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Get the facts you need to understand and manage your glaucoma diagnosis and treatment. In this Glaucoma Fast Facts video, Mark Werner, MD (Delray Eye Associates) discusses "treating glaucoma."
Glaucoma Fast Facts: Treating Glaucoma - Supported by an educational grant from Santen.
Andrew Jackson (Glaucoma Research Foundation): Hello, and welcome to another edition of Glaucoma Fast Facts. In this video glaucoma specialist, Dr. Mark Werner, will tell us all about treating glaucoma. So, Dr. Werner, how is glaucoma treated?
Mark Werner, MD (Delray Eye Associates): Glaucoma is essentially a disease where the eye pressure is too high for the optic nerve, and usually on a gradual basis that will cause deterioration of the optic nerve, which can eventually lead to problems with the vision. So we generally treat glaucoma now by lowering eye pressure, and there are several ways to do this. Medications, laser, and surgery are the principle categories we now have. As far as medications, they usually consist of eyedrops, and these may be used singly or in different combinations. Medications lower eye pressure either by reducing fluid production in the eye, or improving the drainage of fluid out of the eye through one of two different pathways.
One dose of a medication or one eye drop only works for a certain amount of time, so it's important to follow the recommended dosing schedule to maintain the effect. Setting up a routine, such as using eyedrops when brushing your teeth or [when] taking other medications on a daily basis, will help you remember. To place eyedrops, the best way is to lie back, lie your head all the way back in bed or in a recliner. Look up behind your head, which will raise your upper lid, and then use your non-dominant hand to pull your lower eyelid down, and you create a little sack for the eye drop to go in.
Then using your dominant hand, you're going to hold the drop vertically and drop it into your eye. Then you want to close your eyes for about five minutes after each drop goes in to allow absorption, and you also want to wait five minutes between two different drops so as one doesn't wash out the other. Your doctor will need to see you regularly to determine if the drops are effective and that they are not causing any adverse effects. If you experience anything you might consider a possible side effect, please discuss these with your doctor.
Now as far as laser, for most types of open-angle glaucoma, laser trabeculoplasty may be used to supplement or replace medications to treat eye pressure. A light laser treatment is applied to the drainage area of the eye, and a numbing drop will be placed on the eye prior to the procedure so that a mirror can be held on the eye to direct the laser into the drainage angle. The treatment is typically quick, low risk, painless, and repeatable if necessary. A successful laser treatment may last a few years, and as with any treatment, follow up is needed to assure continued effect over time. When effective, laser often has a modest effect on the eye pressure.
The next step in treatment, if needed, may involve surgery. These are performed under local anesthesia in an operating room. A newer group of surgeries known as MIGS, or Minimally Invasive Glaucoma Surgeries, carries lower risk and may be used for milder cases or patients in which it may be best to avoid traditional glaucoma surgery, or to delay such surgery. These surgeries typically have a quicker and easier recovery if they are successful. Some are done in conjunction with cataract surgery. Not everyone is a candidate for a MIGS procedure, and they may be less effective and/or have a lower success rate than traditional surgery. There is a range of MIGS procedures currently in use that you may be able to discuss with your doctor.
Traditional glaucoma surgery on the other hand, involves creating a whole new drain for the eye. In a trabeculectomy, a flap in the eyewall is carefully created and sutured in order to precisely drain fluid out of the eye. Anti-scarring medicine is applied at the time of surgery and after surgery, and regular followup is necessary for a period of time to make sure that the flow continues at the appropriate rate to bring the pressure level not too low or not too high, but just at the level that is desired. A tube shunt is a drainage tube which is attached to a plate that usually goes on the surface of the eyewall, but well behind the eyelids so it's hidden from view. But the tube goes into the front part of the eye generally, and the fluid can be drained onto the plate.
This allows for the pressure to be brought down. Again, the body's healing response is important to the results of the surgery in terms of the eye pressure. As with trabeculectomy, there may be several weeks of recovery with this procedure. With both procedures, you may be advised that light activity is recommended for about two to four weeks after surgery, and follow-up may proceed on a weekly basis on average after the first a week for a several week period. Risks can include droopy eyelid, double vision, pain or discomfort, or loss of vision. The traditional surgeries may have up to a 70 or 80% success rate in certain populations, and may be necessary in more severe or uncontrolled glaucoma.
Slow release medication implants are an active area of research and development. Implants have been designed for placement either inside or outside of the eye. Periodic replacement would be needed for long-term treatment. One device, Durysta, is FDA approved for a single injection into the eye, which may be effective for up to six months or longer. Studies are ongoing to determine its safety and efficacy over multiple injections to allow for use in long-term management, and there are multiple drugs in the pipeline for future use hopefully.
One broad category of glaucoma types includes angle-closure. Primary angle-closure exists in the absence of any other identifiable cause, and this occurs when the outer part of the iris, or the colored part of the eye, blocks the drainage angle. This may occur on a sudden basis or more gradually over time. The first step in treatment is to open the drainage angle. This can be performed initially with a laser iridotomy, which involves putting a small hole in the iris with a laser. Similar to the laser trabeculoplasty, a numbing drop is placed on the eye and a special focusing lens is placed on the eye in order to focus the laser to the desired location on the iris.
This, again, is a generally low risk, easy treatment with relatively little discomfort and minimal side effects generally, though no treatment is risk-free. If the initial laser iridotomy does not open the drain angle, which may occur 10% or 20% of the time, then another laser treatment called laser iridoplasty may be effective as well. And if cataract extraction is reasonable, then removing a cataract can also open the drainage angle and may be preferred in some situations as initial treatment. Medications and surgery, as with other types of glaucoma, may also be required.
Glaucoma is separated into many different types based on how the drainage of fluid in the eye is compromised. Many of the treatments listed above can be used for these different types of glaucoma though some treatments may be preferred in certain situations. In some cases, there is a treatable cause for the glaucoma that can be addressed, including bleeding, lens related problems, and other issues. Your doctor should be able to tell you after examining you if there are special considerations for your type of glaucoma.
There are many alternative treatments offered on the market that have not been shown through established research to be effective for glaucoma. They may be advertised to treat eye pressure or even protect or help regenerate optic nerve tissue or function to prevent vision loss or even restore vision. While a prime goal of glaucoma research is to protect, enhance, or replace damaged optic nerve tissue, there is no proven way to accomplish that as of yet. Alternative treatments should not be used to replace medications you are already taking that are proven to help with glaucoma, and some alternative treatments may even have negative effects.
Please discuss with your eye doctor any non-prescription treatments you are interested in. Healthy diet and lifestyle may be beneficial in maintaining the health of the optic nerve. However, they are not a substitute for lowering eye pressure. It would be more of a supplemental treatment. Lowering eye pressure has been proven in many large carefully controlled studies to reduce the risk of glaucoma getting worse, even in patients with lower starting pressure.
Andrew Jackson: That's a lot of excellent information, Mark. Thank you so much. Now, for more information please visit our website, glaucoma.org, and download our free 40-page booklet, Understanding and Living with Glaucoma.
Last reviewed on March 02, 2021