Glaucoma: Navigating Conflicting Diagnoses and Treatment Options

Questions about glaucoma?

In 2009, during a health check-up, I received a result indicating "enlarged physiological cup." I went to a major hospital (Hospital A) for further examination, where I underwent fundus examination and visual field testing.
The doctor said everything was normal and suggested that my physiological cup might be naturally larger, advising me to have annual follow-ups.
Due to pregnancy and childbirth, I didn’t understand the significance of the enlarged physiological cup and missed two years of follow-up.
In 2012, I visited a nearby ophthalmology clinic, where the doctor expressed shock, stating that 80-90% of my optic nerve was dead, which terrified me.
I returned to Hospital A, and the doctor reassured me that my optic nerve appeared unchanged.
I underwent visual field testing again, which was still normal, and he advised annual follow-ups.
In 2014, I returned to Hospital A for another check-up, and both the fundus examination and visual field tests were normal.
However, in July 2015, during another check-up at Hospital A, the doctor noted that my physiological cup seemed to have enlarged and performed an OCT (this was my first OCT).
The visual field was normal, but this time he asked me to return in six months.
In December 2015, I went back to Hospital A for another examination, and both the OCT and visual field tests were normal.
However, he mentioned that according to his records, he felt my cup had increased in size (from 60-70% to 70-80%), suggesting that I might have normal-tension glaucoma.
I saw his note stating "Glaucoma suspect" and was prescribed medication (Timoptol) to use twice a day.
I was extremely anxious, fearing blindness, as I was still young and had children to care for.
I spent two days visiting Dr.
Lu at the Tri-Service General Hospital, where I underwent numerous tests, including OCT and corneal thickness measurements.
Dr.
Lu didn’t even examine my fundus but concluded that I was normal and questioned why I needed medication, asking if the doctor at Hospital A had used only his naked eye for assessment.
Ultimately, his conclusion was that I did not have glaucoma.
I am unsure what to do because I fear blindness.
Should I continue taking the medication, or should I seek a third opinion? If I continue the medication, what adverse side effects might I experience? What does the cup's enlargement signify? Does it indicate damage to the optic nerve? Should I primarily be concerned with the thickness of the retinal nerve fiber layer? According to Doctor A, my cup has reached 70-80%.
Does this mean that 70-80% of my optic nerve is dead? Will the remaining optic nerve be sufficient for me to live the rest of my life? Thank you for your response.

Sebrina, 40~49 year old female. Ask Date: 2016/04/13

Dr. He Jianxian reply Ophthalmology

If your vision has always been normal, there is no need to worry too much.
As for continuously taking this type of antihypertensive medication, there are generally no significant side effects to be concerned about.
A cupped optic nerve does not necessarily indicate damage; it requires long-term monitoring to determine if there are any abnormalities.
If you have undergone numerous tests with no issues, an annual visual field examination for follow-up should be more than sufficient.

Reply Date: 2016/04/13

More Info

Understanding glaucoma and navigating conflicting diagnoses can be quite challenging, especially when faced with varying opinions from different healthcare providers. Your concerns are valid, and it’s important to address them comprehensively.

1. Should You Use the Medication?
Given the conflicting opinions from different ophthalmologists, it’s essential to weigh the evidence and recommendations carefully. If one doctor has diagnosed you with "glaucoma suspect" and prescribed Timolol (Timoptol), it indicates a precautionary approach to manage potential intraocular pressure (IOP) and protect your optic nerve. However, if another reputable ophthalmologist has assessed your condition and found no signs of glaucoma, it may be reasonable to seek a third opinion. This could provide additional clarity and help you make an informed decision about whether to start medication.

2. Potential Side Effects of Medication
Timolol is a beta-blocker that can lower intraocular pressure, but like all medications, it can have side effects. Common side effects include eye irritation, dry eyes, and systemic effects such as fatigue, dizziness, or changes in heart rate. If you decide to start the medication, monitor for any adverse effects and discuss them with your doctor. If you experience significant side effects, your doctor may consider alternative treatments.

3. Understanding the Significance of Cupping
Cupping refers to the appearance of the optic nerve head (the point where the optic nerve enters the eye) and is often assessed during an eye examination. An increase in cupping can indicate damage to the optic nerve, which may be associated with glaucoma. However, cupping can also be a normal anatomical variation. The key is to correlate the cupping with visual field tests and OCT (Optical Coherence Tomography) results to determine if there is actual nerve damage.

4. Importance of Retinal Nerve Fiber Layer Thickness
The thickness of the retinal nerve fiber layer (RNFL) is crucial in assessing the health of the optic nerve. A thinning RNFL can indicate damage and is often used in conjunction with cupping measurements to diagnose glaucoma. Regular OCT scans can help track changes over time, providing valuable information about the progression of any potential optic nerve damage.

5. Interpreting the Degree of Cupping
When your doctor mentions that the cupping is at 70-80%, it does not necessarily mean that 70-80% of your optic nerve is dead. Instead, it indicates that there is a significant change in the appearance of the optic nerve head, which may correlate with nerve fiber loss. It’s essential to interpret this in the context of your overall eye health, visual field tests, and other diagnostic measures.

6. Remaining Functionality of Your Optic Nerve
The remaining functionality of your optic nerve depends on various factors, including the extent of damage and your individual anatomy. Many individuals with some degree of optic nerve cupping can maintain functional vision for years, especially if the condition is monitored and managed appropriately. Regular follow-ups with your ophthalmologist are crucial to ensure that any changes are detected early.

In summary, it’s essential to have open communication with your healthcare providers. If you feel uncertain about your diagnosis or treatment plan, seeking a third opinion can provide additional reassurance. Regular monitoring of your eye health, including IOP, visual fields, and RNFL thickness, will help ensure that any potential issues are addressed promptly. Remember, managing anxiety about your vision is also important; consider discussing your concerns with your doctor, who may provide resources or referrals for support.

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