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The usual first treatment for glaucoma is prescription eye drops. However, drops can be inconvenient, expensive or hard to use. For some patients, drops have side effects such as stinging or redness. When people get frustrated with their glaucoma eye drops, they might use them less often, which endangers their vision.
New advances aim to make glaucoma treatment easier and more effective. In particular, people who cannot reach their target pressure on eye drops or who do not want to use eye drops have other options besides traditional invasive glaucoma surgeries.
About 5 years ago, the treatment steps for glaucoma changed. From low to high severity of the disease, patients had prescription eye drops, SLT or ALT laser treatment, and/or invasive surgery called trabeculectomy or an implanted tube shunt.
Now we have MIGS, which stands for minimally invasive or micro-invasive glaucoma surgery. These procedures let doctors treat patients earlier and more safely than older surgeries.
Each MIGS procedure involves implanting a tiny device to allow fluid to drain from the eye, reducing internal pressure. Some MIGS devices (iStent) are implanted during cataract surgery. Cataract surgery alone lowers pressure, so the combination lowers pressure more effectively or may help lower medication burden. MIGS implantation adds about two minutes to cataract surgery and only slightly more risk.
Another MIGS devices (Xen Gel Stent) is implanted in a stand-alone procedure for people without cataracts or who have already had cataract surgery. It offers similar efficacy as the traditional surgery called trabeculectomy, but with lower risk for complications and no recovery time.
MIGS procedures are safer than more aggressive surgeries such as trabeculectomy or tube shunt, which are generally recommended only for advanced glaucoma. If someone needs more aggressive glaucoma treatment later on, a previous MIGS procedure does not affect it. Surgeons can determine which MIGS device is best for each patient.
New drug breakthroughs are not frequent, but there are still advances. For example, people with glaucoma who take more than one eye drop per day may see those medications available as a single, combined eye drop in the future. Some combinations already are available, such as Cosopt (timolol and dorzolamide), Combigan (timolol and brimonidine) and Simbrinza (brinzolamide and brimonidine).
In addition, doctors are researching a new class of medication that combines a traditional glaucoma drug (the prostaglandin latanoprost) with nitric oxide in a drug called latanoprostene bunod. Nitric oxide lowers venous pressure in the episclera, an outer membrane of the eyes, so this combination may help lower pressure inside the eye even more than traditional medications alone.
Knowing that many people with glaucoma have problems with eye drops, new ways to deliver glaucoma drugs like prostaglandins to the eye are in development. These tiny slow-release devices are placed on the eye or implanted to lower pressure for months without eye drops.
For example, a plug placed in the tear duct (called a punctual plug), contact lens, or small ring placed on the eye deep under the eyelid could exude medication over time. Also in development are new drug delivery devices injected into the eye to slowly release medication. Doctors will determine the right route and amount of drug to ensure patients reach their target pressures.
This is an exciting time for glaucoma because we are seeing so many new treatments emerge, from drug delivery to surgical options. More new advances are coming. They will make it easier and safer to manage glaucoma.
Michael Greenwood, MD practices at Vance Thompson Vision in Fargo, North Dakota.
Last reviewed on August 29, 2018