My Doctor Online The Permanente Medical Group

Types

.

View larger image(s)

• Open Angle Glaucoma. Intraocular pressure is elevated without any obvious sign of obstruction to the drain of the eye.
• Narrow Angle and Angle Closure Glaucoma. The iris is so close to the drain of the eye that it narrows the fluid pathway out of the eye. This narrowing can be addressed by a procedure called laser iridotomy. If the narrowing progresses to closure, however, it results in angle closure glaucoma. The angle can suddenly, or over a short period of time, become closed, resulting in acute angle closure glaucoma, which requires immediate medical attention.
• Pigmentary Glaucoma. Over time, small granules of eye pigment block the eye's drainage system, elevating intraocular pressure and causing a form of open angle glaucoma.
• Pseudoexfoliation. Protein material that is degenerating from the eye tissues blocks the eye's drainage system. There can also be a narrow angle component to this glaucoma.
• Traumatic Glaucoma. This occurs when the drainage angle of the eye is damaged by injury.
• Inflammatory or Uveitic Glaucoma. The area of the eye containing the iris and surrounding structures becomes inflamed.
• Steroid-Induced Glaucoma. Long term use of, or exposure to, steroid medication can cause this type of glaucoma in susceptible individuals.
• Normal or Low Tension Glaucoma. People can have signs of damage to the optic nerve even though their eye pressure is within the normal range. We refer to these cases as normal or low tension glaucoma.

Symptoms

.

At an early stage, glaucoma causes no symptoms in most people. Some people may notice that their vision is not as clear or that their peripheral (side) vision is diminished. However, usually, there are no symptoms of vision loss until the glaucoma is significantly advanced. If your eye pressure increases suddenly, you may experience:

• Redness
• Severe pain
• Halos
• Nausea and vomiting

If you do have symptoms, the general symptoms of glaucoma are:

• Gradual loss of peripheral vision or central vision often in both eyes
• Blindness with advanced disease

The symptoms of chronic narrow or closed angle glaucoma include:

• Slight aching
• Blurry vision

The symptoms of acute angle closure glaucoma develop much more suddenly and require immediate medical attention. They include the following:

• Severe eye pain
• Blurred vision
• Halos around lights
• Reddening of the eye
• Nausea and vomiting accompanying severe eye pain

If you have any of these symptoms, call my office immediately.

Diagnosis

.

View larger image(s)

There are a number of common factors that can increase your risk for developing glaucoma. We will talk to you about your medical history during your eye exam. If your eyes have been examined by an eye doctor outside of Kaiser Permanente please bring your medical records with you, including your visual fields and any photographs, so that we can compare current eye measurements to the past findings. If we think you are at risk for developing glaucoma, or already have glaucoma, we will perform some or all of the following tests:

• Tonometry. This is a standard measurement for glaucoma that allows us to assess your intraocular pressure (IOP). 
• Visual field test. This test measures your overall vision and your peripheral (side) vision.
• Pachymetry. We use this test to measure your central corneal thickness. 
• Gonioscopy. We use this test to evaluate the drain of the eye called the “angle.” The drain is the area of the eye between the cornea and the iris. This helps us to distinguish between open, narrow, or closed angles.
• Photography. We take a picture of the optic nerve to be used for comparison at a later time.
• Optic nerve analysis. We use a special instrument to look through the pupil to the optic nerve at the back of the eye to see if there are changes that may indicate glaucoma. 
• Ultrasound. Sometimes we use ultrasound to assess your eye structures.

Causes

.

• Intraocular pressure. Glaucoma is often, though not always, caused by increased eye pressure, also known as intraocular pressure. The intraocular pressure elevation is, in part, due to a mismatch of fluid being produced by the eye and that being drained by the eye. Either too much fluid is produced or there is inadequate drainage. This mismatch leads to an increase in intraocular pressure which can cause optic nerve damage.
• Other causes. There are many other factors that cause optic nerve damage in specific categories of glaucoma. Research into these factors is ongoing and may lead to new treatments.

Prevention

.

There are steps you can take to reduce your risk of developing glaucoma:

• Protect your eyes. Blunt or serious eye injuries can damage your optic nerve and lead to glaucoma. Wear a mask or goggles during any activity or sport that could put your eyes at risk.
• Protect your eyes from steroids. Steroids can increase eye pressure. If you take steroid inhalers for asthma or lung diseases, close your eyes when you spray the medication into your mouth or the spacer to reduce exposure. Do not take steroid medications without physician supervision. Avoid over-the-counter steroid creams. If you have been on steroids for a long time, ask us for an eye evaluation.
• Maintain a healthy lifestyle. Diet and exercise help you control your weight and prevent you from developing chronic diseases like diabetes and hypertension that may lead to glaucoma.
• Exercise. Get 20 to 30 minutes of aerobic exercise each day to maintain and improve your overall health.
• Maintain a healthy Body Mass Index (BMI). Studies have shown that having a high BMI puts you at risk for developing many chronic diseases including glaucoma.

Treatment Options

.

Currently, all glaucoma treatments are designed to reduce intraocular pressure by either improving drainage or reducing the amount of fluid the eye produces. We will discuss all appropriate options with you, including whether, or when, to begin treatment. Your treatment plan may consist of medications, laser treatments or surgery, or a combination of these approaches, depending on your type of glaucoma.

Researchers continue to develop new treatments and therapies for treating glaucoma. Kaiser Permanente has a formal process for evaluating these new approaches, including medications, treatments, lasers, other technology, and surgical procedures. All new therapies and treatments are evaluated by a team of physician experts before we will recommend them to patients. Please ask us if you have questions. Please refer to the "Glaucoma Treatment" section for more details.

Lifestyle Management

.

Keep your head up to avoid increasing intraocular pressure.

• If you have glaucoma, especially narrow or closed angle glaucoma, avoid exercises or positions that require you to be in a head-down position because this might increase intraocular pressure.
• For example, avoid head-down yoga exercises or activities that require use of reverse-incline tables or apparatus. If you have had glaucoma surgery, these positions may aggravate your eye condition. Please ask us for advice about any of these activities before attempting them.

Protect your eyes from steroids – steroids can increase eye pressure.

• If you take steroid inhalers for asthma or lung diseases, close your eyes when you spray the medication into your mouth or the spacer to reduce exposure.
• Do not take steroid medications without physician supervision.
• Avoid over-the-counter steroid creams.
• If you have been on steroids for a long time, ask us for an eye evaluation.

Avoid risky activities that can worsen your disease.

• Avoid playing a wind instrument and any other activities, such as diving, that require you to hold your breath for a long period of time.
• Talk to us about any concerns you have about your activities.

Watch for signs of infection and contact us immediately if you get an infection.

• Be vigilant about signs of infection which can include, but are not limited to redness, pain and discharge.
• If you think you have an infection, contact us immediately.
• If you have had a glaucoma surgery, you may be at risk for developing an internal eye infection (blebitis). This can occur any time, even many years after the procedure.
• We may prescribe antibiotics at the time of your surgery for you to keep on hand in case of infection.  However, you must still contact us if you have any symptoms that suggest infection.
• An infection can lead to loss of vision in severe cases.

Manage hypertension and diabetes

• When uncontrolled, high blood pressure and diabetes can damage your eyes.
• Talk to your primary care physician about lifestyle and medication changes that can help you control blood pressure and blood sugar.

Exercise

• We recommend that you get 20 to 30 minutes of aerobic exercise each day to maintain and improve your overall health.
• Check with us before starting an exercise program to make sure that you do not have other health concerns that prevent you from exercising.

Maintain a Healthy Body Mass Index (BMI)

• Studies have shown that having a high BMI puts you at risk for many chronic diseases.
• For example, a high BMI makes you more likely to develop high blood pressure, diabetes and breathing difficulties such as sleep apnea and may put you at increased risk for developing glaucoma.
• Contact your primary care physician for advice about reducing your BMI through diet and exercise.

Your Care with Me

.

If your optometrist sees signs of glaucoma during your regular eye exam, he or she will make an appointment for you to see me or one of my colleagues in the Ophthalmology department. If you are not scheduled for a regular eye exam, and you notice symptoms of acute glaucoma such as halos, vision loss, or blurred vision accompanied by pain, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a comprehensive eye exam. If you have been seen before by an eye professional outside of Kaiser Permanente, please bring those medical records and eye measurements with you. I will administer eyedrops to dilate your pupil so that I can clearly see the structures in your eyes. Your pupils will remain dilated for several hours, so you may wish to bring someone who can drive you home after your exam.

I will explain the findings of your exam and answer any questions or concerns you may have. I may order additional tests to be completed at a subsequent visit. I may also prescribe glaucoma medications, and I will talk to you about how to use eyedrops.

If we decide that your eye(s) need further evaluation, or further treatment or surgery, I will discuss the treatment options that are available, and together we will create a treatment plan that is right for you.

.

.

If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

.

.

Coordinating Your Care

.

Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the "After Visit Summary" that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

Convenient Resources for You

.

As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

.