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VOL. 6 • NO. 5

© January 2012

Glaucoma

EARLY DETECTION OF VISION LOSS KEY TO AVOIDING “THIEF OF SIGHT”

I

t all started four years ago when Chance Flaherty, then 14, could not read the Jumbotron at a Celtics game. Nor could he see the numbers on the back of the players’ jerseys. His mother, Shelley, acted quickly and took Chance to an optometrist for an eye exam. But she wasn’t prepared for what the optometrist told her. It was not the nearsightedness that caused alarm. The pressure in both his eyes was elevated. The optometrist knew that increased eye pressure, or glaucoma, tends to run in families. As a result, he recommended that the entire family make appointments as well. Everyone tested normal. But not Demetri, Chance’s twin brother. He was experiencing vision problems of his own. He was in the ninth grade at Community Charter School of Cambridge when things began to go awry. Demetri admitted that he had trouble seeing the black board at times, but a simple change of seats remedied the short-term problem. The results of Demetri’s eye exam demonstrated a long-term problem. Not only was he nearsighted, but the pressure in both of his eyes also exceeded the normal limit, the right eye worse than the left. Instead of the average eye pressure of 11 to 21 mm Hg (millimeters of mercury) his pressure exceeded 30. It was later determined that both Demetri and Chance had primary open angle glaucoma

(From left to right): Demetri Flaherty, grandmother, Nancy Beckford, mother, Shelley Flaherty and twin brother, Chance Flaherty. Demetri, Nancy and Chance have been diagnosed with glaucoma, which tends to run in families. (Ernesto Arroyo photo)

— the most common form of the disease. Without much warning or fanfare more than two million people in the United States slowly begin to lose their sight. And they don’t even know it. According to experts, by the time they notice a change, more than 50 percent of their vision has been permanently lost. Most often the first symptom is the loss of peripheral or side vision. That’s why it escapes notice. You don’t need peripheral

vision to watch TV, work on the computer or read. But there’s another reason for the lack of awareness, according to Dr. Douglas J. Rhee, an ophthalmologist at Massachusetts Eye and Ear Infirmary. “The brain does funny things,” Rhee said. But it’s not trying to play tricks; it is actually being protective. Glaucoma causes blind spots in our vision, so the brain fills them in for us, Rhee explained. Yet, without treatment, glaucoma — the second leading cause of blindness in this

country — slowly advances. Eventually, the scope of vision is so limited, it’s as though one is looking through a tunnel or telescope. Ultimately, the disease can result in permanent and total vision loss. No one — not even babies and children — is safe from glaucoma. African Americans and Hispanics are afflicted more. And earlier. Glaucoma often strikes blacks around the age of 40. Asians are also afflicted, but tend to suffer from a less common form of glaucoma. By 60, everyone is fair game. Glaucoma results from increased eye pressure. The eye is filled with and nourished by a clear fluid that continually flows, but must drain to accommodate a fresh incoming supply. In most types of glaucoma the fluid does not drain properly causing eye pressure to rise. Elevated pressures can eventually destroy the optic nerve, a bundle of more than one million nerve fibers that connects the retina (tissue at the back of the eye) with the brain. A healthy optic nerve is necessary for good vision. Glaucoma is not one disease. Rather, it is a family of several different types. Congenital glaucoma is rare and develops in infants and young children. Secondary glaucoma results from another cause, such as an eye injury or long-term use of corticosteroids. In low tension glaucoma, which affects up to one third of people with the disease, eye pressure remains within the average range, but still results in optic nerve damage. Demetri, continued to page 4

Still at risk - even with 20/20 Petra Ebisemiju, a 67-year-old retired school nurse, didn’t know much about glaucoma before she was diagnosed with the disease. But she knows a lot now and is absolutely right when she says it is a “tricky little disease.” For Ebisemiju, the disease started in her left eye about 10 years ago. She went for her yearly eye exam and the doctor told her that her pressure was elevated. “I didn’t know what pressure he was talking about,” she said. She soon learned. Ebisemiju was diagnosed with angle closure glaucoma, a less common form of the condition. According to the Glaucoma Foundation, angle closure glaucoma is one more typically seen among Asian Americans. But Ebisemiju had another characteristic often associated with that form of glaucoma. She is farsighted. By the time she saw the ophthalmologist she said the doctor told her she had lost 95 percent of the vision in her left eye. That news really threw Ebisemiju. Even her driver’s license indicates normal vision. “I can see straight ahead, but I can’t see,” she said. “That’s very shocking.” But she couldn’t see to the side.

Talk about being quirky. Though glaucoma is typically characterized by high pressure in the eye, about one third of those afflicted have normal pressure, according to the Baltimore Eye Study. That’s why checking pressure in an eye exam tells only half the story, according to Dr. Douglas J. Rhee, an ophthalmologist specializing in glaucoma at Massachusetts Eye and Ear Infirmary. “The first step should be the appearance of the optic nerve,” he said. In glaucoma the optic nerve shows an indentation or cupping that results when the pressure is too high for the nerve to tolerate. Nerve damage is identified through dilation of the pupil. A test called tonometry measures the pressure in the eye. Side vision is examined to check for blind spots that people may not even notice. People should be aware of the risk factors of glaucoma said Rhee. “The biggest one is age,” he explained. Also, 40 percent of those afflicted have relatives with the same disease. Nearsightedness and high blood pressure are factors. So is race. Petra, continued to page 4

Petra Ebisemiju says that although her driver’s license indicates normal vision, an eye specialist told her she has lost 95 percent of the vision in her left eye due to glaucoma. (Ernesto Arroyo photo)

Every year millions of people start losing their sight…

AND DON’T EVEN KNOW IT! Don’t be one of them. Have a comprehensive dilated eye exam. JANUARY IS NATIONAL GLAUCOMA AWARENESS MONTH


THE DAY-TO-DAY CHALLENGE OF LIVING WITH LOW VISION Gray winter days can leave you longing for brightness. But if wintry dimness rarely seems to lift, it would be wise to consider your answers to these five questions. WHEN WEARING YOUR USUAL GLASSES OR CONTACT LENSES, IF ANY: • Are you having trouble recognizing faces of friends and relatives? • Is it hard to distinguish clothing colors when dressing? • Have close-up tasks like cooking, reading, sewing or fix-it work become trickier to manage due to your sight? • Do lights seem dimmer than in the past at work or home? • Is it hard to pick out signs for streets, buses or stores? A ‘yes’ response to any of the questions may be a sign of low vision. “If you notice problems like these, or other changes in your vision, it’s important to check with an eye care professional,” said Dr. Jan Cook, medical director of Innovation & Leadership at Blue Cross Blue Shield of Massachusetts. “Correct diagnosis and treatment may be able to improve certain aspects of your eyesight and keep your vision from growing worse.”

ness, this complication of diabetes damages blood vessels in the retina. Gaining good control of blood sugar helps slow the onset, or progress, of this disorder. • Glaucoma. Conditions causing increased pressure in the eye may harm the optic nerve, thus prompting partial or complete loss of vision. Lowering this pressure in various ways can slow or stop the progress of glaucoma. If you are over age 60 — or over age 40 and African American — or if you have certain illnesses or a family history of glau-

WHAT DAY-TO-DAY PROBLEMS CAN LOW VISION CAUSE? Low vision affects independence and safety. Everyday tasks like reading, cooking and navigating beyond your front door becomes difficult. Driving may be unsafe. Simple acts like recognizing a loved one, reading a street sign or coordinating an outfit may be impossible.

HOW CAN YOU COPE WITH LOW VISION?

WHAT IS LOW VISION? Impaired eyesight that can’t be corrected with glasses, contacts, surgery or medicine is called low vision. It makes everyday tasks harder to do. While many older people have low vision, it’s not a normal part of aging. It stems from certain eye disorders.

WHICH EYE DISORDERS CAN LEAD TO LOW VISION? Four common eye disorders that can lead to low vision are: • Age-related macular degeneration (AMD). The macula is a structure in the middle of the retina, the light-sensitive tissue at the back of the eye that turns images into signals shuttled to the brain through the optic nerve. AMD slowly destroys the sharp central vision vital to tasks like reading or driving and for clearly seeing any object. AMD may be wet (abnormal blood vessel growth damages the macula rapidly), or dry (light-sensitive cells in the macula break down slowly, causing a blurry spot in the center of your vision) • Diabetic retinopathy. A major cause of adult blind-

for cataracts) by age 80. A comprehensive dilated eye exam is the best way to catch these often silent eye problems before they do too much damage. Ask your doctor or eye care professional how often to have this exam given your health, family history and age.

coma, you’re at higher risk. Having diabetes nearly doubles the normal risk for developing glaucoma, according to the National Eye Institute. • Cataract. Clouding of the lens in the eye, which focuses light on the retina, causes blurred, dulled vision. Risk for cataracts is increased by diabetes, smoking, prolonged sun exposure, family history and eye injuries. Aging factors in, too. More than half of Americans have cataracts (or surgery

Lighting, glare and contrast affect low vision. These tips from the Glaucoma Research Foundation and other experts can help. • Turn it down. Ease glare with amber or dark yellow lenses and caps with visors. Try covering shiny surfaces with fabric. • Turn it up. Add lighting where necessary, especially on stairways and in often-used areas like the kitchen, bathroom and closet. Aim for an even glow throughout a room, plus extra task lighting. • Use contrasts. Try contrasting colors on placemat and plate, stair landings, chopping boards (white onion, dark board) and even furniture (dark chair against light wall). Put colored tape on stair edges and pot handles. Pour coffee into a white mug. • Consider helpful products. Some examples are power-ful magnifiers; devices and software to enlarge type, read text aloud and transcribe spoken words; large-button phones and remotes. • Visit a low vision clinic. Rehabilitation specialists can help you decide on priorities, learn strategies for getting the most from your sight plus other senses and choose aids to help you accomplish tasks and enjoy life. Check with your health care plan or state services for visually impaired people.

USING EYE DROPS

If your doctor prescribes eye drops, carefully follow instructions for using them. Glaucoma can worsen considerably if you skip days or use the drops or other medications incorrectly. Call your doctor with any questions or problems. These tips from the Glaucoma Research Foundation may help, too. • Wash your hands. • Sit, stand or lie down. • Tilt your head backward and gently pull down the skin below the eyelid. • Put one drop into the pocket formed without touching the dropper to your eye or skin. • Slowly release your lower lid and gently close your eye. No squinting or squeezing! • Lightly press the inner corner of your eye for two or three minutes to allow the drop to be absorbed. • Gently blot away excess. What if your hands shake? Rest a part of the hand holding the dropper or bottle against your face. Approaching your eye from the side may make this easier. What if it’s hard to hold the bottle? Try winding a paper towel around the bottle to make it bigger. Or ask your doctor about assistive devices to help you put in your eye drops. For additional tips, check www.glaucoma.org/treatment/ eyedrop-tips.php.

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1. Is glaucoma preventable? No, but early detection and treatment of glaucoma can help prevent irreversible blindness from this disease. There is good evidence showing that lowering eye pressure can help stop or slow progression of glaucoma. Eye pressure is currently Angela V. Turalba, M.D. the only modifiable risk Glaucoma Service factor for glaucoma, and Massachusetts Eye and Ear Infirmary eye pressure can be controlled with medications, laser or conventional surgery. 2. Why is the incidence more common in blacks and other people of color? Epidemiological studies have shown that open angle glaucoma — the most common form of glaucoma — occurs four to eight times more often in blacks than in whites. It also occurs at a younger age in blacks compared to whites. In addition, glaucoma is more common in Hispanics compared to whites, but less common than in blacks. However, the reason why it occurs more frequently in these populations is still unknown. 3. Why does the risk increase with age? It is well known that older age is a known risk factor for glaucoma, especially in persons over the age of 60. The reason for this increased risk is likely multi-factorial. There are a number of structural and physiological changes that occur within the aging eye that can predispose older persons to glaucoma. 4. Can a person with glaucoma do something to improve his or her sight? That depends. Patients with glaucoma can also have other eye conditions such as cataracts that cause poor vision. Poor vision from cataracts can be improved with glasses or surgery. However, vision loss resulting from glaucoma is irreversible, and early detection and treatment are critical in preventing blindness from this disease. Persons with glaucoma often have poor peripheral vision and contrast sensitivity, the ability to distinguish objects from similarly colored or shaded backgrounds. Vision rehabilitation specialists can offer mobility training and optical aids that assist persons with glaucoma perform their daily activities.

A CLOSER LOOK

Questions & Answers

Image courtesy of Medicine Health Department

Fluid that nourishes the eye drains through a spongy meshwork where the cornea and iris meet. In glaucoma, the fluid passes too slowly causing an increase in eye pressure. If left untreated, the pressure can damage the optic nerve and result in vision loss.

ARE YOU AT RISK FOR GLAUCOMA? ACTUALLY, EVERYONE IS, BUT SOME GROUPS ARE AT HIGHER RISK THAN OTHERS. • African Americans and Hispanics • People over age 60 • Those who have family members with glaucoma • People who are very nearsighted • Those who have sustained eye injuries, particularly blunt trauma

• People with thin central cornea (the front part of the eye) • Those on prolonged high doses of corticosteroids • People with certain medical conditions, such as high blood pressure

5. Why does being nearsighted increase the risk for glaucoma? More evidence now shows that nearsightedness, or myopia, is a risk factor for glaucoma, especially for persons with a moderate to high degree of myopia. People with significant nearsightedness often have longer eyes and other structural features of their eyes that can make the optic nerve more susceptible to damage that can result in glaucoma. 6. When glaucoma runs in a family, does it strike at a younger age? Glaucoma can occur at a younger age in patients who have a strong family history of the disease. In a small subset of patients, there are known gene mutations associated with glaucoma that manifests in young adulthood. In general, individuals with a parent or sibling with known glaucoma are at a significantly higher risk for having the disease and should be screened for glaucoma. 7. How often should people have their eyes examined to check for glaucoma? An annual eye exam which includes dilation of the pupil is usually sufficient to screen those without a diagnosis of glaucoma, but have a family history or other risk factors for the disease. Patients already diagnosed with glaucoma are seen on a regular basis, usually every 3-6 months, to monitor eye pressure and vision. 8. Why is pupil dilation recommended during an eye exam? Pupil dilation during an eye exam allows for a complete evaluation of the lens, retina and optic nerve — the parts of the eye that allow us to see images. A thorough examination of the eyes enables eye doctors to diagnose and monitor common eye diseases such as cataracts, glaucoma, macular degeneration and diabetic retinopathy. Detection and treatment for these diseases can help prevent blindness. 9. Is it possible for a person with glaucoma to have 20/20 vision? Yes. Visual acuity is a measure of how well a person can see at various distances. A person with glaucoma can have 20/20 vision because glaucoma typically affects peripheral vision before it affects the central vision used to read. Most patients therefore do not realize they have glaucoma until the disease is in its advanced stages. Formal visual field testing, which evaluates peripheral or side vision, can identify the degree of vision loss to glaucoma even if central vision is intact. Patients who have lost a significant portion of their peripheral vision to glaucoma can have difficulty with night driving and mobility. The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.

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to simulate a watchful eye. “It was blurry around the edges of my A more severe form is acute closedvision,” she said, describing impaired periphangle glaucoma. It results from a sudden and eral vision. “It wasn’t clear.” An eye exam complete blockage causing severe eye pain, confirmed the diagnosis. blurred vision, headaches and nausea. This Though it is not possible to prevent form of glaucoma is a medical emergency glaucoma, the disease can be detected early and requires immediate treatment. before it causes serious damage. A comThe most common form of glaucoma — primary open-angle glaucoma — is frequently prehensive eye exam does the trick. The American Academy of Ophthalmology recreferred to as the silent thief of sight. In Demetri’s case, even the doctor was surprised. ommends that at age 40 adults with no signs “The doctor didn’t want to believe it,” Demetri or risk factors for eye disease should have a comprehensive baseline screening. But Rhee said. “You’re too young.” A second opinion, is quick to point out that people of high risk however, confirmed the initial diagnosis. Demetri’s reaction was one of disbelief as well. “I was surprised,” he said. “I didn’t know it existed.” Demetri had a long haul ahead of him. The eye drops he was prescribed worked — but not well enough. He said that his pressure dropped but not to the levels that doctors were hoping. Two years ago he had laser surgery to open up the drainage in his right eye. So far so good. The Douglas J. Rhee, M.D. surgery combined with Glaucoma Specialist three types of eye drops he Massachusetts Eye and Ear Infirmary takes daily is keeping his pressure in check despite — especially blacks and those with a family some minor side effects. “Sometimes the medicine stings,” he said. “And my eyes are history — should start earlier. Intervals for follow-up examinations will be based on the always red.” findings. Usually exams are recommended He admitted it took some doing to master the eye drops. “You have to be careful every one or two years. Timing is the key. Vision lost from glauthat the nozzle does not touch the eye,” he coma cannot be regained. explained. And you have to tilt your head Demetri has not escaped the disease back just right. Air bubbles, he said, can be unscathed. He has lost some peripheral as deceiving. They feel wet, but contain air well as central vision in his right eye, but his instead of medicine. left eye compensates. Demetri perfected his technique by According to Demetri, his condition practicing with his grandmother. She also has glaucoma and was caught by surprise as well. hasn’t slowed him down. Nor has it forced him to change his study of interest. Despite Nancy Beckford, 54, was playing around his impaired vision, he’s a freshman at Maswith a friend some years back. They were sachusetts College of Arts and Design with singing along with the Hall and Oates song “Private Eyes.” As she sang “we’re watching an interest in industrial design. “You get used to it,” he said. you,” Beckford playfully closed her left eye

Demetri, continued from page 1

THE BEST ATTACK AGAINST GLAUCOMA It may not be possible to prevent glaucoma, but it is easy to diagnose and treat. The American Academy of Ophthalmology recommends — beginning at age 40 — having eye exams every one to two years. Those with increased risk should begin earlier.

A COMPREHENSIVE EYE EXAMINATION INCLUDES: • Dilation Drops are placed in the eyes to dilate, or widen the pupils to look for signs of damage to the retina and optic nerve.

• Tonometry A test that measures eye pressure. Numbing drops may be applied. (See below)

• Visual field test Measures your side or peripheral vision. Loss of side vision is the first sign of glaucoma.

• Visual acuity test An eye chart measures how well you see at various distances. People can have good acuity, but still have glaucoma. Photos courtesy of National Eye Institute

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LIKE LOOKING THROUGH A TUNNEL

Glaucoma initially affects peripheral or side vision, but can impair tunnel vision if left untreated. Vision lost from glaucoma cannot be regained.

Photo courtesy of the National Eye Institute

SUPPORT GROUP MEETING DATE: Saturday, February 4th TIME: 10 a.m. LOCATION: Mass Eye and Ear Infirmary 243 Charles Street, Boston 8th floor board room

Please R Catherin SVP e Duffek 617-797 -6476

Petra, continued from page 1

of the eye. Traumatic glaucoma has halted many a “People of African descent and Hispanics are sports career. Kirby Puckett of the Minnesota high risk,” Rhee said. Though glaucoma is the Twins had his career cut short after being hit in second cause of preventable blindness in this the eye with a baseball. country, it is the primary cause of blindness in Years after the accident, headaches and blacks. And in the world, for that matter. The pain in the eye led Borders to have an eye reasons for this disparity are unknown. examination. He did not have an easy time of it. But there is hope. “We have good treatHis eye pressure could not be well maintained ment,” Rhee said. And the treatments — mediwith eye drops. cine, laser surgery and incisional surgery — all “The pressure would go down and get work well. The type and timing of each depends back up,” he said. Since the medication was not on the individual’s condition. Most of the time the first line of attack is medicine, but for some, working well, he had laser surgery, but that was not the answer either. surgery is the first step. He had to undergo several surgeries as It is important to distinguish between visual acuity and glaucoma, as Ebisemiju quickly learned. Being nearsighted or farsighted is not the same as glaucoma. A person can have 20/20 vision. They can see clearly an object that is 20 feet away, but still have reduced peripheral and tunnel vision and optic nerve damage. A person can be prescribed glasses or contact lenses to improve acuity, but that Bishop John M. Borders, III prescription will not Senior Pastor improve one’s glaucoma. Morning Star Baptist Church “Likewise, If you need glasses, that doesn’t mean that your eyes are well as procedures to break up scarring that resulted from the surgeries. The development of unhealthy,” Rhee said. cataracts further complicated his recovery. As the baby boomers age, they will But a miracle was in the works. After undoubtedly cause an increase in the incimultiple surgeries and follow-up treatment, dence of glaucoma. In response the GlauBorder’s eye pressure has remained normal coma Foundation teamed with the Alliance — and without the benefit of eye drops. He for Aging Research and Merck to develop goes back every six months for a check up. TAKE (Take Action to Know your Eyes) on The only tell-tale sign of his condition is a Glaucoma to teach consumers about the risk drooping eyelid. of glaucoma, the necessity of comprehensive “It’s a miracle that I can see,” said Borders. eye exams, including dilation and proper Ebisemiju must take three different types management if diagnosed. of eye drops daily. She had surgery to improve No one needs to tell Bishop John M. the drainage in her left eye. Now the pressure Borders, III, the senior pastor at Morningstar in her right eye is slowly increasing, but her Baptist Church, about eye examinations. He is hope is that medications will stabilize it. on a personal mission to save his eyesight. His In spite of everything, the glaucoma has problems started during childhood. not changed her lifestyle except for one thing “I was hit in the eye during a rock fight — driving. People passing from behind on when I was a little boy,” he explained. her left are particularly troublesome. “When What Borders did not know at the time you finally see them, they’re right there,” she is that blunt trauma to the eye can cause explained. “That’s scary.” glaucoma immediately or years later. The She has given up on driving at night. “It’s trauma, which can result in an accumulation hard to read the signs,” she said. of blood and debris, clogs the drainage canals

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Be Healthy - Glaucoma