Glaucoma

Glaucoma Treatments

sink-image

Think of an eye with glaucoma like a kitchen sink with a clogged drain. To keep the sink from overflowing, you can either turn down the rate of fluid coming from the tap, or you can clean out the drain so it works faster.

All modern methods for treating glaucoma are designed to lower the eye pressure. This can be accomplished with medications, lasers, and surgery. To treat glaucoma and lower the pressure in the eye, you can either decrease the amount of fluid going into the eye, or open the drain to help fluid leave the eye more easily.

Medications

Glaucoma medications are medicated eye drops or gels that are dropped onto the surface of the eye one or more times each day. The medicine is then absorbed into the eye where it interacts with the structures inside the eye. Eye medications either decrease the production of eye fluid (aqueous) or help clean out the drainage system so it works better. Once started, medications are usually used for many years, and sometimes for the remainder of your life. To be effective, medications must be used every day. A common reason patients go blind from glaucoma is a failure to use the medications on a daily basis. Most glaucoma medications only work for 6-12 hours, so regular dosing is important for them to be effective. If doses are missed, the eye pressure will begin to increase within just a few hours. If you take medications, it is important that you pay attention to how much is in the bottle so that you can get refills at the pharmacy regularly. Try to get to the pharmacy BEFORE the medicine runs out so that you don’t miss any days of treatment. Never stop using a medication without first calling your doctor and discussing with them the problems you are having (side effects, cost, etc.).

To avoid confusion, it is very helpful if you know the exact names of your medications and take the bottles with you when you come in for an eye pressure check at the eye doctor’s office.

Common glaucoma medications (circle any drops you are taking)

Generic Name Branded Name Usual Dosing
 Latanoprost Xalatan One drop in the evening
 Travaprost  Travatan One drop in the evening
 Bimatoprost  Lumigan One drop in the evening
 Timolol  Timoptic, Istalol Once or twice daily
 Dorzolamide  Trusopt Two or three times daily
 Dorzolamide/Timolol  Cosopt Twice daily
 Brinzolamide  Azopt Two or three times daily
 Brimonidine  Alphagan Two or three times daily
 Pilocarpine  ———— Three or four times daily
 Timolol/Brimonidine  Combigan Twice daily

Tips on using glaucoma medications

eye-drops

To help the medication absorb into the eye, close your eyes for a few minutes after putting the eye drop in.

Because some of these drops are expensive, it is good to not waste drops. Helpful ways to get your drops in easily include having a friend or family member put the drops in for you or lying down on the couch or sofa when putting in the drops. To help the medication absorb into the eye, close your eyes for a few minutes after putting the eye drop in. Some doctors recommend gently squeezing the small eyelid drains by the nose for a few minutes after putting the drops in the eye. This is probably no more helpful than closing your eyelids, so we don’t recommend this.

Side Effects

Although glaucoma medications are generally very safe and well tolerated, there are some possible side effects. All topical eye drops can cause an allergic reaction with redness and itching or eye irritation with burning and a scratchy sensation. Timolol and other Beta-blockers can worsen breathing problems if you have asthma, bronchitis, or COPD. They can also lower the heart rate and cause other heart issues. If you experience any side effects with any medication, you should contact your eye doctor immediately.

Other common side effects

Drug Name Side Effects
 Latanoprost
  • Longer eyelashes
  • Increased eyelid skin pigment
  • Darkening of iris color
 Travaprost – Travatan
 Bimatoprost – Lumigan
 Timolol  Rare heart and breathing problems
 Dorzolamide  Burning with instillation
 Dorzolamide/Timolol  Rare heart and breathing problems, burning with instillation
 Brinzolamide – Azopt  Allergy
 Brimonidine – Alphagan  Allergy, dry mouth, fatigue
 Pilocarpine  Head ache
 Brimonidine / Timolol Combigan  Allergy, dry mouth, fatigue, rare heart and breathing problems

Target Pressure

bullseye-target

At one of your initial visits after glaucoma treatments have been initiated your doctor will choose a target pressure as a goal pressure for your eyes.

At one of your initial visits after glaucoma treatments have been initiated your doctor will choose a target pressure as a goal pressure for your eyes. This target eye pressure is your doctor’s best guess as to a “safe” pressure so no further glaucoma nerve damage develops. The number will depend on how high the eye pressure was before treatment, how much damage has developed, and your age and medical conditions. It is beneficial for you to understand the concept of a target pressure and know the target pressure your doctor has chosen for your eyes. If you don’t know your target pressure, ask your doctor at your next visit.

Common Target Pressures

Mild Glaucoma 18-20
Moderate Glaucoma 14-16
Severe Glaucoma 12-14

Laser

Laser treatments in glaucoma are high technology treatments that are safe and effective at lowering the eye pressure. The most common laser treatment for pressure lowering is the SLT (Selective Laser Trabeculoplasty). During this 5 minute treatment an intense green light is directed at the eye drain (trabecular meshwork). This bright light causes microscopic damage to the drain. The eye then heals the small damage, during which time the drain gets cleaner and starts to work better, which lowers the eye pressure. The laser is effective in most cases (85% or so) and is generally safe. Some patients have minor light sensitivity and pain for a few days after. Some patients experience an increase in eye pressure. In many cases eye drops can be avoided or discontinued if the laser is successful.

There are a few other laser procedures done in the treatment of various types of glaucoma. A laser peripheral iridotomy (LPI) makes a small hole in the iris. This laser is done to treat a condition known as a narrow angle which is a risk factor for developing a type of glaucoma known as angle closure. Cyclophotocoagulation (CPC or ECP) is a laser treatment to the ciliary body, the area of the eye that makes the aqueous fluid. If the pressure is high, the CPC laser damages the fluid-producing cells, and decreases the amount of fluid entering the eye.

Surgery

Glaucoma surgeries help create a new way for fluid to drain away from the eye. This helps to lower the eye pressure. Glaucoma surgeries are outpatient surgeries done in an ambulatory surgery center. This means you do not have to stay in a hospital after surgery. Glaucoma surgeries are generally safe, but rare severe side effects such as infection or bleeding can develop. Glaucoma surgeries are usually done when medications or lasers are not effective or not tolerated because of side effects. There are two main types of surgery, a trabeculectomy and a glaucoma tube implant

Trabeculectomy

Trabeculectomy makes a small trap door in the wall of the eye that acts like a pressure release valve to help fluid leave the eye. As fluid leaves the eye, the eye pressure decreases. The final eye pressure depends on how much scar tissue develops after the surgery. If a lot of scar tissue develops the eye pressure can increase and the surgery can fail.

Glaucoma tube implant

With this surgery a small soft silicone tube is implanted in the eye as a new drain to help lower the eye pressure. It is also a relatively safe procedure. Fluid passes out of the eye through the new drainage tube. There are a few different versions of this surgery; the main tubes are either a Baerveldt or an Ahmed.

Other surgical procedures

There are numerous other surgeries in development or in use to treat glaucoma. They are generally designed to help fluid leave the eye and are related to the surgeries mentioned above. Other surgeries include canaloplasty, deep sclerectomy, express implant, and the trabectome. Unfortunately, no surgery stands out as the best option, and the eye pressure can remain high even after a glaucoma surgery.

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