prob-
lems with light, and my eyes were red.
When I came for my follow-up session,
I met Dr. Okeke; it was said that the
pressure in my eye was too high.
The diagnosis given to me was clear. I
remember going to the mailbox one day
in the sunlight, and the light was killing
my eyes; they were so itchy and red that
I had to get them checked out. I took
June Hart, a glaucoma patient the diagnosis seriously because of what I
of Dr. Constance Okeke. had already been through with my retina
and permanently losing my sight in one
eye, and all the struggles with surgery. I did everything I was told to
do willingly, because I don’t know what I would do without my sight.
. . . I know I’d survive; I’ve learned to do so many things by feeling
since I don’t have any eyesight in my left eye, but glaucoma affected my
peripheral vision, and I struggled with that.

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 86 The Glaucoma Guidebook

My advice to any person diagnosed with glaucoma is that you need

to research it and know more about it. Be aware of the damage so that
it doesn’t get to the point where it’s irreparable. Take it seriously, listen
to your doctor, and take the medication as directed. If you go blind due
to damage to the optic nerve, you can’t get your sight back.
Early on, I knew something was going on with my eyes, and I was a
little scared. You don’t want to be diagnosed with something terrible,
but then you have to learn to accept things and just do what you need
to do for your illness and then move forward. That’s what I’ve done.
Generally, men have it worse; they never go to the doctor, their wife
has to make the appointment, make him go. People say they don’t have
time to go to the doctor. Yeah, but you don’t have time to lose your
sight, either.
Talking to people helped me a lot. If you’ve ever struggled without
sight or glaucoma or anything with your retina or whatever, you know
you don’t hesitate to go to the doctor; you need to go. I would suggest
that if somebody was just diagnosed with it, they get involved in a sup-
port group or other patients who have gone through this and get advice
from them and testimonies from them. That way, it would help them
on their journey, because it makes you aware that you’re not alone.
I tell my family always to have their eyes checked. Glaucoma is passed
genetically. You might not know you have it, so make sure you go to
the doctor to get checked, especially if someone in your family has been
diagnosed with it. I have nearsightedness in my family, and I remember
struggling as a child trying to see, and then my grandmother took me to
the eye doctor to get glasses. Then I’d feel some changes in my eyesight,
and I’d think, “It’s just because I’m nearsighted.”
I have learned that the damage that glaucoma does to your optic
nerve is irreparable and that you need to take it seriously, do your drops
as needed, go to the doctor, and have checkups as required. If you’re
having struggles to make sure you tell your doctor everything going on,
it might not seem like it’s something big, but it could be. You also have
to be aware and be responsible for your health, and go to your doctor.

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 Keeping It Real 87

If you’ve been recently diagnosed with glaucoma, my advice is that

you take it seriously and try to stay positive. I have had many trials
through this process, from very scary times, but I lean on God and
know that He gives me the strength. He continues to help me push
forward each day to a new tomorrow with hope and praise.
People don’t want to ask questions sometimes, because they think
they’re stupid questions, but when it comes to your health and your
eyesight or anything like that, no question is stupid, because if you
don’t ask that question, you’re not going to find out an answer. ■

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349-99188_Rothfels_ch01_3P.indd 6
 Conclusion

I hope you have found much value in the words you have read in this
book. This book is designed for multiple audiences: diagnosed glauco-
ma patients, patients without glaucoma but who are at risk, eye care
providers who take care of these patients, and the caregivers, family,
and friends who take care of loved ones with glaucoma. I wish I had
the time to talk to each of you individually and share these messages.
Nonetheless, I hope that my thoughts have been made clear.
Just to recap, here are some take-home messages about glaucoma:

1. Don’t ignore the signs of glaucoma.

2. Do the simple “Cover Your Eyes So You Can See” test for a quick
screening of an eye problem.

3. If you are diagnosed with glaucoma, accept the disease.

4. Conquer your fears. Don’t despair. Have hope. Technology is

advancing, and you can take action to preserve your vision.

5. Take glaucoma seriously. It doesn’t go away because you ignore it.

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 90 The Glaucoma Guidebook

6. Ask your doctor questions. Be prepared for each exam.

7. Know what is expected.

8. Keep your medical records. Take control of your health.

9. Talk to your family members. Glaucoma runs in families.

10. Be honest with yourself, and be open with your doctor.

11. Know the risks associated with glaucoma and cataracts. There
are great technologies that can help if you have both glaucoma and
cataracts.

12. Manage your glaucoma and your dry eyes. Just because you have
glaucoma doesn’t mean that your eyes have to stay uncomfortable.
There are options to help.

If you have found value in this book, please share it with others, as
the message of glaucoma awareness needs to be spread far and wide—
locally, regionally, nationally, and globally. If, by writing these words, I
can help even one person preserve their vision and prevent them from
going blind, then it was well worth the effort, and I will be eternally
satisfied. Knowledge is power. Use it, and we’ll preserve global vision
together.

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 Acknowledgments

First and foremost, I am grateful to my husband, Richard Okeke, who

not only helped in editing this book but was also integral in every step—
from the book’s inception to the reality of production. I am grateful to
my children, Izu, Ify, and Obi, who are a constant source of inspiration
and encouragement.
I would like to thank those who contributed to the reviewing, edit-
ing, and beta reading of my work and helped put together the final
touches for the book. Thank you.
To Vanessa Caceres, Stefan Edemobi, June Hart, Shanon Joynes,
Arlene Kessell, Audrey Lazar, Rosalind Quaye, Roger and Faye Smith,
Charmaign Vauters, and Harold Wheeler—your comments and sug-
gestions were extremely helpful.
I am appreciative of the Virginia Eye Consultants’ doctors, staff, and
patients. My experiences with you inspired and supported the work
within the book.
I am endlessly grateful to God. Through Him, all things are possible.

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349-99188_Rothfels_ch01_3P.indd 6
 Resources

Guide to Putting in Eye Drops Correctly 95

Caregiver’s Guide 96
Additional Resources for Glaucoma Caregivers 101
Guide to Finding a Glaucoma Specialist 102
Additional Resources for Glaucoma Patients 105

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349-99188_Rothfels_ch01_3P.indd 6
 Guide to Putting in Eye
Drops Correctly

How to instill eye drops.

Okeke_Guidebook_Int_3pgs.indd 95 10/4/22 3:33 PM

 Caregiver’s Guide

When a loved one is diagnosed with glaucoma, it can be stressful. If

you are caring for someone who has glaucoma, you may wonder how
you can make that person’s life easier, particularly if they have lost or
are losing sight. We hope this guide helps dispel some of the myths
surrounding glaucoma and leaves you feeling prepared to help your
loved one on the glaucoma treatment journey. Here are a few facts you
should know about glaucoma and how some real-life glaucoma patients
describe it. The photos in this section are representative of glaucoma
patients.
Glaucoma is a disease that damages the eye’s optic nerve:

• It usually happens when fluid builds up in the front part of the eye.

• The extra fluid increases the pressure in the eye, damaging the optic
nerve.

Glaucoma is sneaky:

• Primary open-angle glaucoma, the most common type of glauco-

ma, is usually painless, has no symptoms, and causes no vision chang-
es at first.

• Nearly half of Americans with glaucoma do not even know that

they have it.17

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 Caregiver’s Guide 97

• People with glaucoma sometimes believe they have good vision,

because they can see things in the center of their visual field but are
not aware of things in their peripheral vision.

Here is how some real-life glaucoma patients describe it.18

“I was still seeing well enough, but one
evening I was out walking when a man sud-
denly appeared in front of me. It was, as they
call it, a classic ‘jack-in-the-box’ moment:
one minute my way was clear, and the next
minute he popped suddenly into the middle
of my field of view.”
“[The doctor] had me stand across the
room from her and asked me to focus one
eye on her nose and tell her how much of her
body I could see. I couldn’t believe what I
saw. She only existed above the shoulders and below the hips. Her torso
wasn’t there. I literally felt sick. It was the first time the reality sunk in.”

The Emotional Impact of Glaucoma

Patients with glaucoma often go through a
wide range of emotions. Knowing what your
loved one might be feeling can help you be
patient and understanding. Here are some
fears, similar to what I have heard from my
patients.

Fear of going blind

“There is no light at the end of the tunnel. You don’t know what is
going to happen to you. Maybe you will go blind tomorrow, and the
whole world is dark.”19

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 98 Resources

Feelings of hopelessness
“I was going to do art, but there’s no point at all.”20

Frustration with vision changes

“Reading the paper . . . I would just give up and
say, ‘You know, it’s not worth it.’ ”20

Desire to talk with others with glaucoma

“Some of them have a long period of time managing this disorder, so
they can tell me how to deal with it.”19

Loss of independence
“I think it’s emasculating—you know, for a man to lose his driver’s
license.”20

Worry for their friends and families

“What worries me is my only son. I hope the
tragedy [of having glaucoma] won’t happen
again.”19
“I really hate asking people for lifts.”20

Social difficulties
“I’m not very good at identifying people’s faces. That’s gotten worse
over the years . . . my wife has to explain, ‘That’s so-and-so’s wife.’ ”20

Withdrawal
“I’ve sort of stepped down from positions of responsibility, really, being
on committees and that sort of thing, because I just felt I was really
unreliable and I knew I was going to have to go in for more surgery or
something. That really rocked me.”20
People with glaucoma can experience anxiety or depressive symp-
toms. The ways in which you help your loved one with glaucoma
manage these symptoms is what’s important.21

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 Caregiver’s Guide 99

What You Can Do

Here are some tips to help you in your caregiving:

• Reassure your loved one that glaucoma is treatable.

• Patients with glaucoma can still do many of the activities they have
always enjoyed if they are willing to follow their eye treatment plan
and visit their specialist regularly.

• Make sure your loved one goes to his/her follow-up visits.

• Offer to drive your loved one and take notes during doctor appoint-
ments.

• Help your loved one stick to his/her medications and treatment

plan.

• Your loved one may feel overwhelmed by new medication regimens

and instructions, so offer to help with the treatment plan.

• Ask for help.

• Enlist other family members and friends to rotate responsibilities

and build a strong network of support.

• Talk about the emotional effects of glaucoma.22

• Receiving a diagnosis of glaucoma can cause anyone to experience

a range of negative emotions, from grief and shock to anger and
depression, so it is important to talk about your and your loved one’s
emotions and feelings. By treating it as a family issue, you can help
your loved one feel supported.

• If your loved one with glaucoma is a family member, schedule a

complete eye examination for yourself.23

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 100 Resources

• The most common type of glaucoma, primary open-angle glaucoma,

is hereditary. If a member of your immediate family has glaucoma,
you are at a much higher risk than the rest of the population.

The good news is that with early detection, and by diligently follow-
ing a treatment plan, most people with glaucoma will not lose their
sight.24

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 Additional Resources for
Glaucoma Caregivers

Bright Focus Foundation

[Link]
The Bright Focus Foundation offers a “Disease Toolkit” for glaucoma,
including pointers and how-tos, such as “Tips to Manage Caregiver
Stress.”

Rides in Sight
[Link]
Rides in Sight provides a database of transportation programs that can
assist in getting your loved one to his/her follow-up visits.

[Link]
[Link]
[Link] offers information on how to modify homes to make
them safer for people at risk from falls and other injuries.

Health in Aging
[Link]
Health in Aging furnishes caregiving how-tos and an e-newsletter for a
broad range of conditions, including glaucoma.

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 Guide to Finding a
Glaucoma Specialist

Here are a few tips to keep in mind if you are in the process of choosing
a specialist to diagnose or treat glaucoma. Following these tips can help
you find a competent, caring doctor.

1. Find someone experienced in treating glaucoma.

There are a variety of websites that list glaucoma providers, which can
help you narrow down who is located in your area and who might be
right for you or a loved one.
The American Glaucoma Society (AGS) is composed of glaucoma
specialists dedicated to sharing clinical and scientific information for
the benefit of patients, colleagues, fellows, and residents. As a member,
I often use the AGS website as a reference tool for my patients who are
relocating to other areas to find new doctors. You can find a glaucoma
specialist by doing the following:

• Go to the AGS website, at [Link].

• Click on the link at the top of the page that says “Find a Doctor.”

• Enter the relevant zip code and search your desired geographic
radius.

Learn more about additional resources for finding doctors on the

Glaucoma Research Foundation’s website at [Link]
org/treatment/[Link].

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 Guide to Finding a Glaucoma Specialist 103

Although there are several types of doctors who specialize in eye

care—including opticians, optometrists (OD), and ophthalmologists
(MD/DO)—ophthalmologists are trained medical doctors who have
the most expertise in glaucoma. The training for an ophthalmologist
includes 4 years of college (receiving a bachelor’s degree), 4 years of
medical school (receiving an MD or DO degree), a 1-year internship,
and 3 years of ophthalmology residency training, where they obtain
thousands of hours of medical and surgical training. Some ophthalmol-
ogists go on to further specialize in glaucoma care through a yearlong
fellowship training. The members of AGS have all received glaucoma
fellowship training.
The training for an optometrist includes 2–4 years of college (a
bachelor’s degree is not required) and 4 years of optometric school
(receiving an OD degree). Some optometrists go on to obtain a year
of medical training working alongside an ophthalmologist, though this
is not required. When glaucoma is mild or controlled with medica-
tions, optometrists can be a good resource to manage glaucoma, and
they commonly work with glaucoma specialists to monitor glaucoma
patients and help with post-operative management. Optometrists will
refer glaucoma patients to ophthalmologists when there are medical
issues that are moderate to severe, are difficult to control, or are in
need of more advanced treatment, such as laser treatment or glaucoma
surgery.

2. Come to your first visit prepared with questions.

By asking questions, you make your health care (or care for a loved one)
a top priority. Having questions also has another purpose: you get a
better sense of the doctor’s empathy and knowledge. Because glaucoma
is a chronic disease, you most likely will see this doctor many times.
You want to choose someone with whom you feel comfortable asking
questions.

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 104 Resources

3. Reflect on your first appointment.

After you have an initial appointment with a provider, think back on
your experience or talk about it with someone you trust. Were you
comfortable in the office? Were the staff and the doctor friendly? What
was the wait time like? Could you see yourself going there long term?
Answers to these questions can help reveal if that office is a good match
for you. If it’s not, don’t be shy about finding another provider.

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 Additional Resources for
Glaucoma Patients

Although living with vision loss isn’t easy, there are many resources and
apps available to help with daily tasks and let you better understand
what glaucoma is. Here is a list of some of those resources and apps.

Online Glaucoma Resources

Note: Several of the resources below also have information in Spanish.

American Academy of Ophthalmology’s Eye Health

[Link]
[Link]
The American Academy of Ophthalmology is the largest association of
ophthalmologists in the world, with more than 30,000 members. It has
an EyeSmart website. The first URL focuses on consumer information
about eye health. The second URL is about glaucoma.

American Glaucoma Society

[Link]
The American Glaucoma Society is a group geared toward glaucoma
providers, but its website also has an educational section for patients.

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 106 Resources

American Optometric Association

[Link]
The American Optometric Association’s website has a vision rehabilita-
tion fact sheet, “Finding Help for Vision Impairment, Low Vision, and
Blindness.”

Glaucoma Research Foundation

[Link]
[Link]
The Glaucoma Research Foundation specializes in information about
glaucoma care. The second URL features its patient-geared podcast,
which includes episodes such as “Lifestyle Choices and Glaucoma” and
“Stem Cell Treatment for Glaucoma.”

Hadley
[Link]
The mission of Hadley is to create personalized learning opportunities
that empower adults with vision loss or blindness to thrive—at home,
at work, and in their communities.

Prevent Blindness
[Link]
[Link]
Prevent Blindness focuses on better eye care and eye health. Informa-
tion on the second URL focuses on glaucoma.

National Eye Institute

[Link]
[Link]
-and-diseases/glaucoma/
The National Eye Institute is part of the federal government’s National
Institutes of Health and is heavily involved with eye research and clini-
cal trials. Find its glaucoma information at the second URL.

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 Additional Resources for Glaucoma Patients 107

iGlaucoma Patient YouTube Channel

[Link]
The iGlaucoma Patient YouTube Channel is a resource of free educa-
tional videos and helpful guides about glaucoma and issues that per-
tain to glaucoma patients. This channel was created by Dr. Constance
Okeke to further the spread of knowledge about glaucoma for patients
and their loved ones.

Helpful Glaucoma Apps

Check to see if the apps below are available for your smartphone. In
addition to these specific apps, there also are a variety of magnifying
glass apps for both Apple and Google Play. Some of these also provide
additional light when using the app.

AARP Caregiving
This is a free app that empowers caregivers with information on how to
effectively care for a loved one, coordinate care with other family mem-
bers and friends, and keep track of appointments and medications.

Be My Eyes
This innovative app connects people who are blind or have low vision
with sighted volunteers who can help them with daily tasks. For
instance, you may want to know what color a shirt is, if your milk has
expired, or what button to use on a remote control. Help on the app is
available in 185 languages.

EyeDropAlarm
This app allows you to set an alarm to remind you to take your eye
drops. The names of certain glaucoma drops are embedded in the app,
so you can easily select the names that apply to the drops you use.

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 108 Resources

EyeNote
Designed by the US Bureau of Engraving and Printing, EyeNote can
“read” US currency and let you know its denomination.

Glaucoma Notebook
This app lets patients set phone-based alarms to remind them to use
their drops. You can also use the app to keep track of your intraocular
pressure.

Medisafe
This free smartphone app tracks your prescriptions and reminds you
when it’s time for a refill.

Pocket Glasses Pro

This is a magnifying app to help you see things more closely without
glasses. There are other apps for both Apple and Google Play with sim-
ilar functions.

Seeing AI
Use this app to recognize and narrate text that is detected by your
smartphone camera. This app also can read bar codes, name the colors
of articles of clothing, and perform other tasks that can help those with
vision issues.

Spotlight Text
This app helps those with low vision read e-books. The app has several
books on its site that are ready to read.

Okeke_Guidebook_Int_3pgs.indd 108 10/4/22 3:33 PM

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349-99188_Rothfels_ch01_3P.indd 6
 Philanthropy

Thank you for buying this book. Congratulations! By purchasing this book,
you have joined the fight against glaucoma blindness. Your efforts are help-
ing two great organizations that are working toward a glaucoma cure and
active surgical treatment for those with financial hardships.
I am donating some of the proceeds of my book royalties to the following
organizations:

The Glaucoma Research Foundation

The American Glaucoma Society (AGS) Cares Program

The Glaucoma Research Foundation (GRF) is a nonprofit organization

that is dedicated to improving the lives of glaucoma patients and funding
innovative research to find a cure. I am proud to be a long-standing GRF
Ambassador and provider of educational materials from the GRF to my
glaucoma patients. For additional details about glaucoma diagnosis and
treatment and to learn more about GRF’s research efforts, please visit their
website at [Link] and request or download their free, newly
revised booklet, “Understanding and Living with Glaucoma.”
The AGS Cares Program is a public service program dedicated to deliver-
ing surgical glaucoma care at no cost to uninsured or underserved patients
who qualify for such care. The glaucoma care is provided by members of a
national network of volunteers: glaucoma surgeons who are active or pro-
visional AGS members. I am proud to be a long-standing AGS member
and volunteer for the AGS Cares Program. To learn more about the AGS
Cares Program, go to [Link]
/ags-cares/.

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349-99188_Rothfels_ch01_3P.indd 6
 Index

Page numbers followed by f and t are references to figures and tables, respectively.

Affordable Care Act, 84 argon laser trabeculoplasty (ALT), 38

Africa, glaucoma risk in, 43 arthritis, 28
African Americans, 43, 48f artificial tears, 72, 73
aging: cataracts and, 67; changes in vision Asian people, 16, 43
attributed to, 49–50; eye examination,
frequency of, 47; loss of optic nerve cells baseline eye pressure, 15, 35, 64
due to, 11, 41; marbles analogy, 41–42, beta blockers (yellow top), 36, 37f
41–42f bleb, 39–40
alpha agonists (purple top), 36, 37f BlephEx, 73
American Academy of Ophthalmology’s blindness, 1, 9, 22, 23, 43, 47, 54, 67, 77,
recommended frequency of eye exams, 79, 97
46–47, 46–47t blindness prevention. See expert tips for
American Glaucoma Society (AGS), 13, blindness prevention
102, 103 blind spot, 7, 8, 12f
anatomy of eye, 9, 9f, 24–25f. See also blinking, 74
specific parts of the eye blood pressure, 28, 36, 45–46, 81
anesthesia, 38 blurred vision, 7–8, 36, 43, 50f, 70
angle, definition of, 31 brain’s role, 5, 7, 17, 17f, 51
angle-closure glaucoma: angle-closure burning or stinging eyes, 36, 70
attack, 16, 26; Asian people and, 16,
43; as common type of glaucoma, 15; carbonic anhydrase inhibitors (orange top),
compared to open-angle glaucoma, 36, 37, 37f
25–26; described, 24, 25f; diagnosis of, caregiver’s guide, 96–100; resources for
31; fluid pathway in, 24, 25f; caregivers, 101; tips for caregivers,
laser cyclophotocoagulation as 99–100
treatment for, 39; laser peripheral Caribbean people, 43
iridotomy (LPI) as treatment for, cataracts and cataract surgery, 67–69,
38–39; sink analogy, 25–26, 26f; 68–69f; co-morbid cataract and
symptoms of, 43 glaucoma, 41, 69, 69f, 90; definition
applanation tonometry, 14f, 31, 31f of cataract, 68; pseudoexfoliative
aqueous humor (intraocular fluid), 9f, 13, glaucoma and, 44; as secondary cause of
23, 24, 27, 36, 40 glaucoma, 27

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 116 Index

Centers for Medicare and Medicaid ethnicity as risk factor, 42–44, 48f
Services, 69 examinations of eye. See eye examinations
central vision, 8, 52, 97 expert tips for blindness prevention, 49–74,
cholinergics (green top), 36, 37f 100; accepting the disease, 53–54, 54f,
ciliary body, 9f, 23, 24, 24–25f, 39 89; cataracts and glaucoma, 67–69,
closed-angle glaucoma. See angle-closure 68–69f; “Cover Your Eyes So You Can
glaucoma See” test, 5, 51–53, 52f, 89; dry eyes,
color vision, 22 management of, 70–74, 70f, 90; family
co-morbid cataract and glaucoma, 41, 69, members, sharing diagnosis with, 55,
69f, 90 64–66, 65f, 77, 80, 82, 86; having
congenital glaucoma, 26 hope/conquering fears, 54–56, 56f, 86,
contrast sensitivity, 22–23, 56 89, 97; honesty with yourself, 66–67,
cornea, 9f, 13, 31, 31f, 36 90; ignoring visual changes, 49–51,
cost of eye care, 58, 66, 84 50f, 89; medical records, maintenance
“Cover Your Eyes So You Can See” test, of, 63–64, 90; partnering with your eye
5, 51–53, 52f, 89 doctor, 55, 57–60, 60f; post-diagnosis,
cupping, 11–12, 11f what is expected, 60–63, 90; risks,
cup-to-disc ratio, 11, 64 importance of knowing, 67–69, 68–69f,
90; seriousness of glaucoma, importance
depression, 36, 84, 98, 99 of understanding, 57, 57f, 81, 83,
depth perception, 22 86–87, 89
detached retina, 85 eye. See anatomy of eye
diabetes, 27, 81 eyeball length, 45
diagnosis of glaucoma, 28–34; acceptance eye doctors: appointments and follow-
of, 53–54, 54f, 89; denial of, 53; up care, 58, 61–62, 63, 79, 81–82,
glaucoma suspect, 34; what to 84, 86, 99; confidence in, 58, 79,
expect after, 60–63, 90. See also eye 84; explanations by, 59; glaucoma
examinations; screening, importance of; specialists, 54, 102; honesty with, 58,
tests for glaucoma 66–67, 90; initial visits with, 60–61,
dilation for eye examination, 34, 46 104; partnering with, 55, 57–60, 60f;
drugs. See eye drops; medications questions to ask, 58, 59–60, 80, 83, 87,
dry eyes, 36, 70–74, 70f, 90; artificial 90, 103. See also eye examinations; tests
tears, 72, 73; BlephEx and, 73; blinking for glaucoma
and, 74; drinking water and staying eye drops: artificial tears, use of, 72, 73;
hydrated, 74; humidifiers and, 74; iLux changing types of, 71; classes of and
and, 73; lid scrubs and, 73; LipiFlow corresponding bottlecap color, 36,
and, 73; medications specifically for, 37f; combined in one bottle, 37, 71;
72–73; punctal plugs and, 73; self- dry eyes and, 71–73; most common
care treatments, 74; sunglasses and, treatment for glaucoma, 13, 35–37;
74; 20/20/20 rule and, 74; vitamin preservative-free, 71; refills, 63; side
supplements and, 73; warm compresses effects of, 35–36, 58, 66, 71; staying on
and, 73; ways to combat, 71–74 regimen of, 58, 66, 77, 79–80, 82, 84,
99; steroid eye drops, 28, 45; surgical
early detection. See screening, importance of procedures and, 40–41; using properly,
emergency treatment, 16, 26 62, 95f
emotional impact of glaucoma. See impact eye examinations, 28–30; components of,
of glaucoma 46; dilation for, 34; gonioprism used

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 Index 117

in, 23, 24; recommended frequency of, global loss, 22

46–47, 46–47t; slit-lamp exam, 30, 30f, gonioprism, 23, 24
61; vision charts, 29, 29f, 61. See also gonioscopy, 31, 32f, 61
tests for glaucoma grayed-out images, 7–8
eye inflammation, 27, 28, 73, 81
eye masks, 73 Hart, June, glaucoma experience of,
eye pressure: angle-closure attack and, 85–87, 85f
16, 26; baseline, 15, 35, 64; cataract having hope/conquering fears, 54–56, 56f,
surgery combined with glaucoma 86, 89, 97
surgery, 68; elevated, 13, 27, 28, 45; headache, 16, 36
measurement of, 14 f, 31, 31f; normal, help. See support groups/support network
13, 15; ocular hypertension, 13; target of friends and family
pressure, 15. See also eye examinations; heredity. See family history of glaucoma
risk factors; treatment for glaucoma high blood pressure (hypertension), 28,
eye redness, 16, 36, 40, 43, 71, 73, 85 45–46, 81
eye surgery. See cataracts and cataract Hispanic people, 43, 48f
surgery; surgery honesty: with eye doctors, 58, 66–67, 90;
eyewear, 74, 77 with yourself, 66–67
hopelessness, 54, 89, 98
family help. See support groups/support humidifiers, 74
network of friends and family
family history of glaucoma, 13, 42, 50–51, iGlaucoma Patient channel (YouTube), 74
64–66, 65f, 77, 80, 82–83, 85, 99, 100 ignoring visual changes, 16, 49–51, 50f, 89
fears. See having hope/conquering fears iLux, 73
field of vision. See central vision; peripheral impact of glaucoma, 47–48, 48f, 97–98, 99
vision; visual field infants with glaucoma, 26
fluid drainage system, 24–26, 26f injury to the eye. See trauma
focal loss, 22 insurance coverage, 84
friends, help from. See support groups/ intraocular fluid (aqueous humor), 9f, 13,
support network of friends and family 23, 24, 27, 36, 40
intravenous (IV) medication, 35, 36
glaucoma: aggressive nature of, 44, 57, 62, iris, 9f, 23, 24, 24–25f, 27, 36, 44, 44f
63; asymptomatic, 15–16, 18, 47, 49, irreversible damage, 1, 16, 26, 47, 68, 77,
54, 78, 80, 82, 83, 96; chronic nature 78, 86
of, 57, 62, 63; complexity of, 22, 23;
definition of, 3, 82, 96; incurable, 15, Japan, glaucoma risk in, 43
16, 21, 62, 68, 78. See also diagnosis
of glaucoma; expert tips for blindness Kessell, Arlene, glaucoma experience of,
prevention; stages of glaucoma; tests for 78–80, 78f
glaucoma; treatment of glaucoma; types
of glaucoma lamp analogy, 17–23, 17–22 f ; at 5%
Glaucoma Research Foundation, 17, brightness, 22, 22f; at 15% brightness,
102, 113 21, 21f ; at 30% brightness, 20, 20f ;
glaucoma specialists, 54, 102. See also eye at 50% brightness, 19, 19f ; at 100%
doctors brightness, 18, 18f
glaucoma suspect, 34, 67 laser cyclophotocoagulation, 39
global impact of glaucoma, 47 laser peripheral iridotomy (LPI), 38–39

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 118 Index

laser (light energy) treatment, 13, 16, 35, States, 15–16, 23, 47, 96, 100; normal-
37–39, 38f, 67, 103; advances in, 72; tension glaucoma as type of, 27, 43;
benefits of, 72; records of, 64; reducing selective laser trabeculoplasty (SLT)
need for eye drops, 72; results wearing as treatment for, 38–39, 38f, 72; sink
off, 62 analogy, 25–26, 26f
lens, 9f, 23, 24–25f, 44, 68 operations. See cataracts and cataract
lid scrubs, 73 surgery; surgery
LiGHT Trial (study), 72 ophthalmologists, 103. See also eye doctors
LipiFlow, 73 optical coherence tomography (OCT),
loss of independence, 1, 55, 98 32–33, 33f, 64
loss of vision. See blindness; vision loss optic nerve, 9–13; aging and, 11, 41–42,
low blood pressure, 36, 45–46 41–42 f; anatomy of, 9, 9f; baseline
low-vision optometric specialists, 55–56 evaluation of, 60–61, 63, 64; cup, 10,
10f; cupping of, 11–12, 11f; cup-to-
magnifying glasses, 56 disc ratio, 11; damage from glaucoma
marbles analogy for loss of optic nerve to, 9, 9f, 11–12, 11f, 14f, 23, 25, 26;
tissue, 41–42, 41–42 f disc rim, 10–11, 10f; focal loss and, 22;
medical records, 63–64, 90 global loss, 22; initial measurements
medications, 35–37, 37f; allergic reactions, of, 60–61; in lamp analogy, 17–23,
82; for blood pressure, 46; combination 17–22f; nerve cells/tissue, 11, 16, 33,
use of, 35; for dry eyes, 71–73; elevation 33f, 35, 41; normal, 10–11, 10f, 14f;
of eye pressure from, 26; expense of, 58, photographs of, 34, 34f, 61, 64.
66; keeping to regimen, 58, 66, 77; side See also eye pressure
effects from, 35–36, 58, 66, 71 optometrists, 103
MIGS (minimally invasive glaucoma oral pills, 35, 36, 37
surgery), 40–41, 67, 68–69, 72
myopia (nearsightedness), 45, 80–81, 86 pain, 16, 40, 43, 80
patients’ stories of living with glaucoma,
nearsightedness (myopia), 45, 80–81, 86 75–87
neovascular glaucoma, 28 perimetry. See visual field test
nerve fiber layer analysis, 32–33, 61, 63, 64 peripheral vision, 5, 8, 32, 50, 52, 79,
normal-tension glaucoma, 27, 43 85, 97
pigment dispersion glaucoma, 27
OCT (optical coherence tomography), primary open-angle glaucoma. See open-
32–33, 33f, 64 angle glaucoma
ocular hypertensives, 13, 69f prostaglandin analogs (teal top), 36–37, 37f
omega-3 fatty acids, 73 protein: production by glaucoma, 43–44;
online support groups and resources, 55, sloughing off of, 27
82, 105–108 pseudoexfoliative glaucoma, 27, 43–44, 44f
open-angle glaucoma: argon laser punctal plugs, 73
trabeculoplasty (ALT) as treatment
for, 38; compared to angle-closure Quaye, Rosalind, glaucoma experience of,
glaucoma, 25–26; described, 23, 80–83, 80f
24f ; fluid pathway in, 23, 24f ;
Hispanic people and, 43; laser race as risk factor, 43, 48f
cyclophotocoagulation as treatment red eye. See eye redness
for, 39; most common type in United religious conviction, 82–85, 87

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 Index 119

research on glaucoma, 16–17, 55, 84 40–41; combined with cataract surgery,

rho kinase inhibitors (white top), 36, 37f 41, 68–69; congenital glaucoma and,
risk factors, 41–46; aging, 11, 41–42, 26; follow-up visits, 61; incisional,
41–42f, 67; blood pressure, 28, 45–46; 39–40; minimally invasive, 40–41,
ethnicity, 42–44; family history, 13, 42, 67, 68–69, 72; records of, 64; scarring
50–51, 64–66, 65f, 77, 80, 82–83, 85, from, 62.
99, 100; nearsightedness (myopia), 45; See also cataracts and cataract surgery
steroid use, 27, 28, 45; trauma to the sustained-release delivery of medication,
eye, 27, 28, 44 35, 37
risks: what you need to know, 67–69, symptoms of glaucoma: of angle-closure
68–69f, 90 type, 16, 43; of congenital type, 26; no
symptoms, 15–16, 18, 47, 49, 54, 78,
Scandinavian people, 43–44 80, 82, 83, 96
scarring in the eye, 28, 38, 62
screening, importance of, 12, 16–17, 22, target pressure, 15
28–29, 29f, 45, 54, 68, 82, 86, 100 tests for glaucoma, 29–34; eye pressure,
secondary glaucoma, 27 measurement of, 31, 31f, 61; glaucoma
second opinions, 54 suspect, 34; gonioscopy, 23, 24, 31, 32f,
selective laser trabeculoplasty (SLT), 38–39, 61; nerve fiber layer analysis, 32–33, 61,
38f, 72 63, 64; optical coherence tomography
sensitivity to light, 43 (OCT), 32–33, 33f, 64; optic nerve
seriousness of glaucoma, importance of photographs, 34, 34f, 61, 64; repeated
understanding, 57, 57f, 76, 81, 83, testing after initial diagnosis, 61–62;
86–87, 89 results, 34; slit lamp exam, 30, 30f, 61;
sharing about glaucoma: with family tonometry, 14f, 31, 31f; vision/visual
members, 55, 64–65, 65f, 77, 80, 82, acuity test, 29, 29f, 61; visual field test
86; with others, 75, 82–83, 86, 98 (perimetry), 12, 12f, 32, 33f, 61, 63
side effects from medication, 35–36, 58, tips for blindness prevention. See expert tips
66, 71 for blindness prevention
side vision. See peripheral vision tonometry, 14f, 31, 31f
sink analogy, 25–26, 26f trabecular meshwork, 9f, 23, 24, 2
slit-lamp exam, 30, 30f, 61 4–25f, 38
SLT (selective laser trabeculoplasty), 38–39, trabeculectomy, 39–40, 72
38f, 72 trauma as cause of glaucoma, 27, 28, 44
Smith, Roger Vann, glaucoma experience traumatic glaucoma, 27
of, 83–85, 83f treatment of glaucoma, 34–41, 99;
stages of glaucoma: advanced, 5, 8, 8f, 12, changes in, 62, 71; choices of first-
21, 34, 39, 49, 103; early, 3, 6, 6f, 12, line therapies, 39; choices of surgical
16, 40, 49, 61, 72, 103; end stage, 8, procedures, 40–41; combined use of
13; moderate, 7, 7f, 21, 40, 49, 72, 103 therapies, 35; emergency treatment,
steroid eye drops, 28, 45 16, 26; eye pressure, goal to lower, 13,
steroid-induced glaucoma, 27, 28, 45 15, 35, 55; in-office treatments, 38–39;
sunglasses, 74, 77 medications, 35–37, 37f; surgery,
support groups /support network of friends 39–41. See also eye drops; laser (light
and family, 53, 55, 82, 86, 98, 99 energy) treatment; surgery
surgery, 13, 35, 39–41, 103; angle-closure tube shunt, 39, 40, 72
attack and, 16; choices of, tumors, 27

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 120 Index

20/20/20 rule, 74 normal versus abnormal, 3, 4f, 5–8,

20/20 vision, 5, 8, 29 6–8f ; perfect (20/20), 5, 8, 29;
types of glaucoma, 23–28; congenital peripheral, 5, 8, 32, 50, 52, 79, 85, 97
glaucoma, 26; neovascular glaucoma, vision loss, 1, 3–4, 9, 11, 17; angle-closure
28; normal-tension glaucoma, 27, attack and, 16, 27; early detection of,
43; pigment dispersion glaucoma, 27; 16, 49–51, 54–55; effects of, 1, 79, 98;
pseudoexfoliative glaucoma, 27, 43–44, ethnicity and, 43; focal loss, 22; global
44f; secondary glaucoma, 26–27; loss, 22. See also blindness; irreversible
steroid-induced glaucoma, 27, 28, 45; damage; stages of glaucoma
uveitic glaucoma, 28. See also angle- vision rehabilitation services, 55–56
closure glaucoma; open-angle glaucoma vision/visual acuity test, 29, 29f, 61
visual field, 6, 19, 79
uveitic glaucoma, 28 visual field test (perimetry), 12, 12f, 32,
33f, 61, 63, 64
Vauters, Charmaign, glaucoma experience vitamin supplements, 73
of, 76–78, 76f
Virginia Eye Consultants, 77 warm compresses, 73
vision: central, 8, 52, 97; changes in, water and staying hydrated, 74
49–51; color, 22; contrast sensitivity, watering/tearing eyes, 71
22–23, 56; depth perception, 22;

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 IMAGE CREDITS
CHAPTER 1. All figures are courtesy of Dr. Constance Okeke, with the following
exceptions. page 4: Courtesy of KeithJJ ([Link]), [Link]
/photo/655164/soccer-football-soccer-players-kick-kicking-soccer-ball-game-competition
-action/; pages 6–9: Courtesy of Mangdesain; page 10, bottom right: Courtesy of Willis
Lam, [Link]
_Doughnut_(30801404415).jpg; page 14, top left: Courtesy of [Link], [Link]
.[Link]/[Link]; page 14, top right: Courtesy of [Link], https:
//[Link]/weak-national-government-clipart-united-states-of-eiufp9/; pages
18–22, images on the right only: Courtesy of [Link], [Link]
energy-saving-lamp-1340220/; pages 24–25: Courtesy of Mangdesain; page 29, top:
Courtesy of [Link], [Link] page 29, bottom: Courtesy of Piqsels
.com, [Link] page 30: Courtesy of
[Link], [Link]
page 31: Courtesy of Bright Focus, [Link]
-pressure-measured/; page 33, top: Courtesy of FotothekBot, [Link]
.org/wiki/File:Fotothek_df_n-10_0000776.jpg; page 38: Courtesy of Mangdesain.

CHAPTER 2. page 50: Courtesy of [Link], [Link]

-eeecc/; page 52: Courtesy of [Link], [Link]
-face/[Link]; page 54: Courtesy of Pixabay, https:
//[Link]/photos/hospice-hand-in-hand-caring-care-1793998/; page 56: Courtesy of
[Link], [Link]
-Pray-1926414/; page 57: Courtesy of [Link], [Link]
/Man-Mood-Face-Eye-Emotion-People-Message-Look-164218/; page 60: Courtesy of
[Link], [Link]
-Patient-5710152/; pages 65, 68–69: Courtesy of Dr. Constance Okeke; page 70:
Courtesy of the Centers for Disease Control and Prevention, [Link]
/conjunctivitis/about/[Link].

CHAPTER 3. All photographs are courtesy of the subjects.

CAREGIVER’S GUIDE. page 97, top: Courtesy of [Link], [Link]

//photo/802511/adult-annoyed-blur-burnout-concentration-facial-expression-frustrated
-girl-indoors/; page 97, bottom: Courtesy of Sheldon Botler Photography/Aclew, https:
//[Link]/wiki/File:AlbertLew_Sophisticate.jpg; page 98, top: Courtesy of
[Link], [Link]/photo/433574/sad-woman-expression-stress-depressed
-unhappy-grief-caucasian-head/; page 98, bottom: Courtesy of [Link], www
.[Link]/photo/438791/people-black-homeless-black-people-person-african-young
-adult-american/.

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349-99188_Rothfels_ch01_3P.indd 6
 ABOUT THE AUTHOR

Dr. Constance Okeke is a board-certified ophthalmologist who is commit-

ted to educating her patients and the community about how to fight glau-
coma blindness.
She received her undergraduate and medical degrees from Yale University
and trained in ophthalmology at the Wilmer Eye Institute of Johns Hopkins
University. She completed her glaucoma fellowship training as a coveted
Heed Research Fellow at the Bascom Palmer Eye Institute of the University
of Miami, and then went on to earn a Master’s of Science in Clinical Epide-
miology at the University of Pennsylvania.
Dr. Okeke has practiced ophthalmology, with a specialty in glaucoma and
cataract surgery, for more than 20 years. She has received numerous awards
and honors, including the prestigious recognition of being voted by her
peers to The Ophthalmologist’s global top 100 female Power List for 2021 and
global top 100 combined male and female Power List for 2022. Currently,
she is an assistant professor of ophthalmology at Eastern Virginia Medical
School and the lead glaucoma specialist at CVP—Virginia Eye Consultants
in Norfolk, Virginia. In addition to teaching, she sits on the editorial adviso-
ry board of the journals Glaucoma Today, CollaborativeEYE, and Glaucoma
Physician. Dr. Okeke also has two educational YouTube channels that feature
glaucoma surgical techniques: iGlaucoma, which is geared towards eye care
professionals, and iGlaucomaPatient, which is aimed at patient education
and support.
As part of her efforts to educate doctors in emerging techniques in the
area of minimally invasive glaucoma surgery (MIGS), she wrote her first
book, The Building Blocks of Trabectome Surgery: Patient Selection. Dr. Okeke
is a leading expert, pioneer, and trainer in the area of MIGS on national and
international levels.
Dr. Okeke makes her home in Hampton Roads, Virginia, with her loving
husband and three children.
For more information about Dr. Okeke and her work, visit her website at
[Link].

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349-99188_Rothfels_ch01_3P.indd 6
 [Link]

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