Glaucoma is a disease in which high pressure inside the eye causes damage to the optic nerve, the nerve in the back of the eye that controls our vision. Glaucoma is one of the leading causes of blindness in the United States and is the second leading cause of blindness in the world. Elderly individuals, those with a family history of glaucoma, and African Americans are at a higher risk for glaucoma. There is also evidence that patients have a higher risk of glaucoma if they have a history of high eye pressure, large optic nerves, diabetes, high blood pressure, nearsightedness, long-term use of steroids, or trauma.

Elevated eye pressure is usually due to problems with the natural internal drainage systems of the eye. The eye constantly produces an internal fluid called aqueous humor that circulates in the front of the eye and functions to bring essential nutrients to the eye. Maintenance of normal eye pressure is dependent on the normal constant drainage of aqueous humor as it is produced. When the drainage system does not work properly, the aqueous humor builds up within the eye, causing elevated eye pressure.

Classically, early stages of glaucoma are characterized by damage to the nerve fibers that control peripheral (or side) vision. Individuals with early stages of glaucoma are often able to compensate for problems with peripheral vision by unconsciously turning their head from side to side or using one eye to compensate for the other. In addition, the majority of individuals with glaucoma will not experience pain with elevated eye pressure. As a result, most individuals with glaucoma will experience virtually no symptoms until they reach advanced stages of the disease. In late stages of glaucoma, the nerve fibers that control central vision are affected, and individuals will begin to notice their vision loss. Because vision loss from glaucoma is permanent, it is critical for individuals to get treated for glaucoma as early as possible.

There is no cure for glaucoma, but research has shown that the progression of glaucoma can be slowed by decreasing eye pressure. Currently, we are able to reduce eye pressure by using a combination of medications, laser, and if needed, surgery.

How to get tested?

During a routine eye examination, your ophthalmologist can check your vision, eye pressure, and examine your optic nerve for signs of glaucoma. Additional tests of your peripheral vision and optic nerve may also be performed to help assess your risk of glaucoma.

SLT

Selective laser trabeculoplasty, or SLT, is an advanced laser treatment option for individuals with open-angle glaucoma. In SLT, the laser selectively targets treats pigmented cells in the drainage tracts of the eye. SLT lowers eye pressure by improving the drainage of fluid from the eye. Ophthalmologists often use SLT in conjunction with or in place of using topical medications to lower eye pressure.

Surgical Procedure

SLT is performed in the office, and the laser takes only a few minutes to perform. Prior to the procedure, eye drops will be given to prepare the eye for treatment. The laser applications are made through a special microscope, similar to the one used for eye examinations. A lens coated with a gel is placed on the eye during treatment, resulting in blurred vision for a short time afterwards. Anti-inflammatory eye drops may sometimes be used for a few days after SLT treatment and some patients may notice a mild sensitivity to light for a few days.

Complications

SLT rarely causes complications. In some cases, inflammation, eye pressure elevation, ocular pain or photo sensitivity may occur. SLT is not always effective, but it usually will not make glaucoma worse.

LPI

Laser peripheral iridotomy, or LPI, is a laser treatment used to treat or prevent angle-closure glaucoma and individuals at risk for angle-closure glaucoma with anatomically narrow angles. In individuals with narrow angles glaucoma, the drainage tracts of the eye are at risk of becoming partially or completely blocked by iris (the colored part of the eye). LPI is performed to prevent the drainage tracts of the eye from being blocked by iris. This protects the eye from sudden increases in eye pressure and helps prevent scar formation in the drainage tracts of the eye.

Surgical Procedure
LPI is performed in the office, and the laser usually takes approximately 10 minutes. Prior to the procedure, eyedrops will be given to prepare the eye for treatment. The laser applications are made through a special microscope, similar to the one used for eye examinations. A lens coated with a gel is placed on the eye during treatment, resulting in blurred vision for a short time afterwards. During the laser, a small openinghole called an iritotomy is made in the iris to create a new pathway for the aqueous fluid to drain from the eye. The new drainage hole opening allows the iris to fall back into its normal position, restoring balance between fluid entering and leaving the eye. Almost all patients find the procedure comfortable, but some patients report a mild pinching sensation during the laser treatment. Anti-inflammatory eyedrops are used for a few days after LPI treatment to help the eye heal. Some patients may notice a mild sensitivity to light for a few days.

Complications
LPI rarely causes complications. The chance of your vision being permanently affected from this laser procedure is small. Risks from this procedure, however, include inflammation, cataract formation, bleeding, double vision, perception of light through the iridotomy, scar formation between the iris and lens of the eye that changes the shape of the pupil or prevents the pupil from moving correctly, late closure of the iridotomy that requires repeat laser surgery to open the hole again, and (rarely) damage to the cornea or retina from the laser light. Patients with very thick irises may sometimes need two treatments to achieve the goals of the procedure.

Trabeculectomy
Glaucoma surgeries are performed when medications or lasers are not sufficient to lower eye pressure to safe levels.

Trabeculectomy is performed as an outpatient procedure in an ambulatory surgical center or in a hospital operating room. Local anesthesia, supplemented with intravenous sedation, is used to keep the eye comfortable during the procedure. An anesthesiologist or anesthetist is present during the surgery to monitor vital signs and to administer any additional medications needed to make the patient comfortable. A feeling of pressure may be noted during surgery, but there is usually no pain during the procedure.

Once the eye is anesthetized, the eye and the area around the eye is cleansed with an antiseptic solution. A device is used to hold the eyelids open so that the patient does not have to worry about keeping the eye open during the surgery. A small flap is created in the sclera (the white part of the eye), and a small hole is made in the trabecular meshwork (the drainage system of the eye) beneath the flap. Often, an agent called Mitomyin-C is applied to the sclera during surgery to prevent closure of the newly created opening. Mitomycin-C has both anti-scarring and anti-tumor properties. In eye surgery, small amounts of Mitomycin-C are used to take advantage of its anti-scarring properties.
After surgery, fluid in the eye flows through the newly-created opening beneath the flap and collects between the sclera and the conjunctiva (the clear membrane that usually covers the sclera). The fluid pocket creates a small bump on top of the eye, but it is usually covered by the upper eyelid. Most patients cannot feel the bump on top of the eye, but can feel temporary stitches in the eye for a few weeks after surgery.

Postoperative Care
It is important that patients are seen regularly after trabeculectomy surgery to ensure proper healing after surgery. In most cases, this means a visit to the doctor every week for the first three to four weeks following surgery. It is normal for the vision to be slightly blurry for the first month after trabeculectomy, and sometimes a change in prescription lenses may be necessary after surgery. Eyedrops are used to minimize inflammation and prevent infection for approximately one month after surgery.

Complications
Risks of trabeculectomy include pain, bleeding, infection, cataract, or loss of vision. Additional surgery may be needed if the eye pressure remains too high or becomes too low after trabeculectomy.

Ahmed Glaucoma Valve Implantation
Glaucoma surgeries are performed when medications or lasers are not sufficient to lower the intraocular pressure of the eye.

Ahmed glaucoma valve implantation is performed as an outpatient procedure in an ambulatory surgical center or in a hospital operating room. Local anesthesia, supplemented with intravenous sedation, is used to keep the eye comfortable during the procedure. An anesthesiologist or anesthetist is present during the surgery to monitor vital signs and to administer any additional medications needed to make the patient comfortable. A feeling of pressure may be noted during surgery, but there is usually no pain during the procedure.

Once the eye is anesthetized, the eye and the area around the eye is cleansed with an antiseptic solution. A device is used to hold the eyelids open so that the patient does not have to worry about keeping the eye open during the surgery. The Ahmed glaucoma valve implant is a small silicone tube connected to a small round reservoir. In Ahmed glaucoma valve surgery, the tube is placed in the front of the eye to allow drainage of fluid from the eye. The reservoir of the Ahmed glaucoma valve is attached to the sclera (the white part of the eye) and covered with conjunctiva (the clear membrane that covers the sclera). During the procedure, a pericardial graft, a virally-inactivated and sterile human tissue, is placed over the tube to protect it. After the Ahmed glaucoma valve implant is placed, fluid flows from the tube to the reservoir and collects between the sclera and conjunctiva. The fluid pocket creates a small bump on top of the eye which can be seen if the eyelid is lifted, but is otherwise usually covered by the upper eyelid.

Postoperative care
It is important that patients are seen regularly after glaucoma surgery to ensure proper healing after surgery. In most cases, this means a visit to the doctor every one to two weeks for the first three to four weeks following surgery. It is normal for the vision to be slightly blurry for a few weeks after glaucoma surgery, and sometimes a change in prescription lenses may be necessary after surgery to achieve best-corrected vision. After surgery, patients are given eyedrops for approximately one month to minimize inflammation and prevent infection.

Complications
Risks of trabeculectomy include pain, bleeding, infection, exposure of the Ahmed glaucoma valve implant, cataract, or loss of vision. Additional surgery may be needed if the eye pressure remains too high or becomes too low after Ahmed glaucoma valve implantation.