I thought this is a very interesting chat transcript, because of what glaucoma treatment was like around 100 years ago. - Nancy

Glaucoma Down Through the Ages

From URL:
http://www.wills-glaucoma.org/supportgroup/20050112.php

On Wednesday, January 12, 2005, Dr. George Spaeth,
Director, Wills Glaucoma Service, and the glaucoma
chat group discussed "Glaucoma Down Through the Ages."

Moderator:  Welcome to chat, Dr. Spaeth. The topic
tonight is "Glaucoma Down Through the Ages."

Dr. George Spaeth:  Thank you.  Maybe I can start
things out.  The subject is really important. 

Moderator:  Please do. 

Dr. George Spaeth:  A thousand years ago, glaucoma was
"painless blindness." Later it became apparent that
most people who were thought to have glaucoma really
had cataracts.  About 1850 it became clear that eyes
with high intraocular pressure (IOP) were sick, and
high pressure became the definition of glaucoma.

About 100 years later, work began which eventually
showed that 95% of people with elevated pressure never
got glaucoma, and 50% of those with glaucoma had
normal pressure.  Wow!  Something was clearly wrong
with the old idea that glaucoma was elevated IOP.

Moderator:  What is the thinking now?

Dr. George Spaeth:  Now we think that pressure inside
the eye always plays a role in the development of the
damage to the optic nerve.  That is the hallmark of
glaucoma.  The pressure can be 10 or 15 or 50 mm Hg.

But glaucoma is NOT elevated pressure.  Glaucoma is a
process in which the optic nerve changes from healthy
to sick.  Some people never get really sick nerves and
other people do, but that is not related to the level
of pressure.

P:  In the 1800's, how was glaucoma diagnosed and what
was the treatment?

Dr. George Spaeth:  Doctors just measured the
pressure, and they treated with pilocarpine or similar
drugs that made the pupil small.

P:  At a conference last fall, Dr. Robert Ritch said
that when he first started practicing medicine,
glaucoma had three stages: eyedrops, surgery,
blindness. Can you elaborate?

Dr. George Spaeth:  If the pressure was above 21 mm
Hg, people got treated; if below 21 mm Hg, they were
not treated.  So 95% of the people were treated
unnecessarily.  Some people need surgery first, others
laser first, others drops first.  The care needs to be
individualized.

P:  Since it used to be common to treat patients for
glaucoma purely on the basis of elevated pressure, and
since a family history of glaucoma is considered a
risk factor, how can patients today really know
whether their grandparents or other relatives actually
had glaucoma?

Dr. George Spaeth:  Great question! You can't.  Most
people back then who were told they had glaucoma did
NOT have glaucoma.

P:  What do you consider to be the greatest advance in
the understanding of glaucoma during the last 50
years?

Dr. George Spaeth:  The understanding that glaucoma is
a complex disease, not just high pressure.

P:  How was the difference between blindness due to
glaucoma and other diseases, such as macular
degeneration, discovered?

Dr. George Spaeth:  It is not difficult to learn to
see the type of damage that occurs.  Glaucoma causes
the optic nerve to be damaged. In macular
degeneration, the macula is diseased.

P:  The chronic open-angle glaucomas have been studied
more extensively than any other types of glaucoma, but
is more known about the mechanisms of that type than
the other types?

Dr. George Spaeth:  No. The best understood glaucoma
is primary angle-closure glaucoma.  There the problem
is that the front of the eye is small and the iris
blocks the drain.  With the chronic glaucomas, we
still do not understand why some people get worse and
others don't.

P:  At the beginning of the 20th century, doctors had
only miotics for the medical treatment of glaucoma.
Pilocarpine, the oldest of today's glaucoma
medications, and the prostaglandin, Xalatan, one of
the newest, have opposite effects on uveoscleral
outflow. Are both drugs effective when used together?

Dr. George Spaeth:  Yes, but not additively.  Some
docs don't use them together.

P:  How confident are you that current classifications
and concepts of the glaucomas are correct and useful?
Are glaucoma researchers looking for new paradigms?

Dr. George Spaeth:  We are looking for new paradigms.
I have an editorial coming out about them in several
months.  It is clear that our present classification
system is not adequate.  The difference between
open-angle glaucoma and angle-closure glaucoma,
however, is valid and important.

P:  Where will your editorial appear?

Dr. George Spaeth:  In the journal "Ophthalmology."

P:  What types of surgeries for glaucoma were
available 60 years ago, and how successful were they?

Dr. George Spaeth:  Quite amazingly, the surgery that
we do today was started over 100 years ago.  It has
been refined and modified, but it is still basically
the same thing.  The so-called trabeculectomy is the
same operation that was done 100 years ago, except a
lid covers the drain.

P:  I recently had cataract surgery, which was vastly
different from my mother's cataract surgery.  It's
unfortunate that glaucoma surgery has changed so
little in all these years.

P:  Was the Scheie sclerectomy an early form of a
trabeculectomy?   My Mom had that done 32 yeas ago.

Dr. George Spaeth:  The Scheie procedure was a great
operation.   The problem was that it often (about 1/3
of the time) allowed too much drainage.  The front of
the eye collapsed, leading to cataract and other
problems.  The newer operations put a lid on the
drain, which prevents that kind of complication in
most people, but results in higher pressures.

Moderator:  When were lasers first used for glaucoma
surgery?

Dr. George Spaeth:  Now lasers are new and a great
addition.  About 25 years ago, a doctor in Oklahoma
found that pressure could be lowered by treating the
trabecular meshwork with very low levels of argon
laser energy.  That was a great contribution.

P:  Is it fair to say that advances in glaucoma
treatments have been slow in the last 100 years?

Dr. George Spaeth:  The changes have really been
dramatic, but they have been conceptual.  Think of
what it means that what everybody thought was right in
l950 everybody now knows is wrong. There are so many
misunderstandings.  For example, peripheral vision is
the LAST part of vision to be lost.  Also, surgery is
often the best first treatment, and so on.

P:  One of those misunderstandings is what
"peripheral" vision means.  For instance, the visual
field tests I've taken for years on Humphrey machines
test the central 30 degrees, not peripheral vision.

Dr. George Spaeth:  That depends upon the type of
visual field machine.  Some do test for peripheral
vision.

P:  Why isn't the full visual field tested?  Do
doctors think that the peripheral loss outside the 30
degrees is acceptable to most of us?

Dr. George Spaeth:  Testing outside the 30 degrees is
difficult, and that is not where early field loss
develops.  Thus, it would be time consuming and would
not tell us anything that we can't learn from testing
the more central portion.

[Editor's note:  The central 30 degrees of vision is
straight-ahead vision. It is the part you are using to
see your computer screen.]

P:  Although the visual field tests are now much less
tiring for patients than in earlier years, most
patients still dread taking those tests. Do you
foresee further advances in that area soon?

Dr. George Spaeth:  I think visual field testing has
gone as far as it can.  I predict that the tests we
use now will become increasingly less important in the
future.  They are too difficult and too nonspecific.
Objective field machines are being developed and they
may be a help. That is, the person does not push a
button, but just looks at a target.

Moderator:  Which is more important: the cup-to-disc
ratio or alterations in the topography of the optic
nerve head?

Dr. George Spaeth:  Cup-to-disc ratios are a rough
guide.  But the pattern is more important.  You
differentiate a Van Gogh from a Monet painting by the
pattern, not by the size of the frame.

P:  When my glaucoma was diagnosed in early 1988, I
was torn for years between the arguments of mechanical
versus ischemic theories.  That debate seemed to end
in a blind alley.  Now, Dr. Joseph Caprioli at the
University of California, who served a fellowship at
Wills, says we have to forget that argument, and think
about cellular and molecular pathways.  Do you agree?

Dr. George Spaeth:  Joe Caprioli took his training
with me.  He is very bright and knows a lot.  But he
is falling into the same trap that affected older
doctors.  He is looking for ONE answer. There is no
ONE answer.  Some people lose sight because of
mechanical damage to the nerve, some because there is
not enough blood flow, some because of an abnormal
gene, and so on.

P:  What you are saying is not only very informative,
but gives me hope.  I am so intimidated by the
ophthalmologists I have seen that I didn't dare
question the treatment.

Dr. George Spaeth:  The challenge is always to look at
the individual person -- who is always different from
every other person -- and to figure out what is
happening with that unique person.

P:  Doctor Spaeth, we live in an era where many --
both professionals in various fields as well as lay
persons -- search for the cures in the causes.  Often
it's assumed that if the cause is known, a cure can be
found.  I don't see that clearly in glaucoma research.
Perhaps there's not much to be gained from the popular
methodology. Can you comment, please?

Dr. George Spaeth:  In the 1800s people were dying
from cholera in London.  John Snow, an engineer, noted
that people died in certain areas and not in others.
He concluded that the water supply caused the deaths,
and saved the lives of millions without knowing
anything about the fundamental cause.

P:  If the pressure is high and drops won't lower it,
but the optic nerve is healthy, is surgery still
needed?

Dr. George Spaeth:  If the nerve is healthy, why do
you need any treatment at all?

P:  Don't data show that treating ocular hypertensives
preserves vision over the long term, as opposed to not
treating?

Dr. George Spaeth:  The data are the other way around.
Treating causes cataracts and introduces anxiety.
The only long-term study, by Linner and Stomber,
showed that after 25 years of not being treated,
ocular hyptensives rarely (5%) lost enough vision to
notice any visual loss.  But everybody who is treated
for ocular hypertension has some side effects from the
meds.

P:  How accurate are the tools, such as retinal flow
meters and color Doppler imaging, for measuring blood
flow of the optic nerve?

Dr. George Spaeth:  For populations, they are great.
For individuals, they are almost useless.  If you
measure the temperatures of a large group of people,
the average temperature is usually around 98.6
degrees.  But some people have temperatures that are
above that and others below that.  Some people's
healthy temperature differs from what is thought to be
normal.  And so it is with everything else, including
measurements of blood flow.  Some people go blind with
a pressure of 12 mm Hg, and other people need no
treatment with a pressure of 30 mm Hg. “Healthy” and
“average” are not synonyms, though those who know
nothing about life would have us believe they are.

P:  How do you define a healthy optic nerve?

Dr. George Spaeth:  A healthy optic nerve is one that
works well.

P:  What tests can help determine if an optic nerve
works well (is healthy)?

Dr. George Spaeth:  How well do you see?  How well
does the nerve transmit electrical impulses to the
brain (tested with VEP)? How well do you see colors,
movement, dark objects, etc.?

[Editor's note:  VEP stands for Visual Evoked
Potential, a test involving computerized recording of
the electrical activity at the back of the brain
(occipital cortex) that results from light flashes
stimulating the retina.  The test is used for
detecting defects of the retina-to-brain nerve
pathway, since they can change the brain-wave
patterns.]

P:  I read about the equilateral triangle: pressure,
visual fields, optic nerve scans.  So far, I have had
two optic nerve scans in three years and plenty of
pressure readings. Is that approach lopsided?

Dr. George Spaeth:  Field damage usually occurs after
nerve damage.   The most important thing is looking at
the optic nerve.  The scans are not as good as a good
examination of the optic nerve.  You can usually tell
if a nerve is healthy by the way it looks.  But it is
like looking at a painting.  It is the pattern, not
the cup-to-disc ratio or any other figure, that tells
you the answer.

P:  When do you think we might expect to see clinical
benefits from neuroprotectants and gene therapies?

Dr. George Spaeth:  Neuroprotectants?  We have a great
neuroprotective procedure now: lowering the pressure.
From drugs and so on, perhaps never. From gene
therapies, right now some gene theories work for other
diseases, but for glaucoma, perhaps never.

P:  Do you anticipate an increasing interest in
neuroprotective agents independent of intraocular
pressure?

Dr. George Spaeth:  Yes, but I think it is misguided.
That was a bad answer.  I think that preserving the
health of the nerve by means other than lowering
pressure is terribly important, but it may be diet,
exercise, chocolate.  Who knows?

P:  Is uncontrolled high pressure always a precursor
to optic nerve damage?

Dr. George Spaeth:  Ninety-five percent of people with
elevated pressure never get nerve damage.  Fifty
percent of people with nerve damage never have
elevated pressure.

Moderator:  At what pressure does damage definitely
occur?

Dr. George Spaeth:  The answer is that everybody is
different and some people get worse at low pressures
and others don't.  At pressures above 30 mm Hg, people
are predisposed to getting a clot in the veins of the
eye.  Therefore, I advise treatment in most people
with IOP over 30 mm Hg, not to prevent glaucoma, but
to prevent a blood clot.  When the pressure gets to 50
mm Hg, that's almost always bad.

P:  From what you've said, it seems to me that you do
not favor the use of medications for the treatment of
ocular hypertension, and maybe not even for glaucoma
(that is, when damage has occurred).  Please comment.

Dr. George Spaeth:  I favor the use of medications or
laser or surgery if it is clear that a person has a
condition that will cause visual disability.  If the
nerve is normal and staying normal, treatment is
rarely needed.  If the nerve is getting worse,
treatment is needed in most people.  If the person
already has visual disability, treatment is usually
essential.

P:  Where does early field loss develop?

Dr. George Spaeth:  That depends on the person.  In
some, the earliest field loss is almost straight
ahead; in others, it is near the natural blind spot;
in others, it is in the nasal periphery.

P:  Do doctors routinely look at the optic nerve at
each visit?   Maybe I'm missing that part.

Dr. George Spaeth:  Great question.  The answer is no,
but they should look at the optic nerve whenever there
is a question about determining the person's visual
stability.  Thanks for asking that question.

P:  My eye specialist measures my pressures, then
looks into my eyes briefly, and that's it.  Do you
think he is looking properly for any changes?

Dr. George Spaeth:  That's the usual approach.  If I
had my way, it would be reversed.  Boy!  Will your doc
hate me.

P:  I have seen four glaucoma docs and they all cue
into the high pressure as a red flag that must be
lowered or else optic nerve damage will or could
occur.  Why are so many docs fearful of high pressure
if 95% of those with it never get nerve damage?

Dr. George Spaeth:  Because that's what we all thought
for 150 years.  Habits change slowly.

P:  What has been the result of treating people once
their pressures got to 21 mm Hg?

Dr. George Spaeth:  All treatments cause problems.
Eyedrops cause impotence, heart block,
gastrointestinal upset, back aches, anemia, death, and
more.

P:  I know that the best technology is nothing if not
interpreted correctly.  How can you tell if your doc
is experienced in recognizing nerve changes?  What
questions should a patient ask?

Dr. George Spaeth:  Ask him or her how important
examination of the nerve is.

P:  Is it the preservatives in eyedrops, rather than
the eyedrops themselves, that have the most side
effects?  If so, why don't ophthalmologists insist
that preservative-free medications be developed?

Dr. George Spaeth:  Preservatives protect people from
getting infections. But preservatives are poisons.
Preservative-free drops are dangerous.  But the
preservatives are dangerous, too. It is always a
trade-off.

P:  When you began your training, were there many
glaucoma specialists in the U.S., and how has that
number changed over the years?

Dr. George Spaeth:  When I started training in 1960,
there was a handful of glaucoma specialists.  Now
every hospital or university has one or more. Wills
has 14 glaucoma specialists.

Dr. George Spaeth:  I'm still at work and my wife is
holding dinner for me. So I will say good-bye.  I hope
I have raised questions.  I hope all of you have a
great new year that is healthy and happy.

Moderator:  Dr. Spaeth, thank you for your time.  We
look forward to having you back in the chat room
again.

Dr. George Spaeth:  We doctors do not know as much as
we think we know or as patients believe we know.  If
that message comes across, this evening will have been
worthwhile.  I know that what I am saying will make
some people rethink their whole condition. GREAT!

written by Nancy about her experience.......

I have been a "glaucoma suspect" since I was 21 years old (diagnosed in 1991), and started using glaucoma medication when I was 29 years old in 1999, because my eye pressure went up to 28. My optic nerves were fine all these years though, and it's still fine today.
I went to a glaucoma specialist who found that I have narrow angles through a procedure using a special mirror lens. He recommended me to get a laser iridotomy in my eyes because of a high risk of a glaucoma attack. I finally received the laser surgeries in December 2003 and January 2004...both with excellent results and the ducts in my eyes are now open, not very narrow as before.
If you are interested how the procedure goes or is having this type of laser surgery soon, here's what I have experienced:

This type of laser glaucoma surgery does not have pre-op requirements, so you can eat and drink before your eye surgery. The visit to the surgical clinic can take up to two hours (including waiting time).
Be sure to have someone drive you to the eye doctor/clinic and take you home after the surgery.
First, they will take your eye pressure. Then, they will put some drops in your eye to make the pupil smaller, so the laser can go through the iris easier. You may have to wait in the waiting room so this will take effect. After they see that the pupil is smaller, then they will take you to the surgical room.
When you are in the surgical room, you will notice it looks like any other eye doctor's exam room. The laser machine looks just like the machine that the doctor uses for your eye pressure and looking in the back of the eyes.
To prep for the surgery, the nurse or the doctor will put numbing drops in the eye, then you will have to look at a light while resting your chin on the laser machine. For best results, you have to be still and keep looking at the light, as instructed.
While you look at the light, you will notice flashing lights and some colors (I saw a prism of red), but there is no pain involved. The laser iridotomy only took a minute when I had mine done. You may notice running tears down your cheeks, so that is from your ducts being opened. This is normal, and the nurse may wipe it off for you after the surgery.
You will be taken back to the waiting room with the other surgery patients, until you get your pressure checked again. After you are called in, your pressure will be checked to see if it has lowered. Sometimes the surgery will make the pressure higher, so the nurse or the doctor will put the glaucoma medication in to lower it, then the pressure will be checked again. If it is satisfactory to the doctor, he will let you go home (and give you medication, if necessary).
The doctor will want you to come back later to see if the laser iridotomy works, and if the holes are still open. Some people's holes in the eyes close after this type of surgery, so this is not good (they will have to have the surgery again). After all is successful, and the pressure finally stabilizes, the doctor may either lower the dosage or take you off the medication because of the surgery (unless there is a problem).

That is all there is to it! There is no pain in laser iridotomy, and vision gets clear after a few hours. You can return to work later that day (if your vision is clear and there is no problem), or return the next day. If you have any problems after the surgery, be sure to tell the surgeon or the eye doctor at the surgery site so he/she can help you.
I am glad I had the surgery. Otherwise, I would've gone blind. I was nervous before the first surgery, but I found out there is nothing to it.

Here's a link that tells you more about Laser Iridotomy