Question:

Hi Tony; Tony Wypkema <thepartn…@designwrite.nu

wrote: Can chronic glaucoma patients with stable pressures in the mid-teens experience sudden, central blind spots as a result of their glaucoma? Thank you.

Dr. Robert Ritch responds that it would be extremely unusual. "A central scotoma capable of causing a sudden decrease in visual acuity should prompt a search for another cause."

Response:

Raych responded to my providing information relative to central retinal vein occlusion, etc.:

…I believe there is some agreement today that glaucoma is a tissue defect, not a pressure abstraction.  I don’t believe glaucomatous degeneration is claimed to *cause* a pressure (although it is not unreasonable that it might be found to in some cases).  For something to be "secondary to" to glaucoma, it must, therefore, have  been *caused* by the glaucomatous defect itself, not caused some postulated pressure.  You cite reference only to an *association* of the two ailments.  Do you thoroughly reject causation in the opposite direction, i.e., from whatever central retinal problem to glaucoma?<

The problem of defining glaucoma becomes an issue here, once again. Evidently, though not expressed in so many words, the study considers "glaucoma" elevated pressure, without getting into forms of "glaucomatous" damage other than central vascular. I.e., "It has been suggested that by compressing and stretching the lamina cribosa, elevated intraocular presure might interfere with blood flow and cause endothelial damage to the traversing central retinal vein." So in answer to raych, the CRVO incidents would not appear to be "secondary" to glaucomatous damage, but "secondary" to elevated IOP; and, with the (apparently largely abandoned) definition of glaucoma as elevated pressure, "causation in the opposite direction" MAY have to be rejected as it MIGHT be difficult to make a case that occlusions in the central retinal area raise pressure, although I can imagine some serous conditions in which vitreous pressure (as opposed to aqueous) COULD rise. P.S. Entities included in elements of the study were  U of Illinois, Med College of Wisc., Mass. Eye and Ear Infirmary, Manhattan EET Hosp., Wilmer, Bascom Palmer, National Eye Institute. (Not a professional submission.)

Response:

Tony Wypkema <thepartn…@designwrite.nu wrote: Can chronic glaucoma patients with stable pressures in the mid-teens experience sudden, central blind spots as a result of their glaucoma? Ray Bonar wrote: Dr. Robert Ritch responds that it would be extremely unusual. "A central scotoma capable of causing a sudden decrease in visual acuity should prompt a search for another cause."

Ray: Thanks to you and Dr. Ritch for answering. I think then, that my  strees and blood pressure–which is a bit on the high side–is a more likely cause, and I’m trying to get the stress and blood pressure down. Thanks also to you, Mr. Halterb for all your research. The blind spot is a circle about the size of my ‘baby’ fingernail when my hand is outstretched. Macular degeneration is an unlikely cause, since I take a wide range of vitamins and mineral supplements, and have every day for four years. As I wrote, the retinal doctor didn’t see any damage to my retina (although maybe he missed something; I don’t know. He seemed to do quite a quick check of the eyes, and he couldn’t pin down my i.o.p.s. When he told me my pressures were 14/14, I exclaimed they had never been shown to be so low, so he checked again, and said, "Maybe I can revise that upward a bit" to 16 or 17 in both eyes. Does that mean he was sloppy, or is it normal to come up with a range of three points in the space of a minute?) I  wrote previously that my eye pressures were normal several hours after the spot appeared, and in the mid to high teens (14 to 17) three days after the spot appeared, so high eye pressure would probably not have been the cause. I guess I’ll have to wait another month til my next appointment with my glaucoma doctor to see if he has any answers. Thanks. Tony Wypkema

Response:

- Hide quoted text — Show quoted text -

Tony Wypkema inquired: Can chronic glaucoma patients with stable pressures in the mid-teens experience sudden, central blind spots as a result of their glaucoma?<

Halterb wrote:

I may be among good  people to respond to this having stable pressure in the mid-teens, and having had a couple of experiences with sudden, temporary central blind spots–and knowing of others with this situation. My "episodes" occurred when I was overly tired, and followed a flash of light in the perimeter of my visual field (mirrored florescent ceiling lights in one case and sunlight in another) and lasted for about 20 minutes. I also observed a jagged, bright line in my vision with objects somewhat displaced from one side of the line to another.

My ‘episode’ has lasted for eight days. Unlike floaters, which float around like jellyfish–or jetsam in waves of water–this blind spot is fixed in the same spot all the time, just below the center of vision. When I blink, it flashes blackly or brightly, depending on the background tones that I’m looking at.

The conclusion of my doctors was that this was not glaucoma related and was either a TIA (temporary ischemic attack) or the "aura" of a migraine headache which never developed into a headache.

I’ve never had a migraine, so it couldn’t be caused by that.

An unltrasound of my carotid arteries was done to rule out any reduction in blood flow, and none was found. Dilated examination of the interior of the eye revealed no damage or abnormality in structure. Others I have talked to had similar outcomes.

Tony Wypkema

Response:

This is a multiple response, to posts from Dr. Robert Ritch and raych, concerning "sudden blind spots". Dr. Ritch seemed to indicate that causes other than glaucoma should be considered for the condition poster Tony reported. I wish he had developed this concept further. My suggestion of my own instinct leading me to suspect "something like macular retinal degeneration" drew the latest barb from raych. Since I do not know the exact location of the visual defect Tony reported, but only that it seems "central", the question of macular retinal degeneration came to mind. The macula, being located lateral to and somewhat below the optic disc, is a not infrequent troublesome area. My phrase "something like macular…" could also include central retinal vein occlusion, artery occlusion, branch occlusion, etc., but the symptoms of that particular condition appear more in keeping with CRVO. CRVO is associated with histories of open-angle glaucoma. In fact the odds ratio is 5.4 (95% confidence interval, 3.5 to8.5)(P<.001) (Archives of Ophthalmology/Vol 114, May 1996, page 552). Thus, I differ with Dr. Ritch’s response by seeing some reason to consider these "blind spots" as possibly being secondary to glaucoma due perhaps to pressure on the shared fibrous tissue sheath of the central retinal artery and adjacent lumen of the central retinal vein and stuff like that! The good news is that once standard treatment is exhausted, there are a number of "alternative medicine" approaches to at least attempt to deal with central, macular and other retinal problems (chelation therapy with EDTA, zinc, selenium, vitamin C, B-2, etc.–but, of course, only after consultation with the patient’s physician). And, there is always prayer.

Response:

On 2 Nov 1998 13:58:30 GMT, halt…@aol.com (Halterb) wrote: …………

Thus, I differ with Dr. Ritch’s response by seeing some reason to consider these "blind spots" as possibly being secondary to glaucoma due perhaps to pressure on the shared fibrous tissue sheath of the central retinal artery and adjacent lumen of the central retinal vein and stuff like that!

"Stuff like that", huh?  Well, I believe there is some agreement today that glaucoma is a tissue defect, not a pressure abstraction.  I don’t believe glaucomatous degeneration is claimed to *cause* a pressure (although it is not unreasonable that it might be found to in some cases).  For something to be "secondary to" to glaucoma, it must, therefore, have  been *caused* by the glaucomatous defect itself, not caused some postulated pressure.  You cite reference only to an *association* of the two ailments.  Do you thoroughly reject causation in the opposite direction, i.e., from whatever central retinal problem to glaucoma?  (Not that I’m exactly waiting with bated breath for an answer from a thoughtful and credentialed source.  ;-)  ) Ray – Hide quoted text — Show quoted text -

The good news is that once standard treatment is exhausted, there are a number of "alternative medicine" approaches to at least attempt to deal with central, macular and other retinal problems (chelation therapy with EDTA, zinc, selenium, vitamin C, B-2, etc.–but, of course, only after consultation with the patient’s physician). And, there is always prayer.

Response:

On 1 Nov 1998 19:31:26 GMT, halt…@aol.com (Halterb) wrote: ………..

yet several doctors did feel this could well have been a "migraine that didn’t happen."

Are you quoting them or yourself?  We could use more persons who use such logic not happening.

If by My ‘episode’ has lasted for eight days.< he means that the spot is still present, and by "blind spots" he is referring to only one instance of one, single blind spot, then that would be a different situation than mine. My non-professional instinct would then lead me to suspect something like macular retinal degeneration.

Are professional instincts different from non-professional ones?  I think such a conclusion requires *experience* and/or *reading* — and decent reasoning power. Ray

Response:

Tony Wypkema followed up on my response to his message about sudden blind spots, in which I reported the possibility of TIA or failed migraine:

I’ve never had a migraine, so it couldn’t be caused by that.<

Well, if it might be helpful to Tony or others, I can also add that I, to my knowledge, have never had a migraine either–yet several doctors did feel this could well have been a "migraine that didn’t happen." If by

My ‘episode’ has lasted for eight days.<

he means that the spot is still present, and by "blind spots" he is referring to only one instance of one, single blind spot, then that would be a different situation than mine. My non-professional instinct would then lead me to suspect something like macular retinal degeneration.

Response:

Tony Wypkema inquired:

Can chronic glaucoma patients with stable pressures in the mid-teens experience sudden, central blind spots as a result of their glaucoma?<

I may be among good  people to respond to this having stable pressure in the mid-teens, and having had a couple of experiences with sudden, temporary central blind spots–and knowing of others with this situation. My "episodes" occurred when I was overly tired, and followed a flash of light in the perimeter of my visual field (mirrored florescent ceiling lights in one case and sunlight in another) and lasted for about 20 minutes. I also observed a jagged, bright line in my vision with objects somewhat displaced from one side of the line to another. The conclusion of my doctors was that this was not glaucoma related and was either a TIA (temporary ischemic attack) or the "aura" of a migraine headache which never developed into a headache. An unltrasound of my carotid arteries was done to rule out any reduction in blood flow, and none was found. Dilated examination of the interior of the eye revealed no damage or abnormality in structure. Others I have talked to had similar outcomes. Hope this is helpful.

Response:

On 5 Nov 1998 12:19:01 GMT, halt…@aol.com (Halterb) wrote: ………….

they do need first-rate attention.

*First-rate*?  Gues that leaves out ophthalmologists.  ;-) Ray

Response:

A followup to the blind spot thread as there may be a number of people interested in it. I asked the ophthalmologist last night on the Wills Chat about it. He said that if the "scotoma" is in the retina, it should be visible during an examination. If not, the problem could be in the brain. (One other source I consulted also raised the possibility of a lesion in the optic nerve between the eyeball and brain, often due to perhaps even a minor head injury, such as from a fall, at some time during a person’s life.) Evidently some of these situations can resolve on their own, but they do need first-rate attention.

Response:

Can chronic glaucoma patients with stable pressures in the mid-teens experience sudden, central blind spots as a result of their glaucoma? Thank you.

Response:

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