The doctor must place a mirrored contact lens on your ocular surface, while you cooperate as best you can to permit the doctor to study a circle of tissue 50 microns wide (0.050 millimeters!) that is inspected through the mirror.   [The Barkan gonio lens was a direct technique for such inspection, eliminating the mirrors, but the patient must lay flat (a position normal to us only during sleep) and the doctor must hold a 15 pound microscope to see the fine details.]

Easy to imagine that subtle trouble with the observations will, and often do, happen.  When the drainage angle for fluid closes in part, pressure in the eye will increase slightly.  The goal of treatment is to remove the obstructing iris folds which roll up to and over the fine meshwork which percolates fluid through and out of the eye.

The treatment?  Create a second opening in the iris other than the pupil, which will allow fluid to pass directly to the drains, and eliminate the pupil – blocking part of the fluid stream.

This was performed by surgery prior to the 1970s but the advent of laser technology improved surgery.  Each generation of laser has proved effective at puncturing a hole in the iris, without surgically opening the eye.  The surgeon’s  job is to ascertain who will benefit from this procedure as to eliminate the folds which block fluid exiting the eye.

Patients come in for a routine eye exam, and they may have partly or completely blocked drains.  If the eye pressure has – or has not – built up, should a laser treatment be recommended?  How risky is it for the laser treatment, verses the risk of having low grade glaucoma, or even an acute attack – as decribed at this blog’s outset?

Even second opinion glaucoma patients arrive with the same dilemma – are they “open angle” or “closed angle” patients – and are the treatments correct?

A yearly “gonioscopy” by your eye doctor is an important part of maintenance for every glaucoma patient, and we will perform this exam in any patient with suspicious findings seen during the course of any eye examination.

Nice and simple to take the MBTA Green D Train 4 stops to the Hynes in Boston to rendez-vous with every major glaucoma contributor in the contemporary literature…

A thumbnail of news from the meeting – a fair amount devoted to world issues of health access in Africa and Asia.  Increased recognition of populations with higher risk for the disease?  Caribbean and west African blacks, Japanese with normal tension glaucomas, and aboriginal communities with angle closure disease.

What about medical breakthroughs?  This year’s research award to a North Texas cell biologist who characterized the WH-1 gene in mouse, showing “up regulation” and “down regulation” of intraocular pressure by chemical messaging of proteins to (mouse) trabecular meshwork.  This is important because chemical messengers may be critical for a permanent cure, or for definitive diagnoses.

What is trabecular meshwork?  This important tissue regulates eye pressure by controlling egress of the nutrient aqueous fluid that circulates through and inflates the eye.  Too little exiting?  High pressure.  Is there a over -secretion glaucoma, patients ask?  These are rare and sporadic.  The principal cause of the disease is failure of fluid leaving the eye.  All glaucoma treatments are directed at resolving this defect.

                                                                                 Dr. Kevin Kaufman