What is glaucoma?
Glaucoma, often referred to as the “silent thief of sight” is a leading cause of blindness in the United States and the world. Glaucoma is a group of diseases where the optic nerve is damaged and eventually leads to progressive loss of vision which is permanent. Patients are often not aware of any vision changes since glaucoma usually progresses gradually. Currently, we do not have a cure for glaucoma. However, early detection through regular eye exams and treatment is the best option available to slow the disease and preserve as much vision as possible.
There are many different types of glaucoma, though we often categorize them based on the appearance of the angle. The two major classifications, based on the configuration of the angle, are open angle and angle closure glaucoma (acute or chronic). Open angle glaucoma, the most common form of glaucoma, occurs when people have increased eye pressure. This can lead to damage of the drainage system within the eye and the optic nerve. Acute angle closure glaucoma occurs less frequently and can be more devastating as there is a sudden and rapid increase in eye pressure causing loss of vision. This is considered a medical emergency and needs urgent treatment. Chronic angle closure glaucoma, progresses slowly and can damage the optic nerve and produce peripheral vision loss without symptoms, similar to open angle glaucoma.
Who gets glaucoma?
You can develop glaucoma at any age, but there are certain risk factors that put you at a higher risk for developing glaucoma.
- High eye pressure
- Family history of glaucoma (parent, siblings)
- Age 40 or older for African Americans
- Age 60 or older for the general population
- Suspicious appearance of optic nerves (size of cup is larger than average)
- Potential risk factors include: high myopia, diabetes, eye surgery/trauma, hypertension and corticosteroids (drops, creams, inhalers, pills)
How is glaucoma diagnosed?
Glaucoma is diagnosed by your ophthalmologist as part of a comprehensive eye exam, which includes checking eye pressure, gonioscopy (to evaluate the drainage system) and a dilated exam to examine the optic nerve. Testing for further evaluation includes visual field testing to assess peripheral vision, optical coherence tomography to assess the structure of the optic nerve and retinal nerve fiber layer and corneal pachymetry to assess the thickness of the cornea.
How is glaucoma treated?
Our goal of slowing glaucoma progression is mostly achieved by lowering eye pressure. This is done by using eye drops, performing laser or surgery. The best treatment option is based on the individual and the stage of their disease.
Lifestyle and glaucoma
Some lifestyle activities may have an impact on your eye pressure and modifications should be considered if you have glaucoma. Some activities that may increase your eye pressure include, eye rubbing, sleeping on your side (putting pressure on the eye of that side), playing woodwind or brass instruments, exercises that put your head below your hips (ex. inverted yoga positions like downward dog, head or handstands), neckties and lifting heavy weights. Smoking, obesity, high or low blood pressure, diabetes or excessive caffeine can affect blood circulation and decrease oxygenation thereby making your optic nerves more susceptible to glaucoma damage. Corticosteroids in any form, used in any body part can increase eye pressure. Some medications (antihistamines, decongestants, motion sickness medicines, tricyclic antidepressants) are contraindicated if you have narrow angles and have not had a laser iridotomy.
Who gets glaucoma?
You can develop glaucoma at any age, but there are certain risk factors that put you at a higher risk for developing glaucoma.
- High eye pressure
- Family history of glaucoma (parent, siblings)
- Age 40 or older for African Americans
- Age 60 or older for the general population
- Suspicious appearance of optic nerves (size of cup is larger than average)
- Potential risk factors include: high myopia, diabetes, eye surgery/trauma, hypertension and corticosteroids (drops, creams, inhalers, pills)
How is glaucoma diagnosed?
Glaucoma is diagnosed by your ophthalmologist as part of a comprehensive eye exam, which includes checking eye pressure, gonioscopy (to evaluate the drainage system) and a dilated exam to examine the optic nerve. Testing for further evaluation includes visual field testing to assess peripheral vision, optical coherence tomography to assess the structure of the optic nerve and retinal nerve fiber layer and corneal pachymetry to assess the thickness of the cornea.
How is glaucoma treated?
Our goal of slowing glaucoma progression is mostly achieved by lowering eye pressure. This is done by using eye drops, performing laser or surgery. The best treatment option is based on the individual and the stage of their disease.
Lifestyle and glaucoma
Some lifestyle activities may have an impact on your eye pressure and modifications should be considered if you have glaucoma. Some activities that may increase your eye pressure include, eye rubbing, sleeping on your side (putting pressure on the eye of that side), playing woodwind or brass instruments, exercises that put your head below your hips (ex. inverted yoga positions like downward dog, head or handstands), neckties and lifting heavy weights. Smoking, obesity, high or low blood pressure, diabetes or excessive caffeine can affect blood circulation and decrease oxygenation thereby making your optic nerves more susceptible to glaucoma damage. Corticosteroids in any form, used in any body part can increase eye pressure. Some medications (antihistamines, decongestants, motion sickness medicines, tricyclic antidepressants) are contraindicated if you have narrow angles and have not had a laser iridotomy.
Glaucoma Lasers
Glaucoma Lasers
- Laser Peripheral Iridotomy (LPI)
LPI is a laser treatment used to treat narrow angles. A microscopic hole is created in the colored part of the eye (iris). This hole can change the configuration of the drainage system within the eye, so that aqueous fluid is able to flow more normally and help prevent an acute attack of angle closure glaucoma. Drops to constrict the pupil and an eye pressure lower drop is applied to the eye. The pupil constricting drop may give some people an “ache” over the brow, but this is temporary. The eye is then numbed and a special contact lens is placed in your eye. Usually the laser treatment only lasts a few minutes. Some people may experience a brief pinch of discomfort with the laser. After the laser is completed, your eye pressure is checked and you can go home without any restrictions. If you are taking glaucoma medications, you should continue them. A topical steroid drop is prescribed for a few days to help with the healing process. Risks of laser iridotomy include inflammation (which is expected and treated with steroid drops), increased eye pressure, bleeding, glare or line of light in their vision. The glare or line of light is extremely uncommon and most people notice that this symptom improves with time. Sometimes, if the hole that is created is is too small or incomplete, it may close and a second treatment may be required. Occasionally, the drainage system may still remain narrow after the laser iridotomy and other medical or surgical treatments may be necessary depending on the individual.
If you have narrow angles and decline treatment, certain medications should be avoided as they can precipitate an acute attack of angle closure glaucoma. These medications usually have a warning on the label instructing you to not take them if you have glaucoma. Some examples of medications to avoid include: allergy/cold remedies, some asthma medications (atrovent or spiriva), some anti-depressant medications (prozac, paxil, amitryptiline) or motion sickness medications. The symptoms of an acute attack of angle closure glaucoma includes: sudden red painful eye, blurry vision, headaches, colored halos and nausea and vomiting. If you develop these symptoms, you need to seek immediate ophthalmic attention.
Cataract surgery may be an appropriate alternative to laser iridotomy in some people.
- Selective Laser Trabeculoplasty (SLT)
SLT is a glaucoma laser that is used to lower eye pressure. SLT uses short pulses of low energy to target specific cells in the drainage system and improve their function. The eye is numbed and a special contact lens is placed in your eye. The laser treatment only lasts a few minutes. Some people may experience a brief pinch of discomfort with the laser. After the laser is completed, your eye pressure is checked and you can go home without any restrictions. A topical anti-inflammatory drop is prescribed for a few days to help with the healing process. If you are taking glaucoma medications, you should continue using them unless given different instructions.
Good candidates for SLT are people with open angle glaucoma and need additional eye pressure reduction. This can be done as a primary treatment or as an adjunctive therapy to patients already on topical medications. SLT does not cure glaucoma and glaucoma patients who have had SLT still require regular follow up visits. Risks of SLT include blurry vision, mild inflammation and an increase in eye pressure. The effect of SLT can last anywhere form 1-5 years and SLT can be repeated.
Glaucoma Surgeries
Glaucoma Surgeries
- Trabeculectomy
Trabeculectomy is a glaucoma surgery that creates a new drainage site to allow aqueous fluid to flow outside of the eye, thereby lowering the eye pressure. The fluid flows into a space under the conjunctiva (clear tissue covering the white part of the eye) forming a small blister (called bleb). The bleb is mostly covered by the eyelid after surgery but can be seen if the eyelid is lifted. In order to prevent scarring at the drainage site, anti-scarring medication is used at the time of surgery (5-Fluorouracil or Mitomycin-C). The goal of this survey is not to improve vision or cure glaucoma. This surgery is meant to lower the eye pressure to slow the progression of the disease. Patients will have frequent follow up visits after surgery in order to monitor the progress of the surgery. Since healing varies from person to person, additional procedures may be necessary to achieve optimal results. Some patients may be able to decrease the number of their glaucoma medications after surgery. The most common complications seen with trabeculectomy includes blurry/decreased vision, worsening of pre-existing cataract, corneal swelling, infection, bleeding, suboptimal pressures and possible additional surgery.
- Glaucoma drainage device implants (GDI)
Glaucoma drainage device implants involve placing a plastic tube inside the eye that drain the aqueous fluid to an external reservoir. There are many varieties of glaucoma drainage devices, though they are categorized into valved and non-valved implants. The implant is placed underneath the conjunctiva (clear tissue covering the white part of the eye) and then secured to the eye. The tube is then threaded inside the eye and then covered with a reinforcement patch. The tube is mostly covered by the eyelid after surgery but can be seen if the eyelid is lifted. The reinforcement patch may have a white appearance, depending on the type of patch that is used. GDIs are often indicated for those who have a history of a failed trabeculectomy, history of prior eye surgery, susceptible to increased scarring, diabetes or uveitis. The goal of this surgery is not to improve vision or cure glaucoma. This surgery is meant to lower the eye pressure to slow the progression of the disease. Patients will have frequent follow up visits after surgery in order to monitor the progress of the surgery. Since healing varies from person to person, additional procedures may be necessary to achieve optimal results. Some patients may be able to decrease the number of their glaucoma medications after surgery. The most common complications seen with glaucoma drainage devices includes double vision, blurry/decreased vision, worsening of pre-existing cataract, corneal swelling, infection, bleeding, suboptimal pressures and possible additional surgery.