THE SPECIALIST: Dr. Janet Serle
A professor of ophthalmology at Mount Sinai, Dr. Janet Serle exclusively treats patients with glaucoma. January is Glaucoma Awareness Month.
WHO’S AT RISK
While doctors estimate that 2.7 million Americans over the age of 40 have glaucoma, it’s believed that half of those patients don’t even know they have it.
“Glaucoma is a chronic disease that causes damage to the optic nerve that connects the back part of the eye to the brain,” says Serle. “If inadequately treated, glaucoma can lead to blindness, which is why it’s so important to see an eye doctor regularly and get diagnosed quickly if glaucoma does develop.”
The optic nerve is located at the back of the eye, surrounded by the retina. “The optic nerve is like a telephone wire that contains 1 million fibers. If they get damaged, the visual information can’t travel from eye to brain,” says Serle. “Typically, patients lose central nerve fibers last, so they can see well straight ahead after the peripheral vision goes, though some patients don’t fit this pattern and may lose central vision early in the course of the disease.”
Doctors have yet to identify the underlying cause of glaucoma. “We assume there are genetic and environmental factors, and we have defined several genes that are more common in many patients with glaucoma,” says Serle.
“You’re more likely to develop the disease if you’re African-American or Latino, or if you have a family history of the disease, diabetes, thin corneas, optic nerve cupping, or are a chronic user of steroid pills or steroid eye drops,” says Serle. “A general rule of thumb is that the higher your eye pressure, the higher your risk, but 50% of patients don’t actually have high eye pressure, so the diagnosis of glaucoma can never be solely based on high eye pressure.”
While it is possible for patients to develop glaucoma at any stage of life — some babies are even born with glaucoma — the risk does increase with age. “In whites and Latinos, your risk of glaucoma starts going up after age 50, but for African-Americans risk goes up starting at 40,” says Serle. “If you have any risk factors, you need to be monitored as early as your teens and 20s.”
SIGNS AND SYMPTOMS
One of the problems with treating glaucoma is that it can slide under the radar for years. “Most patients’ glaucoma is completely asymptomatic, which means that it is usually detected during a routine eye exam,” says Serle. “The doctor either finds high eye pressure and explores further, or looks in and visually sees the damage in the optic nerve.” The doctor then performs a series of tests to confirm the diagnosis.
TRADITIONAL TREATMENT
Upon being diagnosed with glaucoma, the first step is to assess the intraocular pressure. “One test isn’t enough — we usually need to do several readings over a few days,” says Serle. “Then, our initial treatment is medications like topical drops to lower eye pressure by 30%, which may or may not be enough.” How and when you apply the drops is vital to maximize their effect.
Although several states have legalized medical marijuana for glaucoma patients, it is not a good treatment option. “When it does reduce eye pressure, the duration of effect is very short, typically 3 to 4 hours, whereas the eye drops we use lower pressure from 6 to 24 hours,” says Serle. “In order for marijuana to effectively reduce eye pressure, it would need to be smoked round the clock, interfering with a patient’s daily activities, due to the common side effects.”
If eye drops don’t work, the next option is laser surgery. “The goal is to enhance the flow of fluid out of the eye and thus decrease the eye pressure. We apply 50-100 shots of the laser to the angle of the eye,” says Serle. “Laser surgery basically buys us time before a more invasive surgery. It’s a temporary measure that usually works for anywhere from a few weeks to a few years.”
Laser surgery can only be performed three times, and the efficacy usually decreases each time.
Surgery is the final option. “There are two traditional surgical approaches: one puts a hole in the eye and one puts a tube in the eye, in both cases to drain fluid out,” says Serle. “There are also newer procedures, like MIGS [minimally invasive glaucoma surgery], in which we put little devices in the angle of the eye.” The traditional surgeries are the most effective, but even they sometimes need to be repeated years down the road.
While glaucoma can have dire consequences if left untreated, the current treatment options are highly effective. “For the majority of patients this disease can be held in check,” says Serle. “The key is to take your meds religiously and come back for your eye exams.”
RESEARCH BREAKTHROUGHS
Promising new medications are currently under clinical investigation. “It’s exciting to have three potential new meds to lower eye pressure, all of them working with different mechanisms,” says Serle. “We haven’t had a new drug to treat glaucoma since 1995, so it’s time.”
QUESTIONS FOR YOUR DOCTOR
A good leadoff question for everyone is, “What is my eye pressure?” If it turns out to be over 21, then ask, “Am I at risk of glaucoma?” Follow up by asking, “Do I have any suspicious findings on my eye exam?” and “Should I see a specialist?”
“Sometimes you have to push your doctor a little bit,” says Serle. “But it’s worth doing, because early detection and intervention is so essential for treating glaucoma.”
WHAT YOU CAN DO
Get informed. There are many glaucoma-focused websites; Serle recommends starting with the American Academy of Ophthalmology (aao.org) and Mount Sinai (mountsinai.org/eyecare).
Don’t skip eye checkups. The checkup schedule depends on your age. Newborns with any risk factor should be checked on the first day of life; schoolchildren should be checked once; teens to thirtysomethings should be checked every 2-4 years; patients in their 40s and 50s should be checked every one to three years; and patients over 60 should be checked annually.
Comply with your prescription. If you have glaucoma, one of the most important things you can do is to be vigilant about taking your meds are prescribed. “Enlist a spouse or caregiver to help with the eye drops, which can be hard to instill,” says Serle.
