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Glaucoma can be treated with eyedrops, laser surgery, traditional surgery or a combination of these methods. Unfortunately, vision loss from glaucoma is irreversible so the goal of any treatment is to prevent further loss of vision. The good news is that glaucoma can be managed if detected early and with medical and/or surgical treatment, most people with glaucoma won’t lose their sight.
Selective laser trabeculoplasty (SLT) is becoming the first line of management for open-angle glaucoma followed by eye drops then other surgical interventions.
Laser trabeculoplasty is a form of laser surgery that is used to treat patients with open-angle glaucoma and lower pressure inside the eye by improving the flow of fluid out of the eye.
There are two types of trabeculoplasty: argon laser trabeculoplasty (ALT) and more commonly selective laser trabeculoplasty (SLT). ALT and SLT both involve lasers which target microscopic bursts of energy at the drainage pathway of the eye (called the trabecular meshwork) to stimulate it to drain the fluid more efficiently and lower the pressure in the eye. We recommend SLT over ALT because ALT can only be performed once which limits its long-term control. SLT, however, can be repeated multiple times as needed to manage pressure inside the eye.
Eye drops contain medicines that are used to treat many eye diseases and conditions. Medicated eye drops are the most common way to treat glaucoma. These medications lower eye pressure in one of two ways – either by slowing the production of aqueous humor or by improving the flow through the drainage angle. These drops must be taken daily and consistently.
Putting drops in your eye may seem difficult at first, but it becomes easier with practice. Unsure how to put eye drops properly? Click here.
In some glaucoma patients, surgery is recommended when eye drop medications aren’t effective in lowering the pressure inside the eye or are causing significant side effects.
Laser iridotomy is recommended for treating people with closed-angle glaucoma and those with very narrow drainage angles. In laser ididotomy, a laser creates a small hole about the size of a pinhead through the top part of the iris to improve the flow of aqueous fluid to the drainage angle.
Rather than flowing out through the blocked drainage angle, trabeculectomy is performed to create a new path is made for the fluid to flow out of your eye. By opening a small flap in the sclera (the outer white part of your eye) then removing a small piece of tissue, the fluid can flow out of the eye, through the flap, and collects in a bleb under the conjunctiva (the thin film that covers the white part of your eye).
The bleb looks like a bump or blister on the white part of the eye above the iris, but the upper eyelid usually covers it so it’s generally not noticeable. After collecting in the bleb, the fluid ends up being absorbed back into the blood vessels around the eye and circulates again.
Eye pressure is effectively controlled in three out of four people who have trabeculectomy. Although regular follow-up visits with your doctor are still necessary, many patients no longer need to use eye drops.
If trabeculectomy can’t be performed, aqueous shunt surgery is usually successful in lowering eye pressure. An aqueous shunt is a small plastic tube connected on one end to a reservoir (a roundish plate). The reservoir is placed under an eyelid and stitched into the white of the eye. The other end of the tube is inserted through a tiny incision into the front chamber of the eye (in front of the iris). Fluid from inside the eye can then leave the eye through the tube to the reservoir where it collects to be absorbed into the blood vessels of the eye (similar to a trabeculectomy). When healed, the reservoir is not easily seen unless you look downward and lift your eyelid.
The current approach in the management of patients with glaucoma begins with medications followed by laser trabeculoplasty. If those don’t control eye pressure, either a trabeculectomy or a glaucoma drainage device/tube shunt surgery is performed. Both are highly effective solutions, yet invasive and unreliable as they resulting in variable eye pressures (too little or too much). A recent and exciting advance in surgical treatment for glaucoma is micro-invasive glaucoma surgery (MIGS).
Traditional glaucoma surgeries generally involves an external approach through the conjunctiva (transparent outer layer) or sclera (thick white wall). Like traditional surgeries, MIGS aims to reduce pressure by increasing flow of fluid from the eye but is a more minimally invasive internal approach, often with small cuts or micro-incisions through the cornea, so they are safer, a bit more comfortable, with quicker recovery times and fewer side effects.
It’s important to keep in mind that while MIGS procedures offers quicker and safer surgery, the procedures tend to result in less eye pressure lowering than with trabeculectomy or tube shunt surgery. Trabeculectomy is better for patients who have advanced glaucoma and need much lower eye pressures. Fortunately, MIGS procedures minimize tissue scarring, allowing for the possibility of traditional glaucoma procedures to be performed in the future if needed.
Here we outline a few MIGS procedures so you are well-informed of your options and ready to ask Dr. Youssef to find out if a MIGS procedure is right for you.
Many of the MIGS procedures involve implantation of small devices that are inserted into the eye through a small self-sealing incision using a simple injector. Below are a few of the MIGS micro-stent/shunt devices we use at PVSC.
iStent is the smallest implantable device approved for use in the human body. It’s a titanium device implanted from inside of the eye into the drainage pathway in order to bypass it and improve flow of eye fluid.
The Hydrus Microstent (roughly the size of an eyelash) is placed in Schlemm’s canal, a part of the drainage system of the eye. The Microstent is curved and spans approximately 1/4 of the eye allowing the fluid to flow along the canal through the Hydrus Microstent and into the eye’s natural outflow channel. This allows for advanced flow through the eye’s drainage system to reliably reduce eye pressure.
About 77% of Hydrus Microstent patients saw a significant reduction in eye pressure and 78% of all patients with a Hydrus Microstent were drop-free at 2 years.
XEN® Gel Stent is made of soft, collagen-derived gelatin. It creates a gentle, diffuse outflow of fluid from the eye resulting in reduced eye pressure (mainly for patient with open-angle glaucoma). It’s well-accepted by the human body and is non-inflammatory. The gelatin material allows it to be pliable and soft, allowing it to conform to the eye’s tissue which minimizes many of the issues seen with synthetic materials (like migration, erosion, corneal endothelial damage).
Endoscopic cyclophotocoagulation (ECP) is an effective tool for the treatment of glaucoma. ECP is a procedure performed on an outpatient basis in which the part of the eye which creates the fluid called the ciliary body (located behind the circumference of the iris) is treated with a laser. This reduces its production of fluid which ultimately reduces the pressure inside the eye. To ensure the precise placement of the laser beam during the procedure, the surgeon can view the area using an endoscopic camera and a light source.
ECP offers the advantages of precise tissue treatment, short surgical times, rapid postoperative recovery, and reduced complications. It’s an appealing surgical option in patients with mild to moderate glaucoma.