Glaucoma

There are many different types of glaucoma. Any age may be affected, ranging from infants to the elderly. The most common type of glaucoma, which we refer to as primary open angle glaucoma, may affect as many as 1% of the population over the age of 40 in the U.S. As you get older, the chance of having glaucoma increases – it affects 15% over age 80. Glaucoma is responsible for 15% of legal blindness in the U.S. There are certain risk factors that increase the likelihood that you may develop glaucoma. These include age, diabetes, African American heritage, myopia (nearsightedness), family history of glaucoma, certain eye conditions, and elevated pressure in the eye (this is not the same as high blood pressure).

This describes a condition in which the drainage structures of the eye are crowded due to the anatomy of your eye. All healthy eyes produce fluid that nourishes the eye. This takes place inside your eye and is not related to tears on the outside. Normally this fluid exits through a portion of the eye that we call the “trabecular meshwork.” This is located in a part of the eye we refer to as “the angle.” In some people the iris (the colored portion of the eye) gets very close to the trabecular meshwork and may prevent adequate drainage of fluid. This may elevate the pressure in the eye and cause glaucoma. If the angle is totally occluded, the pressure may become greatly elevated and cause significant loss of vision in a relatively short period of time. More often, if the angle is narrow, portions of the angle may scar and cause a chronic elevation in pressure that may cause loss of vision over time.

Years ago this required a trip to the operating room. Fortunately, we can now use a laser in the office to treat this condition. This is painless and only takes several minutes to perform. We use the laser to make a tiny hole in the iris, the colored portion of the eye, to change the anatomy of the eye so that the angle is no longer narrow and fluid can exit normally. This is called a “laser iridotomy.” Usually, this procedure is sufficient to achieve a permanent change in anatomy, in effect, a cure. Sometimes the angle stays narrow even after the laser, so a second laser procedure may be necessary. This is called an “iridoplasty.” We use the laser to contract the peripheral iris out of the angle and allow normal drainage of fluid. These procedures may be performed prophylactically to prevent glaucoma.

Sometimes narrow angle can be caused by a developing cataract and if so, your doctor may recommend cataract surgery as the best treatment.

Pseudoexfoliation is a condition that is very common in people of Eastern-European and Scandinavian descent. It can be seen in the eye under a microscope as a very fine, dandruff-like material that coats the structures in the front of the eye. It does not affect vision. In some people this substance can accumulate in the drainage structures of the eye (the trabecular meshwork) and obstruct drainage of fluid. If this happens the pressure in the eye may rise; this may result in glaucoma. Pseudoexfoliation is common – not all people with pseudoexfoliation will develop glaucoma. But it is a risk factor for future development of glaucoma and must be watched carefully. If glaucoma does develop, it is usually asymmetrical and affects one eye first. However, the condition is bilateral, so both eyes must be watched carefully. Pseudoexfoliation can sometimes cause problems during cataract surgery because the ligaments that hold the cataract in place are often weak. If you have cataracts and pseudoexfoliative glaucoma you should discuss this with your doctor.

Glaucoma is a condition that causes changes in your eye and in your vision over time. When it is first diagnosed, it is important to obtain baseline tests so that comparisons can be made using those same tests in the future. In this fashion, changes can be detected. The visual field test involves watching a central target while lights are projected in the periphery. When you see a light in the periphery, you depress a button so the computer registers that this as seen. This is a very important test that measures your peripheral vision. Remember — glaucoma affects the peripheral vision long before it affects the central vision. It is very difficult for you to detect any change in your peripheral vision on your own. In fact, the ideal goal of treating glaucoma is to ensure that you never do detect any change in your vision. This test, when performed regularly, helps your doctor to ensure that you do not suffer any further damage to your vision from glaucoma. If the tests do show changes in your peripheral vision over time, treatment can then be changed to help ensure that these changes stay confined to your peripheral vision and never affect your central vision. Photographs may be taken of the back of your eye — this helps document the appearance of your optic nerve so that comparisons may be made in the future.

Your eye pressure will be checked regularly to make sure that it is at a level that is safe for your optic nerve. You may require regular dilated eye exams so that your glaucoma doctor may carefully examine your optic nerve and ensure that it remains healthy. Other measurements and tests are also helpful in detecting and monitoring glaucoma.

Yes. We can use a laser to treat the trabecular meshwork of the eye, that is, the portion through which fluid drains inside the eye. This is called a “laser trabeculoplasty.” It is more effective in some types of glaucoma compared to others. Although effective in many patients, this is an option that must be discussed with your doctor to determine if it is right for you. We offer the newer “cold” laser treatment, or selective laser trabeculoplasty, as well as the “hot” or argon laser treatment. Results may be similar in many patients. Discuss with your doctor which laser may be best for you.

Yes. In most patients surgery is reserved for more advanced glaucoma that has become difficult to control with medicine. Some patients cannot tolerate medicines and therefore opt for surgery. Sometimes this surgery is combined with cataract surgery in a single procedure. The goal of the surgery is to lower the pressure in the eye to a level which is safer for the optic nerve. We build a new drain out of the tissue already present in your eye, enhance the current drain and sometimes use a shunt or device to drain the fluid. Glaucoma surgery is not designed to improve vision. It is done to prevent progression of glaucoma and preserve the vision that you currently have. The decision whether or not to have surgery must be carefully discussed with your doctor. There are several traditional surgeries for glaucoma, including trabeculectomy, tube shunt surgery, and cyclophotocoagulation. There are newer, “minimally invasive” glaucoma surgeries (MIGS) designed for people with mild to moderate glaucoma to reduce their dependence on drops and improve pressure control. They carry less risk than traditional glaucoma surgeries. They do not lower pressure as well on average and may not be appropriate for severe or advanced glaucoma. These procedures are often combined with cataract surgery. iStent , Hydrus, and goniotomy procedures are examples.  Dr Lehrer is well versed in all of the newest procedures and will choose the best procedure for you based on your individual needs.

Below is a link to the Glaukos website, including a brief animated video on the iStent:
www.glaukos.com/patients/howitworks

The Hydrus microstent is also placed in the canal at the time of catacract surgery and in addition to providing a bypass to the canal, it also creates a scaffold to keep the canal open. Below is a link to the Ivantis website for more information on the Hydrus stent:
www.ivantisinc.com/patients/understanding-hydrus

The XEN gel stent technology, released in 2017, offers yet another option for some patients requiring surgical treatment for glaucoma. This procedure is a somewhat less invasive alternative to traditional glaucoma surgeries and may offer easier and quicker recovery in suitable patients. Please click the link below for more information:
www.xengelstent.com

Obviously, this depends on many factors, and every patient is unique. The science of glaucoma has advanced tremendously over the last decade. We are now able to diagnose glaucoma in far earlier stages. We have many more medications at our disposal. Laser and surgical techniques have become much more sophisticated and safer. Current research will provide us with even more information about this disease and open new avenues of treatment. If diagnosed and treated earlier, chances are excellent that you will maintain your vision. Although there are no absolute promises in medicine, as long as you follow up regularly with your doctor, you are likely to continue to see for the rest of your life.

For more patient education please visit the American Glaucoma Society website below. For patients spending time in other locations there is an option to search for a local glaucoma specialist.
www.americanglaucomasociety.net

Another excellent resource for additional information about glaucoma is the Glaucoma Research Foundation. See link below.
www.glaucoma.org