What is the treatment for glaucoma?

The main aim of glaucoma treatment is to preserve adequate vision during a person’s lifetime.

This is achieved chiefly by reducing the pressure of the eye. There is no cure as yet for glaucoma but if the pressure can be adequately controlled then it can prevent blindness in the vast majority of patients.

Sometimes glaucoma treatment is done to correct an anatomic abnormality or to reduce pain.

Treatment for glaucoma involves drops, laser or surgery. Occasionally pills are used to control eye pressure mainly as a short-term measure.

There are several groups of eye drops and combinations. Relevant ones are chosen or added based on your type of glaucoma and side effect profile.

In general if you need more than two eye drops to control the eye pressure then further treatment in form of laser or surgery is considered.

Sometimes laser or surgery is considered as a first line treatment depending on your individual circumstances.

There are several types of lasers that are used for glaucoma treatment depending on the type of glaucoma and severity of the disease.

Laser treatment for glaucoma

Selective laser trabeculoplasty (SLT)

This treatment is done as an outpatient. The laser itself takes 1-2 minute but you have an examination and drops before the laser and a check up with in an hour after the laser. The eye is made numb with an anaesthetic drop and a special lens placed on the eye to deliver the laser to the fine drains of the eye (Trabecular meshwork). No cut or holes are made and no patch is required afterwards.

Primary SLT laser reduces the pressure by 20% or more in around 80% of patients.

It can be used as alternative to drops in ocular hypertension or early glaucoma. It can also be used in addition to drops if the pressure is not adequately controlled with drops alone.

Click here to download a leaflet on Selective laser trabeculoplasty (SLT)

Laser Iridotomy

This type of laser (ND-YAG laser) is used to treat patients with angle closure. It is done as an outpatient and the laser itself takes 1-2 minute. Laser is used to create an alternative channel in the iris (coloured part of the eye) to drain the fluid better as it cannot flow through the pupil.

The eye is examined before the laser and drops are used to prepare the eye. The eye is checked again within the next hour and drops prescribed for a few days to use afterwards.

This alone helps to open the angle in 3 out of 4 people with angle closure.

Click here to download a leaflet on YAG laser peripheral iridotomy (PI)

Laser Iridoplasty

Sometimes if the angle is still narrow or closed after laser iridotomy then further observation, drops or laser iridoplasty is considered.

This is also done as an outpatient and takes 1-2 minute. Argon lasers is used to make the peripheral iris (coloured part of the eye) thin so that it does not touch the drain (trabecular meshwork) and allow better access to drain the fluid (aqueous humor)

Click here to download a leaflet on laser peripheral iridoplasty

Cyclodiode laser

This laser is done in theatre under local or general anaesthetic. The procedure takes about 5-10 minutes. Laser energy is delivered from the outside of the eye to the ‘tap’ (ciliary body) of the eye from where aqueous fluid is produced. This reduces the amount of fluid coming in to the eye to reduce the eye pressure.

No external cuts are made and the eye recovers quickly afterwards when the anaesthetic wears off.

Click here to download a leaflet on cyclodiode laser.

Cataract surgery (phako) with Endoscopic Cyclophotocoagulation (ECP laser)

In this procedure cataractous lens of the eye is removed and at the same time laser is applied to the ciliary body (‘tap’ inside the eye) from inside under direct endoscopic view to reduce the aqueous fluid and reduce the pressure.

This procedure has the advantage that the vision is improved due to cataract removal and at the same time eye pressure can be reduced in the vast majority of patients.

This procedure leaves the conjunctiva (superficial skin of the eye) untouched such that any further glaucoma drainage surgery (e.g. Trabeculectomy or Tube surgery) can still be performed in future if needed.

Click here to download a leaflet on phako ECP procedure.

Surgery for glaucoma

Surgery for is generally recommended for glaucoma in the following circumstances

• Progressive glaucoma
• Very high intraocular pressure
• Advanced glaucoma
• Uncontrolled pressures
• Inability to use or intolerable side effects of the drops
• Inability to afford or non-availability of drops for extended use
• Patient choice

In certain other types of glaucoma e.g. secondary glaucoma, congenital glaucoma, pseudoexfoliation and pigment dispersion glaucoma surgery is more likely to be required.

In angle closure type of glaucoma cataract extraction is an effective treatment on its own.

Types of surgery-

The choice of surgery is offered by the surgeon by considering several factors including glaucoma type, extent of glaucoma damage, target pressure, lens status, patients age, risk factors for failure, other eye status, ability to follow up etc.

Trabeculectomy

This is considered the ‘gold standard’ of glaucoma surgery. It has been around for over 60 years and has been modified with the safe surgery system. In this surgery tissues of the eyeball are utilized to create a filter under the lid where the aqueous fluid drains.

It can be done under local or general anaesthesia and takes 40-60 minutes.

Click here to download a leaflet on Trabeculectomy surgery

Drainage Tube surgery (aqueous shunt implantation)

This is a more specialized procedure for glaucoma. In this surgery a device called as aqueous shunt or simply ‘tube’ is implanted under the tissues of the eyeball. This is connected to the inside of the eye and to drain the aqueous fluid.

This can also be done under local or general anaesthesia and the procedure takes around 60-90 minutes.

There are two main types of shunts- Baerveldt tube and Ahmed valve. Device is selected based on individual glaucoma type and circumstances.

Click here to download a leaflet on aqueous shunt/ glaucoma tube implantation

Phako+ procedures

Certain newer procedures can be done at the time of cataract surgery to reduce the IOP at the same time. Some of these are also called ‘MIGS’ (minimally invasive glaucoma surgery)

These procedures include

• Phako ECP laser
• I-stent implant
• Hydrus imlant
• Trabectome
• Xen gel implant
• KDB (Kahook Dual Blade) internal trabeculectomy
• Preserflo (Innfocus microshunt)

Among these Phako-ECP has been around the longest. Many of these devices are still investigational or offered as part of clinical trials. Some are already approved for use in the NHS but may not be widely available.

More long-term data is awaited to make their use more widespread.

An advantage is that they are generally quick and safer. But these may not achieve low enough pressures or sustained reduction in pressures as can often be achieved by traditional glaucoma surgery like trabeculectomy and tubes. This is exciting time for glaucoma surgeons to find a quick, easy, safe and effective operation that can work long term to reduce the risk of glaucoma related blindness.

Click here to download a leaflet on phako-ECP procedure

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