Glaucoma

Primary open-angle glaucoma (POAG), also called primary or chronic glaucoma, develops gradually, often with no early warning signs. In this condition, the angle where fluid leaves the eye is open.

Acute and chronic angle-closure glaucoma develop when the iris blocks the normal drainage of fluid from inside the eye.

Acute angle-closure is a medical emergency. It happens when the eye pressure rises very quickly, causing eye pain, headaches, halos around lights, dilated pupils, vision loss, red eyes, and nausea and vomiting.

If the drainage system closes over time, the pressure can rise slowly, typically without any symptoms.

Normal-tension glaucoma occurs when the optic nerve is damaged, even though the eye pressure is not very high. It is unclear why the optic nerves in some people become damaged, even though they have near-normal pressure levels. It is associated with having other conditions, such as migraines and low blood pressure. About half of all glaucoma cases occur at normal pressures. The treatment for this form of glaucoma is the same as for glaucoma that develops at higher eye pressures.

Congenital glaucoma occurs in babies when there is incorrect or incomplete development of the eye's drainage canals during the prenatal period. This is a rare condition that may be inherited. The treatment for this condition is typically microsurgery, but other cases can be treated with medications.

Other, less common forms include secondary glaucoma, pigmentary glaucoma, neovascular glaucoma, traumatic glaucoma, uveitic glaucoma, irido corneal endothelial syndrome, and pseudoexfoliation syndrome.

Prescription eye drops are often the first line of treatment for glaucoma. Examples include:

• Prostaglandins work near the drainage area of the eye to improve fluid outflow
• Beta blockers, carbonic anhydrase inhibitors, and miotics reduce the amount of fluid produced
• Alpha adrenergics reduce the eye's resistance to fluid drainage
• Combination eye drops include two medications in one bottle

Overview

Minimally invasive glaucoma surgeries are designed to lower intraocular pressure, usually in patients with mild-to-moderate glaucoma. These procedures involve less recovery and risk than other glaucoma operations. Most MIGS procedures can be used in combination with cataract surgery, and several MIGS procedures can be done as standalone procedures.

Although MIGS surgeries often help lower eye pressure, these operations are not presently as effective at lowering eye pressure as traditional surgery. MIGS may not be appropriate if you have advanced glaucoma. Drops to lower eye pressure may still be needed after any glaucoma surgery, but the goal of these operations is to reduce the eye pressure to a safe range for your eye.

Mass. Eye and Ear offers several types of MIGS procedures. Examples include:

iStent®: This implantable device helps fluid drain by bypassing the trabecular meshwork—the main drainage system of the eye.

Trabectome®: A specialized device opens up the drainage system (trabecular meshwork) to improve the outflow of fluid.

New laser procedures: Endoscopic cyclophotocoagulation (ECP), micropulse cyclophotocoagulation, and diode cyclophotocoagulation (CPC) are laser procedures that reduce the amount of fluid that is produced without the need for incisions to the outer part of the eye. ECP is done in the operating room and involves operating inside the eye, often at the time of cataract surgery.

Trabeculotomies/canaloplasties: New devices, such as iTrack® or Omni® and Trab360®, are used to open the entire drainage system (trabeculotomy) or to dilate the drainage system without damaging it damaging (canaloplasty).

Kahook dual blade: This tiny blade is used to open up the trabecular meshwork (the drainage system) and improve fluid drainage.

Xen Gel Stent: is like traditional glaucoma surgery, but the doctor uses smaller surgical wounds to put a tiny gelatin tube, called the XEN gel stent, to connect the inside of the eye to the space under the conjunctiva. Recovery is faster compared to traditional glaucoma surgery, and there will be a bleb under the eyelid.

Hydrus Microstent: This stent is inserted into the trabecular meshwork to dilate the drainage system up to four times its normal size. This treatment aims to improve eye drainage. This surgery must be done at the same time as cataract surgery.

What to Expect

MIGS procedures are performed with sedation under local anesthesia in the operating room. After numbing eye drops are applied, a sterile drape is put over the face and body, leaving only the eye uncovered. This keeps the area of the operation clean and sterile. The eye is held open with a lid speculum.

After the surgery, a patch and shield will be are placed over the eye. This is removed the day after surgery, on the first postoperative visit. Postoperative care varies depending on the procedure.

What are the Risks?

Risks include, but are not limited to, bleeding, infection, very low eye pressure, scarring, swelling, retinal detachment, droopy eyelid, double vision, loss of vision, or even loss of the eye. In general, most of these risks are uncommon.

Overview

This laser procedure can open a closed angle. It is generally used as a preventative measure for patients with angle closure. It can also be used as a treatment if a patient already has angle-closure glaucoma.

Sometimes additional medications or surgery may be needed to control eye pressure.

What to Expect

This outpatient procedure can usually be done in the eye doctor's office and typically takes a few minutes. You will be seated at a slit-lamp with your forehead resting against a headpiece and your chin on a chinrest. After numbing eye drops are applied, a lens will be placed on your eye to prevent you from blinking and moving your eye. The laser is then directed into the eye.

Most people experience minimal discomfort during the procedure. Afterward, you may experience some eye irritation and some blurry vision, but this is largely resolved within a few hours. Usually, you will have your eye pressure checked 30 minutes after the procedure. Typically, you are seen a few weeks after the procedure. The number and frequency of visits may vary depending on the condition of your eye. Most people will need to take an eye drop four times daily for one week to help the eye heal.

What are the Risks?

Risks include, but are not limited to, bleeding, inflammation, eye pressure elevations, and vision loss, but these are uncommon. Some people may see bright lights or flashes. In general, serious risks are rare. However, you are encouraged to discuss the benefits and risks with your doctor.

Overview

This laser procedure is used to open the drainage site of the eye in patients with open-angle glaucoma that continues to progress, despite the use of medications. It may also be recommended prior to trying medical treatment. These decisions vary, depending on the type and stage of glaucoma, as well as other factors.

What to Expect

This outpatient procedure can usually be done in your eye doctor's office and typically takes a few minutes. You are seated at a slit-lamp with your forehead resting against a headpiece and your chin in a chinrest. After numbing eye drops are applied, a lens will be placed on your eye to prevent you from blinking. The laser is then directed at the drainage area, which is along the front wall of the eye, not near where people see. Most people experience minimal discomfort during the procedure. Afterward, you may have some eye irritation and blurry vision for a few hours.

You will usually have your eye pressure checked one hour after the procedure. You are then usually seen the day after the laser procedure and then the following week. The number and frequency of visits thereafter will vary, depending on your type of glaucoma and on the judgment of your doctor.

Most people will need to apply an eye drop four times a day for one week to help the eye heal. This new eye drop is taken in addition to your regular glaucoma drops. Because ocassionally only half of the trabecular meshwork is treated at one time, you may need another laser procedure.

Are Eye Drops Still Needed After Surgery?

You will need to continue your glaucoma eye drops for at least a few weeks after the procedure, until the effects of treatment are known. The long-term need for eye drops after this treatment varies greatly, depending on your type of glaucoma and how quickly it is progressing. Even if you still take the same glaucoma medications, the procedure is considered successful if your eye pressure is lowered.

What are the Risks?

Risks include, but are not limited to, inflammation, eye pressure elevations, and vision loss. In general, loss of vision after a laser treatment is usually from progression of the glaucoma and not from the procedure itself. Although serious risks are not common, you are encouraged to discuss the benefits and risks with your doctor. Sometimes the laser procedure needs to be repeated.

Does Trabeculoplasty Work for Everyone?

It is successful for most, but not all, patients. It tends to be more successful in patients with primary open-angle glaucoma, pigmentary glaucoma, and pseudoexfoliation glaucoma. Even if the laser procedure is successful, its effect is usually not permanent. Sometimes the laser treatment can control pressure for up to three to five years.

Overview

During trabeculectomy surgery (also called glaucoma filtration surgery), a new opening under the outer covering (the conjunctiva) of the eye is created for fluid to drain. Trabeculectomy may be recommended if your glaucoma continues to progress, despite the use of medications and/or laser treatments. In some cases, it may be recommended before trying other treatment options. These decisions vary, depending on the type and stage of glaucoma, as well as other factors. Sometimes this surgery can be combined with cataract surgery.

What to Expect

The procedure is done under local anesthesia in the operating room, typically with sedation. After numbing eye drops are applied, a sterile drape will be placed over your face and body, leaving only your eye uncovered. This keeps the area of the operation clean and sterile. Your eye will be held open with a lid speculum.

After the surgery, a patch and shield will be placed over your eye. This will be removed the day after surgery, on your first postoperative visit. You should expect to be seen frequently by your surgeon until the eye completely heals. For many people, this may take up to two or three months. During this time, you will be applying multiple eye drops, frequently.

Postoperative care varies greatly and may include suture removal, injections with supplemental medications, or other procedures to guide the healing process. During this time, you will need to restrict yourself from strenuous activities.

Preventing Scarring

The main reason trabeculectomy surgery can fail is that the new drainage site scars and closes up. Some patients may need to take special medications, called antimetabolites, to prevent scarring. You will be examined carefully to look for scarring, and your doctor will talk with you if they feel that you would benefit from an antimetabolite after surgery. You may be at risk for scarring if you have had an unsuccessful trabeculectomy surgery in the past, are younger, have had eye surgery before, and if you have uveitis (or inflammation in the eye).

Are Eye Drops Still Needed After Surgery?

The need for eye drops after trabeculectomy surgery varies greatly, depending on your type of glaucoma and the rate it is progressing. You will definitely need eye drops for two or more months after the surgery. Some people do not have to take eye drops after that period, but many people will eventually need some glaucoma eye drops to keep their pressure under control. In some cases, people will be taking fewer eye drops than they were before the surgery.

What are the Risks?

Risks include, but are not limited to, bleeding, infection, very low eye pressure, scarring, swelling, retinal detachment, droopy eyelid, double vision, loss of vision, or even loss of the eye. Sometimes the trabeculectomy fails and needs to be needled or revised. This can be done either in the operating room or in the clinic (depending on your surgeon's preference and your particular case). In general, many of the risks are uncommon, but you are encouraged to discuss the benefits and risks with your surgeon.

Overview

A small tube, or shunt, is surgically implanted into the eye to allow extra fluid to drain and reduce the pressure in the eye. Glaucoma shunts come in many different varieties. Most, if not all, of the device will not be visible after surgery.

Tube shunt surgery may be needed if you have glaucoma that is not controlled by medications, after a previous trabeculectomy surgery (or surgeries) have failed, or in certain types of glaucoma where traditional trabeculectomy surgery is likely to fail, or if you are not a good candidate for a trabeculectomy. Examples of such patients are those with neovascular glaucoma, corneal transplants, or severe blepharitis.

What to Expect

The procedure is done under local anesthesia in the operating room. Some surgeons may also give you sedatives to keep you completely comfortable. After numbing eye drops are applied, a sterile drape will be put over your face and body, leaving only your eye uncovered. This keeps the area of the operation clean and sterile. Your eye will be held open with a lid speculum.

After the surgery, a patch and shield will be placed over your eye. This will be removed the day after surgery, on your first postoperative visit. You should expect to be seen frequently by your surgeon until the eye completely heals (usually six to eight weeks). During this time, you will be applying multiple eye drops, frequently.

Postoperative care varies greatly and may include suture removal and/or other minor procedures to maximize the outcome of the surgery. During this time, you will need to avoid strenuous activities.

Are Eye Drops Still Needed After Surgery?

The need for eye drops after tube shunt surgery varies greatly, depending on your type of glaucoma and the rate it is progressing. You will definitely need eye drops for two or more months after the surgery.

What are the Risks?

Risks include, but are not limited to, bleeding, infection, very low eye pressure, scarring, swelling, retinal detachment, droopy eyelid, double vision, loss of vision, or even loss of the eye. Sometimes the tube fails and a second surgery will need to be done. In general, many of the risks are uncommon, but you are encouraged to discuss the benefits and risks with your surgeon.

Overview

This laser procedure reduces the eye’s ability to produce fluid in the eye. It is usually only recommended after other, more conservative, surgeries (such as trabeculectomy or tube shunt surgery) have failed, or there is existing conjunctival scarring.

What to Expect

This outpatient procedure is done in the operating room after the eye is numbed. A laser beam partially destroys part of the ciliary body, where the eye’s fluid is produced. Multiple treatments may be needed.The whole procedure takes only one or two minutes. Most people experience only minor discomfort during the procedure. Afterward, you may have some blurry vision or eye soreness, but it usually resolves within a few days.

You will usually have follow-up visits the day after the procedure and the following week. The number and frequency of postoperative visits vary, depending on your type of glaucoma and the discretion of your doctor. Most people will need to take two eye drops up to four times daily for a few weeks to help the eye heal after the procedure. If your pressure is not sufficiently lowered with one treatment, repeat treatments may be needed.

Are Eye Drops Still Needed After Surgery?

You may need to continue your eye drops for at least a few weeks after the procedure, until the effects of treatment are known. The long-term need for eye drops after this treatment varies greatly, depending on your type of glaucoma and the rate at which it is progressing. But many patients are able to reduce the number of eye drops they are taking. Even if you still take the same glaucoma medications afterward, the procedure is considered successful if your eye pressure is lowered.

What are the Risks?

Risks include, but are not limited to, failure of treatment, pain, inflammation, loss of vision, very low eye pressure, and even loss of the eye. However, because of the risk of some decrease in vision, this procedure is usually only done if a person’s vision and visual prognosis are already poor or there are not good alternatives for other glaucoma surgeries. You are encouraged to discuss the benefits and risks with your surgeon.

Does the Procedure Work for Everyone?

Unfortunately, this procedure does not bring everyone’s pressure down into an acceptable range with one treatment. Multiple treatments may be needed. Alternative treatments, such as Nd:YAG laser or cryotherapy, may be discussed with your physician. However, they are less commonly used because of either decreased effectiveness or increased complications. This procedure may not be recommended if you have a history of significant eye inflammation.