Although we know eye pressure is not the only cause of glaucoma, at present our only way to halt any further glaucoma damage is by controlling the pressure. All the different treatment modalities in principle work in 2 ways: by decreasing the production of aqueous fluid, or by increasing its outflow in order to lower the eye pressure.
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There are a number of different topical medications (drops) available to help control the eye pressure and this, in most cases, tends to be the first line of treatment. They are available in both preserved (one bottle) or preservative free (single use containers) formats and vary in the number of times per day they need to be used. Most of the drops are very safe to use with minimal if any systemic or eye side effects but we will discuss which drop would be most suitable for you at your consultation.
Depending on the type of glaucoma you are diagnosed with, there are a number of laser treatment modalities that can be used to lower intraocular pressure.
For open angle glaucoma, in some patients it might be worthwhile to consider Selective Laser Trabeculoplasty (SLT) to control the eye pressure. SLT has been available for over 10 years and the recent LIGHT trial published in the Lancet highlights its benefits. Patients are seen in a clinic setting and achieve the desired intra-ocular pressure reduction without the need for ongoing drops in 75-80% cases. The effects of SLT can last up to 5 years and the treatment can be repeated if needed. Any side effects of the treatment are minimal and very rare.
Selective laser Trabeculoplasty is an outpatient procedure and performed using a machine very similar to the examination slit lamp. Topical anaesthesia and drops to reduce eye pressure are instilled into the eye prior to the treatment. A small special contact lens is then placed on the eye with a coupling agent (usually a jelly-like sterile lubricant such as viscotears) to keep the eye open during the duration of the treatment and help focus the laser. The treatment usually takes 10-15 minutes per eye and both eyes can be treated in the same setting. After the treatment is complete, the vision can be blurred (usually no more than 24 hours). You will be given anti-inflammatory drops to use for one week after the laser and then a clinic appointment 3-4 weeks later is arranged to check if the laser has been successful. Side effects of the laser include failure (25%), transient blurring of the vision, and on-going inflammation (1%). The effects of SLT do not last indefinitely and on average will need to be repeated after 2-3 years.
For closed-angle glaucoma, we would recommend laser peripheral iridotomy as a treatment option. This is also a good option for people who don’t wish to have clear lens extraction.
A YAG laser is essentially used to make a 50-100 micron hole in the iris (the coloured part of the eye) to create a new channel for the fluid to pass through. This opens up the drainage angle and hence lowers the eye pressure. This is an outpatient procedure and is performed using a machine very similar to the examination slit lamp. Topical anaesthesia and drops to reduce eye pressure are instilled into the eye prior to the treatment. A small special contact lens is then placed on the eye with a coupling agent (usually a jelly-like sterile lubricant such as viscotears) to keep the eye open during the duration of the treatment and help focus the laser.
The treatment usually takes 10-15 minutes per eye and both eyes can be treated in the same setting. After the treatment is complete, the vision can be blurred usually for no more than 24 hours and the eye can look slightly red. You will be given steroid drops to take for 1 week after the laser and will be booked into a clinic appointment 3-4 weeks later to check if the laser has been successful. The success rate of the laser is over 95%.
At the time of the treatment, you may feel some discomfort and some blurring but these symptoms usually subside within 24 hours.
During your consultation, you will be informed of the possible side effects of the laser. Although side effects are very rare, they include failure (5%); a spike in the eye pressure that then requires further treatment (1%); ongoing inflammation, and visual disturbance due to light going through the laser hole (1:200 cases).
For both types of glaucoma, laser to the ciliary body can be used to lower the eye pressure by reducing the amount of production of fluid. The laser can be delivered externally to the eye or internally using 2 different laser modalities.
For patients where other types of treatment haven’t been successful, cyclodiode laser treatment can be used to help control fluid production (aqueous humour) which then reduces the pressure within the eye. Cyclodiode laser treatment can also be useful for patients with painful symptoms in non-seeing eyes, and usually will remove the pain completely and also remove the need for eye drops.
The treatment is usually performed as a day case under local anesthetic. A laser sends pulses of energy through the eye to the ciliary body, which then reduces the fluid production.
This is one of the newer forms of laser to the ciliary body. It involves the interrupted application of short diode laser pulses to the Trabecular Meshwork (TM) – the area of spongy tissue that drains the fluid from the eye. Microseconds interrupt the continuous wave and so it prevents build up of thermal energy and this makes the laser generally more comfortable. Much like SLT, the reduction in pressure is achieved by increasing the outflow of fluid through the eye, as opposed to reducing the fluid production.
The laser is performed in the operating theatre, under local anesthesia. It takes 10-15 minutes to complete the treatment and the patient will be given a combination of antibiotic and anti-inflammatory drops to take for 2 weeks. The effects of the laser are normally detected at the first clinic appointment, which is usually at 1-2 weeks. Side effects include discomfort during the procedure, and inflammation (red painful eye) afterwards but both these are mild and resolve within a day or two after the laser.
This is essentially the same surgical procedure as a standard cataract operation but done primarily to open the drainage angle. Taking the natural lens out and replacing it with a slim line intraocular lens, hence curing primary angle closure, will permanently open the angle. The treatment is successful 95% of the time. Side effects include post-operative inflammation, failure, and intra-operative complications that may mean a second operation. The risk of blindness is 1:2000 and is usually due to an infection after the surgery. The new intraocular lens does have a refractive power, which means it can correct for any glasses prescription the patient was already wearing.
This refers to direct visualisation of the drainage angle in the operating theatre. It can be done as a stand alone procedure or usually combined with cataract surgery. It is recommended in patients with angle closure. The procedure involves making a small incision in the cornea (2mm in size) and placing a special lens onto the eye in order to assess the angle. If there is any evidence of the angle being closed (i.e. the iris is blocking the drainage pathway), this can be mechanically broken. The procedure usually takes 10-15 minutes and the patient is discharged home on topical antibiotics and steroid drops. Follow up is normally at one week where we assess if the treatment has been successful in permanently opening the drainage angle.
The istent is a titanium implant and is considered to be the smallest implant that can be placed in the human body. The stent has recently undergone modification and re-named as the istent G2 inject (the previous version was known as the G1). The insertion of the istent is done in the operating theatre, through a small corneal wound. The injector has 2 istents pre-loaded and both are placed directly into the drainage angle at the same time. This stent is both FDA and NICE approved and has been in wide use worldwide for many years. It is very safe and an effective method to lower eye pressure in patients with mild open angle glaucoma. It can be done as a standalone procedure or in combination with cataract surgery.
Trabeculectomy achieves pressure reduction in the eye by creating a new outflow for fluid to drain out through the eye. A small hole is made in the eye, which is then covered by a small trap-door to control the flow of fluid. The fluid drains to a small reservoir called a bleb, which is hidden from view below the eyelid – and is rarely felt by patients after surgery.
The procedure is successful in 95% of cases, and as with other glaucoma treatments can halt the worsening of eyesight, but cannot restore it.
This involves the insertion of a plastic tube inside the anterior chamber of the eye to create a new outflow pathway for the aqueous fluid and so lower the eye pressure. The surgery can take up to 2 hours and will require general anaesthesia. There are 2 different designs of the tube implant: the valved (ahmed tube) and non valved (Baerveldt). Lower eye pressure can be achieved by the non-valved but that also means there is a slightly higher chance of the pressure dropping too low (hypotony). Success rate is 95% and it carries essentially the same risks as a trabeculectomy. It is used in cases where a trabeculectomy has failed or sometimes as first line filtration surgery if it is considered to be the better option.
OCT, Visual Fields, Pachymetry – £500 (or £200 each if performed individually)
SLT Laser or Iridotomy Laser – £650 for one eye & £950 for both eyes
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