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Glaucoma Q&A

What is Glaucoma?

To understand the eye disease called glaucoma, it is important to recognize that the eye normally makes fluid that circulates inside which exits slowly to keep it formed and functioning properly. If the fluid can’t exit at the proper rate, this will result in eye pressure elevation. It many ways it is like a kitchen sink that is starting to clog. (This fluid inside the eye should not be confused with our tears or tearing which is on the outside of the eye).

Glaucoma occurs when the pressure in the eye becomes too high for the optic nerve resulting in progressive damage of the optic nerve. The optic nerve carries the image that the eye sees into the brain. 

Source: American Academy of ophthalmology

Progressive damage to the optic nerve can eventually result in blindness. There has been tremendous progress in understanding glaucoma. As a result, we now recognize many patients (as high as 30% of glaucoma patients) who we had in the past thought had little risk of glaucoma - because their eye pressure was ‘normal’ - were actually were losing vision. Many studies demonstrate eye pressure is only one of many factors that determine a diagnosis of glaucoma. It is important for patients to have their eyes examined by professionals who understand the subtleties in diagnosing and treating glaucoma. This includes the use of several sophisticated modern diagnostic devices.

It is also important to recognize that there are many types of glaucoma.

Symptoms:

The most common symptoms patients experience from glaucoma, is - nothing. That is because they are undergoing a slow imperceptible painless loss of peripheral vision. This is why the disease is called the ‘thief in the night’. Once a patient starts to experience symptoms from glaucoma, it is most likely very advanced and there has been a very substantial irreversible nerve damage. 

 There is a type of glaucoma called acute glaucoma because it starts very suddenly and is accompanied by a sudden onset of any of the following: haloes around lights, light sensitivity, a painful tender eye, and in more extreme cases even nausea and vomiting. If you experience these symptoms, this is an emergency and you should seek immediate care. 

Causes:

There are many causes of glaucoma, as there are many types of glaucoma. The most common type is called open-angle glaucoma. Glaucoma is often inherited and is more prevalent among older adults. Glaucoma can also result from eye injuries, taking certain medications, being too farsighted, sleep apnea, eye inflammation, and many other conditions. Furthermore, in patients who underwent laser vision correction (Lasik/PRK), there is a need to inform your eye care professional since the eye pressure that is measured may not be accurate and in need of adjustment.

Diagnosis:

Diagnosis can only be made by an educated professional. It will require careful examination, including eye pressure measurement, optic nerve examination, computer imaging of the optic nerve (OCT), corneal thickness measurements, and visual field testing. Once the diagnosis is made, repeat exams & testing must be performed on regular basis to monitor how the disease and treatment are progressing. There is also a genetic test available to detect certain types of glaucoma (< 20%).

Treatments:

Once the diagnose of glaucoma is made, the primary treatment focuses on the reduction of eye pressure. There are, however, in some cases, other things that can also help treat glaucoma in addition to eye pressure reduction. This includes weight loss, exercise, good blood pressure control, and the diagnosis and treatment of sleep apnea.

The following are treatment categories for glaucoma treatment: 

Selective Laser Trabeculoplasty (SLT)
SLT is the use of a specially designed laser that allows for a painless in-office treatment to reduce eye pressure in most patients. It takes seconds to perform and can be repeated. SLT is our ‘go-to’ for most patients who have initially diagnosed with glaucoma because it has very little risk if performed properly and spares or delays the need for taking eye drops. Taking eyedrops can be difficult for a number of patients, irritating, and expensive for a number of patients.

Yag Laser Iridotomy
As we age the front part of the eye becomes more crowded due the growth of cataracts putting one at risk for acute glaucoma. This is called a narrow-angle. A simple laser in the office called a Yag iridotomy cures this condition.

Medications - Glaucoma Eye Drops
There are many classes of eye drops to treat glaucoma. Most are well tolerated. Compliance taking the drops is a challenge especially if they need to be taken more than once a day and/or multiple drops are needed to control glaucoma. Glaucoma drops generally have a preservative in them called benzalkonium chloride (BAK). Over time this can cause eye irritation and dry eyes. Sometimes switching to preservative-free preparations helps alleviate this problem.

Medications -Glaucoma Eye Drop Alternatives
There are new classes of glaucoma medications that will not require taking eyedrops. The latest one is called DURYSTA. DURYSTA is a small microgel implant that has in it a glaucoma medication that can be painlessly injected directly into the eye. It has several advantages. It lasts from 1-2 years after one injection. It does not require physical coordination like taking drops or the need to remember to take daily drops. In addition, it does not irritate the eye surface.

Marijuana
While there is much publicity over the use of marijuana for glaucoma, it has been determined that the efficacy of glaucoma is substantially less than available glaucoma medications which are also safer. Therefore, very few doctors prescribe marijuana. https://www.aao.org/eye-health/tips-prevention/medical-marijuana-glaucoma-treament

Glaucoma Surgery: There are several categories of glaucoma surgery.

• Microinvasive Glaucoma Surgery (MIGS)
  MIGS surgery is a new revolutionary surgery that allows for the use of special microscopic devices to control eye pressure with many risks of serious eye complications generally associated with more traditional glaucoma surgery. There are numerous types of devices available today including the iStent and Xen Gel stent. We have had a good experience with a number of these devices. They may be performed with cataract surgery.
• Traditional Glaucoma Surgery
  For many decades this was the only option for patients a