3. Glaucoma: The Sneaky Thief of Sight

 It's called the sneaky thief of sight — and for good reason. Glaucoma is one of the leading causes of blindness in the world, and most people who have it don't even know it. No pain. No blurry vision. No warning. Until it's too late. 

I'm Dr. Parul Khator, a board-certified ophthalmologist and glaucoma specialist in Marietta, Georgia — and glaucoma is my specialty. I treat it every single day. And the thing that breaks my heart most? So much of the vision loss I see could have been prevented if patients had known what to look for sooner. 

This episode is my chance to change that. 

In this episode, I'll cover: 

• What glaucoma actually is — and why it's so different from other eye conditions
• How glaucoma silently damages your optic nerve and steals your vision without you ever feeling a thing
• The different types of glaucoma — because not all glaucoma is the same
• Who is most at risk — and why your family history matters more than you think
• The treatment options available today — from eye drops to surgery — and what they actually do

Glaucoma doesn't have to mean blindness. Caught early, it is absolutely manageable. But you have to know to look for it first — and that starts right here.
 
I believe the more you know, the better you do. So let's talk about glaucoma. 👁️
 

📬 Have a question or topic you'd love me to cover? I'd love to hear from you! Email me at demystifytheeye1@gmail.com

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🌐 Learn more about Dr. Parul Khator, MD: https://www.gaeyepartners.com/metro-atlanta-eye-doctors/parul-khator-md/

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Demystify the Eye is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your eye doctor or qualified healthcare provider with any questions you may have regarding your eye health.

Transcript

SPEAKER_00 0:00

Hello, my name is Carl Kator MD. I'm an ophthalmologist in Atlanta, Georgia, specializing in cataract and glaucoma surgeries. After practicing medicine for over a decade, I have learned that the more a patient knows about their disease, the better they do. Patient education is a passion of mine. But like most doctors, I have a lot of patients and not a lot of time to see them. So I created this podcast where I could spend the time I don't have during the day to give you insights into the eyeball and ocular disease. Let's empower you as a patient or a patient support system. Together, let's demystify the eye. Today we are going to be talking about an ophthalmology topic near and dear to my heart. Glaucoma. I love treating glaucoma so much, I decided to subspecialize in it. My sister is a glaucoma specialist as well and older than me by three years. So she will be very quick to tell you that she did it first and I copied her, which, as much as I hate to admit it, is true. I was going to do OBGynecology, quite the opposite end of the body. It was my fourth year of medical school, and I had done everything necessary to land a great residency in OBGYN. I had done all the rotations, loads of research, and kissed all the right butts. I knew all of my attending kids' pets' names. And then my sister, who was already in residency and ophthalmology, said, Why don't you just take one rotation? Just so you know what I'm going to be doing. All right, all right, I finally agreed to get her off my back. My first day of my ophthalmology rotation, I thought to myself, crap. I loved everything about ophthalmology, but it was an early match, which meant I only had two months to do all the rotations, as much research as I could, and kiss all the prerequisite butts. Fortunately, it all worked out, and I got into a residency at Emory University. Okay, I said to myself after starting, you copied your sister by going into medicine, and then again by going into ophthalmology. You will not copy her by also going into glaucoma. Glaucoma was the first rotation I took as a resident, and my very first day I thought to myself, crap, I loved everything about glaucoma. Does my sister give me grief every chance she gets for copying her yet again? Of course she does. Has it been worth it? Of course it has. Statistics. Glaucoma is a really tough disease. It's the number one cause of irreversible blindness worldwide. Let me give you a few stats from the glaucoma research foundation that show how challenging glaucoma is to treat. Number one, approximately 10% of people with glaucoma who are receiving treatment for the disease still have vision loss. How is this possible if it's being treated? Well, unfortunately, glaucoma is a progressive disease, meaning the disease will continue to want to worsen during a patient's lifetime. We as doctors still have limited understanding of all of the contributing factors that lead to glaucoma, which means that as a medical community, we still have limited understanding of how to treat it. Number two, there is no cure for glaucoma. The disease can be controlled but not completely cured. Number three, vision loss from glaucoma is irreversible. Once you lose vision, there is nothing we can do to get it back for you. Number four, with this in mind, imagine how scary this fact is. It is estimated that of the 3 million people in America who have glaucoma, only half know they have it. How could this be? Well, vision loss from glaucoma is usually painless and slow. Many times a person does not even realize they have lost vision until the very late stages of the disease. Finally, number five, everyone is at risk for this disease. Glaucoma is not an old person's disease. Yes, the chances increase as you get older, but I have many patients who are children, teenagers, young adults, or even middle-aged. This is not a disease you get screened for when you're over 75. It is something you should be screened for once a year, no matter your age. With all of these dismal statistics, things can seem kind of hopeless when it comes to glaucoma. But let me assure you, things are not. There is so much research being done into this disease by some of the brightest minds around the world. Each year, I attend the American Glaucoma Society Conference, which is actually a gathering of glaucoma specialists from all around the world. Our field is going through a renaissance period with new drugs, new surgeries, and new diagnostic devices to help us treat glaucoma better. Pathophysiology. So, what is glaucoma, anyways? Let's go back to our ocular anatomy. If you remember, there is a structure in the back of our eyes called the optic nerve. This structure is like a cable that connects our eye to our brain. What is its function? Well, just like a USB cable, it takes information from one place to the other. So it takes all the pictures our eyeball creates and sends them to the brain for processing. You could have a healthy eyeball and a healthy brain, but you will not be able to see if the connection between the two is lost. Glaucoma is a disease whereby this structure, this optic nerve, gets damaged, resulting in permanent vision loss. Let's stop and think about that for a second. We hear about someone not being able to see because of their cataracts, but then that person has a 15-minute surgery and voila, all that lost vision comes back and they can see clearly again. This is unfortunately not the case with glaucoma. Once a vision is lost, it is lost forever. There is no technology available to bring that vision back. The reason for this is because the optic nerve cannot be regenerated and it cannot be transplanted. Of course, in my line of work, I get asked all the time about eyeball transplants. Well, can't you just get me a new eye? We can actually transplant lots of different parts of the eye, but we cannot give one person's eyeball to another. And this is in large part thanks to the optic nerve. I said the optic nerve is like a cable, and just like a cable, it has many little fibers inside of it. How many fibers, you ask? About 1.2 million. Yes, one point two million. Each little fiber takes one tiny fraction of a picture to the appropriate spot in the brain. Now, imagine if you tried to take 1.2 million fibers from person one and put them into person two. You would have to make sure every single one of those 1.2 million fibers connected exactly right, or the picture would be distorted. Perhaps one day, with the help of computers, we may be able to do something like this, but it probably won't be in my lifetime or yours. A common misconception is that the optic nerve is a part of the eyeball. It is actually not. If I had the sound effect of a record scratching, I would play it here. The optic nerve is actually a part of the brain. Now, think about a person who gets into a car accident and is paralyzed. Their spinal cord tissue is damaged and eventually atrophies or dies. Currently, we don't have the technology to make that person walk again because we don't yet have the technology to regenerate dead nerve tissue. The optic nerve is a lot like the spinal cord. So once it's damaged and atrophies or dies, we cannot bring it back to life. What does this mean? It means it is incredibly important to be preventative. Remember, glaucoma is not just an old person's disease. Anyone can get it at any age. So everyone should get an eye exam at least once a year. And if you have a family history of glaucoma, especially in a first-degree relative, so that's mom, dad, siblings, kids, you yourself are at nine times greater risk of having it yourself. Nine times greater risk. The most common type of glaucoma is open angle, and around half of patients with this glaucoma have a hand family history for it. So please, please, if you have a family history of glaucoma, get yourself into the eye doctor for an exam pronto. Going back to this optic nerve, why does it get damaged? Well, to understand this, imagine lying on the ground and then someone putting a five-pound weight on your chest. It might be mildly annoying, but you can still breathe. Now, imagine increasing that weight to 20 pounds, then 40 pounds, then 80 pounds. It's going to get harder and harder for you to breathe. Now imagine that weight is 300 pounds. You would not be able to breathe at all. You really wouldn't be able to survive. Our eyeballs are like water balloons. They have pressure inside of them, and that pressure pushes on the optic nerve in the back of the eye. If we remember our analogy, imagine the pressure inside the eye is five points higher than it should be. The nerve is mildly annoyed but still able to function. Now imagine the pressure increasing until it is 30 points higher than it should be. The nerve is going to get suffocated and will not be able to survive. This leads to an obvious next question. What determines the pressure inside the eye? Well, that, my friends, is simple plumbing. Our eyes make fluid. That fluid circulates through the eye, delivering oxygen and nutrients. Our eyes then drain that fluid. If the drain of the eye is not working well, our eye will make fluid but be unable to drain it fast enough. This causes fluid to back up, and this backup of fluid leads to a buildup of pressure. One common misunderstanding of glaucoma is that there is only one kind. There are actually two major categories of glaucoma, and within those categories, there are lots of even more specific subcategories. And within some of those subcategories, even more specific types. I routinely treat 10 different types of glaucoma each day. So if you have a friend or relative with glaucoma and it seems like their treatment is a lot different than yours, don't get too worked up. They may have a completely different kind of glaucoma than you do. The key is for you and your doctor to know which kind you have so you can be started on the right treatment strategy. The most common type of glaucoma is called open angle glaucoma. How common is it? According to the National Institute of Health, nine out of ten people with glaucoma in the United States have this kind. This is also kind of a bummer because this kind of glaucoma is generally asymptomatic until the later stages of the disease. This means it is painless. So you may not even realize you have it. This type of glaucoma is a genetic disease. We know it's genetic because we see it pass down in families. Thank you, ancestors. Did you know that if you have a first degree relative with glaucoma, you yourself are at nine times greater risk of having the disease? My mom is constantly telling me about her health problems. Sometimes, admittedly, I totally zone out. Okay, okay, a lot of times I totally zone out. In my defense, I spend all day listening to people talk about their medical problems. And yes, yes, my mom is not all people, as she's made clear many times, but still, outside of work, I usually want to talk about anything other than your medical problems. But this is one thing you should listen for at your next family dinner because it's that important. And because it's one of the first questions I'll ask you. Now, I cannot tell you how many times a patient will tell me they have a family history of glaucoma. But when I do a little bit of digging, it turns out they were talking about cataracts. These two are not the same folks. We will hit on cataracts in a later podcast, but cataracts are a normal aging process, not a disease. So, yes, every single person in your family has cataracts over the age of 40. A lot of them probably had surgery for cataracts. If your family member has glaucoma, on the other hand, they have probably been on eye drops at some point in their lifetime. So that's a good way to distinguish between the two. The other big type of glaucoma is angle closure glaucoma. And this one is quite different. This one usually has symptoms like pain and decreased vision and sometimes even vomiting. I call this type of glaucoma the trash can glaucoma. If I walk in an exam room and the patient is clutching the trash can, there's a pretty good chance angle closure is going to be our diagnosis. Diagnosis. So I've already talked about how it's very important to get into our offices for an eye exam in order to be diagnosed. But how exactly do we diagnose you? Have you ever been to a fun house in a state fair? A glaucoma evaluation can feel a bit like this, but no one's really having any fun. Diagnosing glaucoma and understanding how to treat it requires building a whole clinical picture. This involves a lot of exams and a lot of tests. And it also means a lot of time in the office. I would recommend you pack a snack, a meal, a phone charger, a laptop, a good book, and some knitting you've been trying to get done. I'm kidding. Kind of. If you call to book an appointment with me, my call center will be sure to tell you a few times to expect three hours for your visit. Outrageous? Maybe. But worth it to keep seeing your snack, seeing your meal, seeing your phone, laptop, and book? My patients think so. I'll quickly walk you through a typical glaucoma patient visit. All exams begin with a screening by an ophthalmic technician. My texts are amazing and will get your history, read the prescription off your current glasses, and do the basics of the examination. Things like vision, the movement of your eyes, and of course your eye pressure. Next comes testing. You might take a visual field test for me. This test is like playing the world's most boring video game. You essentially sit in front of a box. You look into the box at a little green light in the center. The machine then flashes lights at you everywhere except where the little green light is. The lights will be different sizes and different intensities. Anytime you see a light, you click on a button on a joystick, but you cannot look away from the green light. So we are testing your peripheral vision. Sounds simple, huh? Let me assure you, it is not. This is one of the most despised tests out there. It is designed to make you feel like you're going crazy. Did I just see a light or is my brain tricking me? On top of that, the machine does try to trick you. It will make a noise when it flashes a light most of the time. But sometimes it will make a noise as though it has flashed a light when it hasn't. Why? The machine is testing to see if you are trigger happy or if you are really seeing the flashes of light. This test is awful, but also so important. It will detect vision loss in your peripheral vision before you notice it in your day-to-day life. This is because the visual field test is done with each eye isolated, not with both eyes open. Unless we are pirates or playing pirates, we as humans don't walk around the world with one eye closed. Peripheral vision loss in one eye can be made up for with the other eye. So we really don't even notice it happening. Also, as I mentioned before, vision loss from glaucoma is quite slow, so we may not even realize we are losing vision. The visual field is one of the few tests I have that tell me about the function of an eye. This means it's one of the few tests that lets me get inside your head to see what you are seeing, and importantly, what you are not seeing if you have glaucoma. Once you have had your visual field test, you might be dilated. Here, my technician will put two drops in each of your eyes to open your pupil very wide. Opening the pupil allows me to see the nerve in the back of your eye. It also allows me to see your peripheral retina. The retina is a layer of tissue that plasters the back wall of the eye. The optic nerve is just an accumulation of fibers from the retina. So it is important for me to look at both structures. Dilation is also my patient's second least favorite part of the glaucoma exam. Dilating the eyes lets a lot of extra light in, making things seem overly bright. I'd recommend you always bring a good pair of sunglasses with you to the eye doctor. Dilating also decreases your ability to see up close. So now is not the time to be signing any contracts, for example. Patients often ask me if they will be able to drive home after dilation. The answer is yes, but you might need a good pair of sunglasses. The dilation effects last anywhere from four to six hours. And yes, you can drink alcohol after being dilated. After your diagnostic testing is complete, you head back into an exam room to see me. You probably won't like me because I will take a good long look into the back of your eye, which means a lot of light. Though quite annoying, I promise this light will not hurt your eyes. I will review all of your testing from that day as well as previous visits, and then you and I will talk. I tell my patients at every visit what their eye pressure is and how they are doing. I go through their testing with them. I think it is really important for a patient to be involved in their care, especially if the disease we are treating is asymptomatic. You have to really understand why, for example, you are taking medications or why I might have recommended a laser procedure. It takes 14 years of schooling to be a glaucoma specialist. So, no, you won't understand every little nuance of your disease. But you should always walk out of a doctor's office with a good general understanding of your disease, if it is progressing, and of course, all of your treatment options. Treatment. The treatment for glaucoma will get a podcast episode all to itself, but I'll cover some of the basics here. Glaucoma treatments are broken up into three different buckets, from least invasive to most invasive. The first and least invasive bucket consists of eye drops. These are drops a patient takes every day, anywhere from one to three times a day. The next bucket includes laser procedures that I will do in the office on a patient's eyes. A laser treatment for glaucoma generally takes only a few minutes to perform. There are no activity restrictions afterwards, and the eye should feel back to normal within a day or so. Finally, the most invasive bucket is surgery. Here I will take a patient to the operating room. There are small surgeries that are done for glaucoma called minimally invasive glaucoma surgeries. These take under five minutes to perform, and a patient is healed within a week, though it generally takes a month or so to know if the surgery worked. Then there are maximally invasive surgeries called full thickness filtration surgeries. These have the most bang for their buck, but also are the most involved. They generally take 30 minutes to an hour to perform and involve multiple incisions and stitches. A patient will take weeks to months to heal. As you can imagine, these surgeries are generally reserved for more severe glaucoma stages. The general principle behind treatment for glaucoma is to lower the eye pressure in the eye. Lowering the eye pressure takes the stress off the optic nerve. It allows the optic nerve to breathe again. This means healthy optic nerve tissue stops dying, which means a patient will keep seeing. Years from now, doctors will be able to treat glaucoma in more ways than just by lowering the pressure inside the eye. We will be able to increase blood flow to the optic nerve to make it stronger and more resistant to damage, for example. Years and years and years from now, doctors will call us all barbarians. Because in the future, we will have the ability to modify genes. So we will be able to treat glaucoma at its root source, which is through gene modification. But for now, we can only do what our current technology allows us to do. Right now, we can lower the pressure in the eye to stop nerve damage. We talked about how eye pressure is simple plumbing. The eye makes fluid and then it drains that fluid. So the treatment for glaucoma can either involve decreasing the amount of fluid the eye makes, aka turn down the faucet, or it can involve increasing the amount of fluid the eye drains, aka enhance the drain. That's what the first two buckets do. In the third bucket, the major surgery bucket, we say the natural drain of the eye is just not worth saving anymore. So the natural drain of the eye is bypassed and an alternate surgical drain is created. Regardless of which treatment option is utilized, it is important to understand that once diagnosed, glaucoma needs to be treated every single day for the rest of a patient's life. So if a patient is on eye drops, these need to be taken every single day. If a patient has a laser or surgery, these need to be checked at least once a year to ensure they are still working. Routine and rigorous monitoring is the name of the game. Conclusion. I do hope this podcast episode has given you some insight into this important and challenging disease. We will deep dive much more into different facets of the disease in later episodes. But you have to start at the beginning. If you didn't catch everything in this episode, listen to it again. Remember that education is the key to prevention and treatment. Until next time, see well and be well. Stevie, do you like going to see the doctor?

SPEAKER_01 25:08

Yes.

SPEAKER_00 25:09

And what do you do to get ready to see the doctor?

SPEAKER_01 25:14

We dress up and then get in the car and then go to the doctor, and that's that's my favorite part. It's so crazy and so visible, and I do not even like it, because it's so boring.

SPEAKER_00 25:28

What part is boring?

SPEAKER_01 25:31

Shot.

SPEAKER_00 25:32

Oh, so you like going to the doctor's, but you don't like getting the shot. That's not my favorite. Well, thank you, Stevie.