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Glaucoma

Glaucoma is usually associated with the build-up of fluid pressure inside the eye. If left untreated it can damage the optic nerve, which is responsible for transmitting visual information from the eye to the brain, and lead to vision loss.

Glaucoma is commonly referred to as the silent thief of sight, because in most cases it progresses gradually and quietly. Your vision can be damaged without any noticeable symptoms. It may begin with loss of peripheral vision and then advance to a reduction in central vision and blindness. This disease affects nearly two out of every 100 people over the age of 35. Half of those people are at risk for blindness because they may not even know they have the disease.

Significant damage is nearly always preventable. At Bennett & Bloom Eye Centers, our doctors use the most up-to-date technology to diagnose and treat glaucoma. With early detection and careful management, significant damage to your eyesight from glaucoma is nearly always preventable; however, treatment cannot restore any vision that has already been lost.

What is glaucoma?

Glaucoma is a complex disease associated with the build-up of fluid pressure inside the eye that, left untreated, can damage the optic nerve. The optic nerve, a bundle of over a million nerve fibers, transmits the message of sight from the eye to the brain. In glaucoma the nerve fibers carrying peripheral vision are normally lost first. This reduction in side vision can be gradual and is not usually noticed. By the time it affects central or reading vision, tremendous damage to the nerve has occurred.

Normal Vision
Normal Vision

Glaucoma
Glaucoma

To understand what’s happening with glaucoma, imagine the eye as a bathtub with water. The clear fluid inside the eye, the aqueous humor, is always flowing through the eye, just like an open faucet. As long as the drain is open, the tub won’t overflow. But if anything happens to block the drain, the water level rises and spills over the edge.

Any blockage in the drainage system of the eye (trabecular meshwork) creates a similar problem, but the fluid has nowhere to overflow. Rather, the fluid pressure increases and damages one of the most sensitive and important parts of the eye, the optic nerve. Treatment, usually just with eye drops, can prevent further loss of vision but cannot restore what has already been lost; therefore, early detection is essential.

What are the types of glaucoma?

Although there are many different causes of glaucoma, there are two broad categories, open angle glaucoma and narrow angle glaucoma. The most common form is chronic open angle glaucoma. In this condition, a partial blockage in the drainage system of the eye causes the pressure to gradually increase inside the eye, just as though you were standing in your shower and noticed the water rising. You look down at the drain and see nothing is blocking it. The clog is somewhere deep inside the drain. This form of glaucoma usually causes no pain or sensation. The vision is lost slowly, starting in the periphery so that it is generally not noticed until significant damage has occurred, unless it is detected earlier by your eye specialist.

The other major form of glaucoma is narrow angle glaucoma, also known as angle-closure glaucoma. This form of glaucoma can again be likened to your standing in the shower and noticing the water filling up in the tub. As you look down, you notice that your foot is covering the drain. With angle closure the iris, the colored part of the eye, moves forward and blocks the openings into the eye’s drainage system, causing a sudden rise in pressure. This can result in halos around lights, severe pain and rapid loss of vision.

Both of these types of glaucoma can be inherited. Therefore, if someone in your family has glaucoma, your risk of developing glaucoma is increased. Likewise, if you have glaucoma, others in your family need to be made aware that their risk is heightened.

There are numerous other types of glaucoma, including secondary, juvenile, pseudoexfoliation syndrome, pigment dispersion syndrome, and closed angle glaucoma.

How is glaucoma diagnosed?

At Bennett & Bloom Eye Centers, our doctors use the very latest technology to identify patients with glaucoma. The diagnosis of glaucoma is not always clear-cut and simple, since individuals vary in their susceptibility to eye pressure. Successful diagnosis and treatment of glaucoma begins with a careful ocular evaluation. First, we measure the fluid pressure within the eye. Corneal thickness may affect this pressure reading and can be checked with an ultrasonic pachymeter. We examine your eyes thoroughly and look for optic nerve damage, both visually and photographically. Using the state-of-the-art OCT we can measure the nerve fiber layer thickness around your optic nerve. This test may determine if you have glaucoma even before you experience any vision loss. Next we test for central and peripheral vision loss using a sophisticated, computerized visual field analyzer. Gonioscopy helps determine which specific type of glaucoma you may have.

We’re always careful to consider any additional risk factors that may contribute to your possibility of vision loss from glaucoma. Family history, general health problems, including diabetes and anemia, as well as prior eye trauma and race are all risk factors.

View Video
Finally, we analyze all the information to arrive at your diagnosis and then decide on a treatment plan if indicated. Special eye drops, usually taken once or twice a day, are all that is needed to stop sudden damage or loss of sight.

How is glaucoma treated?

  1. Open angle glaucoma.

      1. Eye drops. In most cases, open angle glaucoma can be treated with eye drops. These drops help lower the intraocular pressure and reduce the risk of vision loss from glaucoma. Sometimes more than one drop is needed. If these drops do not adequately control the pressure, there are surgical options that can be performed as the next step. Some patients are able to decrease the number of eye drops they use (and in some cases, eliminate them completely) after surgery. However, it is important to realize that this is not always the case, and drops may still be necessary in addition to surgery to keep the pressure at a safe level. There are many types of eye pressure lowering drops:
        • Alpha agonists: Reduces the production of fluid in the eye. Drugs include Alphagan P (Brimonidine tartrate) and Iopidine (Apraclonidine hydrochloride).
        • Beta-blockers: Reduces the production of fluid in the eye. Drugs include Betimol (Timolol), Timoptic XE (Timolol maleate), Betoptic S (Betaxolol hydrochloride).
        • Prostaglandin/prostamide analogues: Improves the outflow of fluid. Drugs include Travatan (Travoprost), Lumigan (Bimatoprost), and Xalatan (Latanoprost).
        • Carbonic anhydrase inhibitors: Reduces the production of fluid in the eye.
        • Cholinergic agonists (Pilocarpine): Improves the outflow of fluid from the eye.
        • Combination drops: Some of the above drops are combined together to lower eye pressure. Drugs include Combigan (Brimonidine and Timolol), Cosopt (Dorzolamide and Timolol), and Simbrinza (Brimonidine and Brinzolamide)
      2. Selective Laser Trabeculoplasty (SLT).
        SLT can be used to widen the openings in the eye’s drainage system, thereby lowering the pressure. This medical treatment is normally safe, painless, quick and is performed in our office utilizing the Lumenis Selecta II laser. Compared to traditional argon laser trabeculoplasty, selective laser trabeculoplasty does not burn the trabecular meshwork tissues. SLT uses an extremely short burst of laser energy to selectively treat pigmented cells found in the trabecular meshwork. Pigment cells that may be clogging the trabecular meshwork are removed without causing any structural changes or scarring to the trabecular meshwork. This offers a distinct advantage over ALT in that SLT can be repeated as needed. Lowering intraocular pressure by SLT may also reduce the need for patients to use eye drops. Eye drops have obvious disadvantages of expense, potential side effects and a lifetime of compliance. SLT is also a patient friendly procedure. It can be performed in the office in about 5 minutes with only topical anesthesia. Patients who are not controlled by eye drops, who cannot afford eye drops, or who have poor compliance with eye drops are good candidates for SLT.View Video
    1. Argon Laser Trabeculoplasty (ALT). An argon laser can be used to widen the openings in the drainage system, thereby lowering the pressure. This medical laser treatment is normally safe, painless, quick and is performed in our office. It has largely been replaced by SLT.
    2. iStent Trabecular Micro-Bypass.
      istentThe iStent represents the first FDA approved MIGS or micro-invasive glaucoma surgery. This tiny stent is placed within the eye’s natural drainage structure during cataract surgery. It works by allowing a direct communication between the inside of the eye and its natural drainage canal (Schlemm’s canal behind the trabecular meshwork). Once fluid can access this drainage canal easier, the pressure inside the eye often decreases.After the surgeon has removed the cataract and replaced it with an intra-ocular lens, a specially designed mirror enables the surgeon to carefully and gently place the stent into its correct position. This additional procedure adds little time to the surgery itself, and does not require any additional post-operative recovery or risk of complication. Because the iStent is the smallest medical device available, patients are unable to see the stent after it has been implanted.The iStent is an excellent option for patients with mild to moderate open angle glaucoma who are interested in having cataract surgery. Because the iStent is covered by Medicare and most private insurance companies, most patients do not have any additional out of pocket expense. Because the iStent is designed to lower IOP, your eye doctor may change or even stop some of your glaucoma drops after the procedure.View Video

    3. Ex-PRESS™ Mini Glaucoma Shunt.
      Rarely, in cases in which traditional medical and surgical techniques are not working, the Ex-PRESS™ Mini Glaucoma Shunt can also be used. This is a minimally invasive procedure compared to some other surgical alternatives for glaucoma. It involves the implantation of a miniature device that reduces pressure inside the eye by diverting the excess fluid away from the affected area.The potential of trauma to the delicate eye tissue is greatly decreased. The procedure allows for a very small incision to be made, using a specially designed disposable insertion tool. The actual device is a 400-micron diameter tube less than 3 mm long, made from implantable stainless steel. The surgery also does not require removal of any portion of the iris (iridectomy) as is required with conventional glaucoma filtering surgeries.The use of only eye drops for anesthesia combined with the minimal invasiveness, allows the procedure to be completed in a fraction of the time of conventional glaucoma filtering surgery. Clinical studies have shown the procedure produces low complication rates with fast recovery and minimal discomfort to the patient. Implantation of the device can reduce or eliminate the reliance on glaucoma medications. Studies show a 40% reduction in intraocular pressure with an 88% success rate. Doctors at Bennett & Bloom Eye Centers were among the first physicians in the U.S. to be successfully certified to perform this procedure.View Video

    4. Trabeculectomy. The doctor surgically creates an incision in the drainage channel of the eye. This creates an artificial drainage channel, allowing the fluid to escape from the inner part of the eye, lowering the pressure. This procedure may be done alone, or in combination with cataract surgery if a visually significant cataract is present. There are no lasers used in this procedure. Some forms of glaucoma respond better to laser treatment, while others respond better to conventional surgery. There is an overall 80% success rate with trabeculectomy.View Video

    5. Drainage Device.
      This surgery is often reserved as a last resort to control eye pressure and blindness in eyes with severe and otherwise uncontrollable glaucoma. In most situations, combinations of drops and lasers have been exhausted before considering implanting a drainage device. For those individuals whose glaucoma continues to progress despite maximum medical therapy, or who do not respond to medical management, a glaucoma drainage device can provide a significant drop in their pressure. Unlike previous glaucoma procedures, the drainage device bypasses the eye’s natural drainage structure. A small tube inserted into the eye provides a path for the fluid to escape the eye and be reabsorbed by the body. There are often small releasable sutures that your eye doctor can remove at various stages after surgery to either increase or decrease the eye pressure. Risks of the surgery include bleeding, infection, and vision loss. It is possible for the eye pressure to remain too high or too low, either of which may require more surgery. Rarely, patients experience double vision as a result of the drainage device, although this is typically correctable with glasses. All glaucoma surgery patients should anticipate to have very blurry vision in the operated eye for a few months. Once the inflammation and swelling subside, vision often improves to the same level it was before surgery. Patients often require a change in their glasses once the eye has fully healed. Since this type of surgery requires frequent postop examinations, patients are often seen at least once a week for the first month. Unfortunately, the process that caused the glaucoma in the first place (poor drainage function) continues following surgery. Soon after surgery, the combined function of the natural and new drain usually results in good pressure with minimal or no eye drops. In time, both the new and natural drains will continue to loose function and may result in the eye pressure slowly rising again. Thus eye drops may eventually need to be restarted and some may even require more surgery. It is very difficult to predict exactly how long the drainage device will last, with some working for more than 10 years and others failing in under a year.A drainage device increases a patient’s life long risk of developing an infection, and early detection is crucial in preventing serious vision loss. While these serious infections are very uncommon, they may be possible many years after surgery. For this reason, it is imperative that any patient who has had glaucoma surgery see their eye doctor immediately for new redness, irritation, pain, or blurry vision in the operated eye.View Video

    6. Endoscopic Cyclophotocoagulation (ECP). This state of the art procedure utilizes a laser that treats the ciliary body of the eye to reduce the production of fluid, resulting in a lower eye pressure. This can be done at the time of cataract surgery or any time after cataract surgery. The goal of this treatment is to reduce or eliminate the dependence of glaucoma eye drops. After this procedure, 95% of patients achieve a lower eye pressure on fewer or the same number of pressure lowering drops.View Video

    7. Transscleral cyclophotocoagulation (CPC). Transscleral cyclophotocoagulation (CPC), utilizing our Iridex CYCLO G6 Glaucoma Laser System, is an outpatient procedure designed to lower eye pressure similarly to ECP in that laser energy is used to decrease fluid production by treating the ciliary body. Unlike ECP, CPC is used externally and is not done in conjunction with other surgery. The MP3 probe is used for treating mild to moderately elevated eye pressures. The G-probe with low energy is used for more severely elevated eye pressures. The G-probe with high energy is used for severe refractory glaucoma. Most patients experience a significant decrease in pressure and eye pain after the procedure which has little post-operative recovery.View Video

  2. Narrow angle glaucoma

    In most cases narrow angle glaucoma is treated by YAG laser iridotomy. The laser is used to create an opening in the iris (colored part of the eye) for fluid drainage. This may be preventative, or may be performed in an emergency setting to prevent permanent vision loss. While the procedure infrequently causes pain, the sensation of the laser in this part of the eye often startles individuals. Depending on the color of your iris, the procedure may have to be repeated before a new opening can successfully be obtained. Risks of bleeding, inflammation and a temporary increase in eye pressure are small and there are no restrictions or healing period once the laser is performed. Your eye doctor typically prescribes an anti-inflammatory eye drop for a few days after the procedure to help limit any irritation the laser might have caused.

    Will I go blind from glaucoma?

    Virtually no one should be blinded from glaucoma. The treatments are highly effective and, while vision already lost cannot be restored, significant further loss can be avoided.

    The most important ingredient in the successful management of glaucoma is your cooperation. Continuous pressure control is possible only by strictly following your treatment plan…and that is primarily up to you. In most cases, the only people who become blind from glaucoma are those who do so before their condition is diagnosed or those who do not adhere to their treatment regimen.

    Will some medications worsen my glaucoma?

    Many over-the-counter medications are labeled not to be used if you have glaucoma. These warnings do not apply to open angle glaucoma, but only to untreated narrow angle glaucoma.

    A few reminders about glaucoma.

    In most forms of the disease, glaucoma has little to no warning signs. It is impossible to “feel” a change in the eye pressure unless it becomes extremely high. Once the vision becomes so reduced that visual changes are noticed, damage to the optic nerve has already begun and cannot be reversed. The goal of treatment at that point is to preserve any remaining vision. This is why routine examinations and compliance with medications are so important. If detected early enough, there is an excellent chance of lowering the eye pressure and preventing sight threatening damage from occurring.

    Even after undergoing a surgical or laser procedure, eye drops may still be needed to reduce the pressure to a safe range. It is also important to remember that certain types of glaucoma respond better to laser surgery, while others respond better to conventional surgery.

    With eye drops, compliance is the key. Most people will probably not notice any difference in their vision after starting eye drops. The goal of eye drops is to lower eye pressure, prevent damage and further vision loss, not to improve the current vision. Therefore, even though patients may not feel any different or see better, it is important to continue to use the prescribed medication. By measuring the pressure and performing various tests at follow up visits, your doctor will be able to tell you if the treatments are effective.