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Glaucoma

Glaucoma Care

Glaucoma

All of the physicians at Lexington Eye are skilled in treating patients with glaucoma. They are able to diagnose and treat the many types of glaucoma that present to our practice. For patients with advanced disease or for those who require more advanced laser or surgical therapy, we also have three glaucoma specialists: Dr. James Umlas, Dr. Mandi Kunen, and Dr. Matthew D. Lazzara.

At Lexington Eye Associates, we have the most advanced diagnostic tools available to help to determine whether a patient has glaucoma, to assess the type of glaucoma that may be present, and also to monitor the disease over time. These tools include the latest software for visual field testing to assess peripheral vision, digital photography to image the optic nerve, and ocular coherence tomography (OCT) to further evaluate the health of the optic nerve and monitor changes in the nerve.

Your physicians at Lexington Eye Associates are familiar with the latest medical, laser, and surgical techniques in treating glaucoma. Most importantly, they are dedicated to providing their glaucoma patients with continued support, education on their condition, and personalized care throughout their treatment.

Types of Glaucoma

In cases of open-angle glaucoma, if one were to look at the angle or the drainage system of a patient’s eye, it looks “open.” This is the more common type of chronic glaucoma, where patients generally do not know they have the disease. It is usually diagnosed on routine examination by finding an elevation of intraocular pressure (the pressure within the eye), or by typical appearance of the optic nerve. If your doctor suspects glaucoma, they may ask you to return for Visual Field testing to assess your peripheral vision. You will have a photograph taken of the optic nerve to document its appearance, and also OCT testing to assess the overall health of the optic nerve.

Risk Factors for Open-Angle Glaucoma

The following groups have an increased risk for open-angle glaucoma: males, African-Americans, those with high blood pressure, diabetes, a history of steroid use or trauma, near-sightedness, and a family history of glaucoma. Those with elevated intraocular pressure and thin corneas also have an increased risk for developing glaucoma.

The other broad category of the glaucomas is narrow angle glaucoma. Although open-angle glaucoma is more prevalent in the United States, narrow-angle glaucoma is still quite common. Narrow-angle glaucoma can be further divided into chronic narrow-angle glaucoma and acute angle-closure glaucoma.

The common feature in the narrow-angle glaucomas is the fact that the anterior chamber, or the front of the eye, is quite shallow. This occurs because the iris and the cornea are in close proximity. The junction of the iris and cornea, or the “angle”, is where the eye’s internal fluid normally drains. If this angle closes, the pressure inside the eye can become elevated, resulting in damage to the retinal cells and optic nerve.

Narrow angles can be diagnosed by a test called gonioscopy on a routine eye exam in the ophthalmologist’s office. The eye is given an anesthetic eyedrop and a small contact lens is gently placed on the cornea, allowing the eye doctor to assess the depth of the front of the eye and determine the risk for developing acute or chronic angle closure glaucoma. This is a quick and painless test done at the microscope.

There are other newer types of non-contact and ultrasound methods for determining the depth of the anterior chamber, but it is not yet clear how these tests will ultimately be utilized in the assessment of narrow angles.

If your ophthalmologist finds that you have a sufficient narrowing of the angle that makes it likely the angle will close in the future, he or she will suggest an iridotomy to prevent angle closure. This is a quick and safe out-patient procedure that utilizes a laser to create a very small opening in the iris and allows the angle to stay open.

Following the procedure, your ophthalmologist will prescribe anti-inflammatory drops to be used for a few days. Usually, this procedure will open the angle; however, in some cases, further treatment may be necessary to completely open the angle.

Risk Factors for Narrow-Angle Glaucoma

People at high risk for angle closure glaucoma include Asians and far-sighted people, among other risk groups. The risk increases with advancing age due to enlargement of the lens inside the eye. In a person with a narrow angle, certain medications can potentially start an attack of angle closure glaucoma. These include certain cold medications, antidepressants, scopolamine patches, and eyedrops to dilate the pupils in an eye doctor’s office. Be sure to check any warnings on the package inserts of medications. If you have glaucoma or are at risk, it is a good idea to check with your ophthalmologist whether certain medications pose additional risk.

In acute angle closure glaucoma, the iris and cornea can suddenly come in contact, resulting in a very rapid rise in eye pressure. This typically occurs in one eye and is usually quite painful, sometimes even inducing nausea and vomiting. People sometimes have an intense ache in and around the eye, and it can be confused for a severe headache. The vision often becomes very blurry, the eye is red, and the pupil often reacts poorly. The classic symptom is seeing halos around lights. The onset of symptoms can sometimes evolve in less than an hour, but often happen over several hours.

Acute angle closure glaucoma is an emergency because prolonged periods of high eye pressures can cause irreversible damage to the optic nerve. You must call your eye doctor immediately if any of these symptoms or signs are present. The initial treatment often includes eyedrops and oral medications to lower the eye pressure. However, the definitive treatment is laser iridotomy. This involves using a laser to make a small opening in the peripheral iris, which usually results in rapid lowering of the pressure.

It is important to treat the other eye in rapid succession, because it is at very high risk of developing the same condition. Typically, the laser treatment is curative, but in some cases, there is irreversible damage to the drainage system of the eye, and eyedrops or even surgery to lower pressure is required.

Chronic angle closure glaucoma refers to a condition in which the anterior chamber gradually narrows over a much longer time, sometimes resulting in a gradual rise in eye pressure. On occasion, the slow closure of the angle results in permanent damage to the drainage system of the eye. Often, people have no symptoms, and this is discovered coincidentally on an eye exam. The treatment is also laser iridotomy, but at times, patients may require eyedrops or other treatment to control the glaucoma.

Glaucoma Treatment Options

Treatment for glaucoma ranges from medical therapy to laser treatment to surgery. The goal of therapy is to lower the intraocular pressure and maintain the health of the optic nerve.

Most glaucoma patients are controlled with topical medication: eye drops that are applied once or twice daily. Although most drops are well-tolerated, as with any medication, there can be possible side effects or allergy. If you experience any adverse effect while taking glaucoma medication, it is important to discuss this with your physician. Compliance, or the regular application of glaucoma drops, is vital to the success of your glaucoma therapy.

Often, laser treatment is used in addition to medical therapy. The laser therapy for open-angle glaucoma is called laser trabeculoplasty or Selective Laser Trabeculoplasty (SLT). In this treatment, laser energy is delivered to the drainage system of the eye, the trabecular meshwork. This treatment is extremely safe and well-tolerated by patients.

The SLT technique is very gentle, and studies show that it does not damage the tissue of the drainage system. It is performed at our surgery and laser center, Surgisite Boston. The treatment takes only minutes to apply, and there is usually no discomfort felt by the patient. Following the laser treatment, one usually continues any existing glaucoma drops. After several weeks, you will return to have the intraocular pressure measured and the success of the procedure assessed.

If medical and laser therapy are not sufficient in treating the glaucoma, surgery can be performed. The most common type of glaucoma surgery is the trabeculectomy. In this procedure, a small area of the drainage system (the trabecular meshwork) is removed. A flap is made in the wall of the eye, the sclera, through which the fluid from within the eye can pass, decreasing the pressure within the eye. The fluid flows through the scleral flap into a space underneath the conjunctiva, and this space is called a bleb.

In a second type of surgery is called a tube shunt, or glaucoma drainage device, a small tube is placed through the sclera, or the wall of the eye, into the anterior chamber of the eye. Similar to the trabeculectomy, excess fluid is able to pass out of the eye and collect in a reservoir, the bleb, underneath the conjunctiva.

With both types of glaucoma surgery, frequent visits are required in follow-up care to monitor the intraocular pressure and the healing of the eye. There is often mild irritation due to the manipulation of the eye tissue and also due to sutures on the surface of the eye. With time, these symptoms improve.

There are several newer glaucoma procedures such as trabectome and canaloplasty. However, the long-term efficacy of these has not been demonstrated, and it is not clear what place these procedures have in the decision tree of glaucoma treatment.

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