Glaucoma Treatments

Glaucoma can be treated with eye drops, oral medication, laser surgery, traditional surgery or a combination of these. The goal of any treatment is to prevent loss of vision, as vision loss from glaucoma is irreversible.

Topical treatment (eye drops)

If you are prescribed eye drops to help control intraocular pressure, it is important to take your medications regularly and exactly as directed. Since eye drops are absorbed into the bloodstream, tell your doctor about all medications you are currently taking. To minimise absorption into the bloodstream and maximize the amount of drug absorbed in the eye, close your eye for one to two minutes after administering the drops and press your index finger lightly against the lower nasal corner of your eyelid to close the tear duct which drains into the nose. While almost all eye drops may cause an uncomfortable burning or stinging sensation at first, the discomfort should last for only a few seconds.

Surgical Procedures

When medications do not achieve the desired results, or have intolerable side effects, your ophthalmologist may suggest surgery.

Laser Surgery

Laser surgery has become increasingly popular as an intermediate step between drugs and traditional surgery though the long-term success rates are variable. The most common type performed for open-angle glaucoma is called trabeculoplasty. This procedure takes between 10 and 15 minutes is painless and can be performed in a doctor's office. The laser beam (a high energy light beam) is focused upon the eye's drain. Contrary to what many people think, the laser does not burn a hole through the eye. Instead, the eye's drainage system is changed in very subtle ways so that aqueous fluid is able to pass more easily out of the drain,thus lowering IOP.

You may go home and resume your normal activities following surgery. Your doctor will likely check your IOP one hour following laser surgery. After this procedure, many patients respond well enough to be able to avoid or delay surgery. While it may take a few weeks to see the full pressure-lowering effect of this procedure, during which time you may have to continue taking your medications, many patients are eventually able to discontinue some of their medications. This, however, is not true in all cases. Your doctor is the best judge of determining whether or not you will still need medication. Complications with laser are minimal, which is why this procedure has become increasingly popular and some centres are recommending the use of laser before drops in some patients.

Selective Laser Trabeculoplasty (SLT) -- for open-angle glaucoma

SLT is a newer laser that uses very low levels of energy. It is termed "selective" since it leaves portions of the trabecular meshwork intact. For this reason, it is believed that SLT, unlike other types of laser surgery, may be safely repeated. Some authors have reported that a second repeat application of SLT is effective at lowering IOP.

Laser Peripheral Iridotomy (LPI) -- for angle-closure glaucoma

This procedure is used to make an opening through the iris, allowing aqueous fluid to flow from behind the iris directly to the anterior chamber of the eye. This allows the fluid to bypass its normal route. LPI is the preferred method for managing a wide variety of angle-closure glaucomas. This laser is most often used to treat an anatomically narrow angle and prevent angle-closure glaucoma attacks.

Cycloablation

This type of laser reduces the amount of aqueous humour in the eye by destroying part of the ciliary body, which produces the fluid. This treatments is usually reserved for use in eyes that either have elevated IOP after having failed other more traditional treatments, including filtering surgery, or those in which filtering surgery is not possible or advisable due to the shape or other features of the eye. Trans-scleral cyclophotocoagulation uses a laser to direct energy through the outer sclera of the eye to reach and destroy portions of the ciliary processes, without causing damage to the overlying tissues. With endoscopic cyclophotocoagulation (ECP), the instrument is placed inside the eye through a surgical incision at the end of cataract surgery, so that the laser energy is applied directly to the ciliary body tissue.

Traditional Surgery



Trabeculectomy

When medications and laser therapies do not adequately lower eye pressure, doctors may recommend conventional surgery. The most common of these operations is called a trabeculectomy, which is used in both open-angle and closed-angle glaucoma. In this procedure, the surgeon creates a passage in the sclera (the white part of the eye) for draining excess eye fluid. A flap is created that allows fluid to escape, but which does not deflate the eyeball. A small bubble of fluid called a "bleb" forms over the opening on the surface of the eye, which is a sign that fluid is draining out into the space between the sclera and conjunctiva. Occasionally, the surgically created drainage hole begins to close and the IOP rises again. This happens because the body tries to heal the new opening, as if it was an injury. Many surgeons perform trabeculectomy with an anti-fibrotic agent that is placed on the eye during surgery and reduces such scarring during the healing period. The most common anti-fibrotic agent is Mitomycin-C. Another is 5-Fluorouracil, or 5-FU.

About 50 percent of patients no longer require glaucoma medications after surgery for a significant length of time. Thirty-five to 40 percent of those who still need medication have better control of their IOP. A trabeculectomy is usually an outpatient procedure. The number of post-operative visits to the doctor varies, and some activities, such as driving, reading, bending and heavy lifting must be limited for two to four weeks after surgery.

Drainage Implant Surgery

Several different devices have been developed to aid the drainage of aqueous humour out of the anterior chamber and lower IOP. All of these drainage devices share a similar design which consists of a small silicone tube that extends into the anterior chamber of the eye. The tube is connected to one or more plates, which are sutured to the surface of the eye, usually not visible. Fluid is collected on the plate and then absorbed by the tissues in the eye. This type of surgery is thought to lower IOP less than trabeculectomy but is preferred in patients whose IOP cannot be controlled with traditional surgery or who have previous scarring.

Nonpenetrating Surgery

Newer non-penetrating glaucoma surgery, which does not enter the anterior chamber of the eye, shows great promise in minimizing postoperative complications and lowering the risk for infection. However, such surgery generally does not lower IOP as much as trabeculectomy. Furthermore, long term studies are needed to assess these procedures and to determine their role in the clinical management of glaucoma patients.