Although doctors are constantly discovering new treatments for glaucoma, the traditional methods of treatment are still safe and effective. Sometimes, traditional methods may be preferable depending on your condition. Your doctor will go over what treatment options are available and make recommendations for which treatment or combinations of treatments are best for your specific condition. Your treatment plan is an ongoing “prescription” that may include innovative technology as well as traditional drugs and procedures to provide you with the best care possible in treating your glaucoma.
Glaucoma treatment is a team effort and requires cooperation and communication among you and all the doctors who provide your care. All medications must be taken exactly as directed to prevent the advancement of your glaucoma.
Your doctor may prescribe eye drops as an initial treatment of glaucoma. All eye drops are absorbed into the blood stream, so your doctor will evaluate all medications that you are taking to verify that they are safe to be taken in conjunction with one another.
There are many types of eye drops that have various functions:
- Prostaglandin analogs are the newest class of glaucoma eye drops and they lower intraocular pressure (IOP) by opening up a new passage by which aqueous humor exits the eye. They are taken once per day. Some examples are Lumigan, Xalatan, Travatan and Travatan Z.
- Beta blockers reduce the production of aqueous humor in the eye. Some examples are Betopticm Ocupress, Betagan, Timoptic and Istalol.
- Alpha-2 Adrenergic Agonists reduce aqueous humor production and increase drainage of intraocular fluid. Some examples are Alphagan, AlphaganP and Iopidine (used at the time of laser treatment to prevent a sudden rise in IOP).
- Miotics open the eye’s drain and increase the rate of fluid flowing out of the eye. Some examples are Iosptocarpine and Pilocar.
- Topical Carbonic Anhydrase Inhibitors decrease the production of intraocular fluid. Some examples are Azopt and Trusopt.
- Cholinesterase Inhibitor increases the amount of fluid that drains from the eye. One example is Phospholine Iodide.
- Fixed combination Glaucoma Drugs decrease the production of aqueous humor. Many patients require more than one medication to control IOP so a few drug companies joined to create combination drops. Some examples are Cosopt and Combigan.
If eye drops are not sufficient to lower IOP, your doctor may prescribe pills which help to reduce the amount of aqueous humor in the eyes. Pills are usually taken 2 to 4 times each day. The disadvantage of pills is that they have more systemic side effects and can interact with other prescription drugs that you take. It is important to write down all medications that you are currently taking so your eye doctor can evaluate whether pills will be an effective part of your glaucoma treatment plan.
Glaucoma pills are part of the oral carbonic anhydrase inhibitors family of drugs and some examples are Diamox and Neptazane. This drug helps reduce fluid flow in the eye. Medication should be taken with meals or with milk to reduce side effects. Eating bananas or apple juice is helpful to minimize potassium loss.
When eye drops and laser surgeries do not remedy intraocular pressure (IOP), your doctor may recommend conventional surgery. Trabeculectomy, also called filtration surgery, is a surgical procedure to remove part of the trabecular meshwork in the eye to reduce pressure caused by glaucoma. Your surgeon will create a tiny opening in the sclera (the white part of the eye) to drain excess aqueous humor, thereby lowering IOP.
Trabeculectomy is used to treat open-angle glaucoma and chronic closed-angle glaucoma. If your medicated eye drops are not effective in reducing pressure in your eyes, you could be at risk for permanent sight damage. Trabeculectomy could be essential in slowing the progression of your glaucoma.
Preparing for Trabeculectomy
Most trabeculectomy procedures are performed at an outpatient surgery center. Your surgeon will ask for a list of your prescription medications to review before the surgery and will make any necessary recommendations. If you are on anti-inflammatory medications or blood thinners such as Coumadin or Plavix, you may need to cease taking your medications about a week before the surgery. You will also receive some anti-glaucoma drugs before the procedure.
What Happens during Trabeculectomy?
Several eye drops will be administered before surgery begins. Your eye will be sterilized and you will receive local or even topical anesthetic.
The goal of trabeculectomy is to create a filtration system for the buildup of aqueous humor so the intraocular pressure is diminished. This is done by removing a piece of your eye tissue from the drainage angle of the eye to create an opening. The outer white coating of your eye, called the sclera, is cut open to make a flap for the aqueous humor to drain. A filtration reservoir called a bleb is created under the thin membrane called the conjunctiva that covers the white part of your eye. Similar in appearance to a blister, the bleb looks like a bump on the white part of the eye above the iris. The trapped aqueous humor can now circulate and drain through the flap and collect in the bleb. The fluid will be absorbed into the surrounding blood vessels and intraocular pressure will decrease. Your surgeon will then close the scleral flap and conjunctiva with sutures.
What Happens after Trabeculectomy?
You may experience discomfort after surgery but this is normal. You will probably be given antibiotics directly after the procedure, and you may receive an injection of antibiotics under the lining of the conjunctiva. Your eye will be covered with an eye dressing during the first night after surgery, but after that your eye will be taped shut, and you will wear a hard covering called an eye shield at bedtime. If you had the procedure done at an outpatient surgery center, you will have an appointment with your eye specialist the day following the procedure.
You may experience a few temporary side effects such as blurred vision, eye pain and sensitivity to light. Your doctor will prescribe antibiotics and corticosteroids (anti-inflammatory eye drops) that you will use for at least six weeks after the procedure. Occasionally, the surgically created drainage opening can close and cause the IOP to increase again. Many surgeons use an anti-fibrotic agent to reduce scarring and prevent the hole from closing, and you may also need to take additional medication to reduce scarring.
What are the Outcomes of Trabeculectomy?
About half of all trabeculectomy patients do not require glaucoma medication for a considerable amount of time after surgery. Of the 35 to 40 percent of patients who require medication experience a significant decrease in their IOP. The number of post-op visits will vary from patient to patient, and you should plan to limit certain activities such as driving, reading, bending and straining for 2 to 4 weeks after surgery.
Although trabeculectomy has proven to reduce intraocular pressure in most patients, but many individuals need more trabeculectomy surgery as well as other glaucoma treatments. This procedure is not considered a cure, and people can still experience vision loss even after surgery. Regular visits to your eye doctor are imperative to maintain a safe level of eye pressure.
Glaucoma Drainage Devices
Sometimes, a trabeculectomy is not effective, or the eyes may exhibit extensive scarring from previous surgeries. If this is your experience, your doctor may recommend a tube shunt procedure called a glaucoma drainage device (GDD). Glaucoma drainage devices are designed to route fluid (aqueous humor) from the anterior chamber of the eye to an external reservoir. GDDs have been performed for about 40 years and have been improved for maximum success and IOP control.
How does the procedure work? There are many GDDs but they have a similar design which consists of a silicone tube that extends into the anterior chamber of the eye. Your doctor will place the silicone tube, which is attached one or more tiny plates, in your eye. Working similarly to a heart stint, the tube shunts aqueous humor to the plate(s) which is/are sutured to the white portion of your eye called the sclera. The drained fluid collects in a blister or bleb in the conjunctiva and then is absorbed into the blood vessels on the surface of your eye. The device is usually not visible and is hidden under the eyelid.
Preparing for GDD Surgery
Your surgeon will go over your current medications and advise you accordingly. If you are taking blood thinners such as Coumadin, you will have to get your levels checked two weeks before the procedure. Often GDD surgery will be done under general anesthesia but under certain circumstances local anesthesia will be used.
What Happens during GDD Surgery?
After your anesthesia has been administered, your surgeon will make a small incision in the conjunctiva to allow adequate exposure for the plate. The implant will be anchored between two rectus muscles and will be secured with sutures. The entire surgery will take about two hours.
What Happens after GDD Surgery?
You may experience redness or swelling after the surgery, and your eyelid may droop a bit. This will go away after a few weeks. You will be seen by your doctor the day following the GDD implant surgery. Often, you will be given a topical antibiotic and steroid to use four times daily for 4 to 6 weeks.
Most patients take about two weeks off work, but if your job is manual labor you will want to take more time to recuperate. During the recovery period, you should avoid bending down as this puts tremendous pressure on the eye. You should also avoid activities such as swimming, tennis, running and any contact sports. You will probably be seen again one week after surgery, and after that, your doctor will determine the frequency of subsequent visits. You may or may not have to continue your glaucoma drops after surgery, but your doctor will discuss this with you at your post-op appointments.
What are the Outcomes of GDD Surgery?
GDDs have proven to be extremely effective in controlling IOP and have a low risk of surgical failure. Sometimes, GDDs are often preferred over trabeculectomy because there is a lower risk of infection and low eye pressure called hypotony. This surgical method is especially effective in patients whose IOP cannot be controlled with traditional surgery or who have previous scarring.
Contact one of our treatment centers to make an appointment to discuss a traditional glaucoma treatment plan that is best for you. Your vision is one of your most precious possessions, so call a center near you to meet with one of our professionals.