Glaucoma & Treatment

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OVERVIEW

Glaucoma is a disease that can slowly destroy the delicate nerve fibers that carry signals from the back of the eye to the brain. While glaucoma typically affects people age 40 and older, it can strike at any age. Generally, high pressure within the eye is responsible for the damage, but even patients with normal pressure can experience loss of this important nerve function due to glaucoma. Glaucoma is called “the silent thief of sight” as there is no pain or noticeable change in vision during the early stages of this disease.

Most of the time, patients cannot feel high pressure or notice vision loss because it occurs from the periphery first. Therefore, patients may not take notice until it is too late. The goal of treatment is to prevent further vision loss.

Treatment needs to occur before vision is lost as optic nerve damage cannot be reversed. This is why it is important to schedule yearly eye exams. Especially if you have a family member with glaucoma as family history is the highest risk factor.

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PRIMARY-OPEN ANGLE GLAUCOMA

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ANGLE CLOSURE GLAUCOMA

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NARROW ANGLE GLAUCOMA

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*Drs. Del Negro & Senft have an ownership interest in Seashore Surgical Institute.

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Glaucoma Treatment

Treating Glaucoma with Medication

Various eye drops and oral medications can sometimes be used when treating glaucoma. They work either by increasing outflow or reducing production of fluid in the eye, or both. One of our doctors will discuss your potential candidacy during your visit.

Treating Glaucoma with Trabeculectomy

Dr. Del Negro may recommend a surgical procedure called “trabeculectomy” if medication, eye drops, laser, or another procedure have not been effective in lowering the pressure within your eye.

This procedure helps to lower pressure by altering the eye’s drainage system and creating a controlled leak of fluid. Essentially, Dr. Del Negro will create a new pathway for fluid to drain from the eye when the usual pathways have become blocked. The fluid exiting the anterior segment of the eye collects in a tiny pocket (called a bleb) where it is then re-absorbed naturally by the body. This lowers the pressure within the eye protecting the optic nerve from further damage done by high pressure.

Anti-metabolite medications (i.e. Mitomycin C), may be applied at the time of surgery to reduce the risk of scar tissue, a common cause of failure in glaucoma surgery. When used with other medications that reduce inflammation, the success rate of glaucoma surgery is greatly improved.

During the weeks following the surgery eye drops are used to prevent inflammation and infection.

Treating Glaucoma with Ahmed Valve (Tube Shunt)

If eye drops and other medications prove ineffective, or if you cannot tolerate side effects from medications, Dr. Del Negro may recommend the Ahmed valve procedure— the most commonly used type of shunt. The purpose of this outpatient procedure is to preserve vision by controlling the pressure in the eye.

This glaucoma surgery uses a tube shunt, which is a flexible glaucoma drainage device that is implanted in the eye to divert fluid from the inside of the eye to an external reservoir.

The Ahmed Glaucoma Valve or Tube Shunt is a drainage implant made of silicone, a material that will not break down in the body. During surgery Dr. Del Negro will expertly conceal and protect the implant with your own tissue so the onlooker cannot see the device but it is functioning to keep the pressure down within the eye.

The small device resembles a miniature computer mouse with a tube at the end of it. The tube portion is inserted through the sclera into the front of the eye, or anterior chamber, while the rest of the implant sits comfortably on the surface of the eyeball underneath the conjunctiva and is hidden by the eyelid. The fluid that collects is then absorbed by the body and transported out of the eye cavity.

Am I a Good Candidate?

Traditionally, tube shunts were used to control eye pressure in patients in whom traditional eye surgery such as trabeculectomy had previously failed, or in patients who have had previous surgeries or trauma that caused substantial scarring of the conjunctiva, as a last line of defense.

The valve function of a glaucoma drainage device limits the flow of eye fluid in one direction, which puts a limit to how low the eye pressure can drop. However, in many patients, supplemental glaucoma medications such as eye drops are still required after an Ahmed valve is implanted to keep eye pressure within the normal range. Dr. Del Negro will monitor your progress and customize your treatment accordingly.

Treating Glaucoma with Peripheral Iridotomy

Peripheral Iridotomy is a laser procedure that is recommended most of the time to protect the eye from an acute attack of angle closure glaucoma. It may also be used to treat angle closure glaucoma once it occurs. When the eye’s iris blocks the drainage of fluid, Drs. Del Negro, Senft, or Glatman use a laser to create a tiny hole in the iris to improve drainage.

Treating Glaucoma with ECP (Endoscopic Cyclophotocoagulation)

Performed during the cataract procedure, ECP is both a safe and effective means of reducing the amount of pressure present in the eye. The objective of the combined cataract/ECP procedure is to lower eye pressure and reduce the need for glaucoma medication.

After Drs. Del Negro, Senft, or Glatman remove the cataract by creating small incisions, he/she would then insert the endoscopic laser probe through those same incisions to begin the ECP portion of the procedure. Once inside the eye, the probe is carefully guided by your surgeon. Drs. Del Negro, Senft, or Glatman will use a video monitor to locate the cillary process tissue in order to deliver laser treatment to that specific tissue. This additional step adds a negligible amount of time to the overall cataract procedure.

The need to reduce or eliminate your glaucoma drops will be determined by your surgeon as he/she continues to monitor your progress following the initial procedure. No additional post-op appointments are required outside of the usual cataract post-op regimen.

Treating Glaucoma with Micropulse Laser Trabeculoplasty (MLT)

Indications - The Micropulse Laser Trabeculoplasty surgeries are used for patients with open angle glaucoma. The laser is utilized to treat the drainage system of the eye known as the trabecular meshwork. Treating this area of the natural internal draining system is designed to improve the outflow of fluid from the eye.

This type of laser surgery will be effective in some patients, but not others. Your response is determined by the type of glaucoma you have and the specific structures found in your drainage system. Drs. Del Negro, Senft, or Glatman cannot predict how well the laser will work before the laser surgery.

Procedure - The laser machine is similar to the examination microscope that the Ophthalmologist uses at each visit to look into your eyes. The laser itself makes little noise and flashes a light about as bright as the flash on a camera. Nearly all patients find the procedure comfortable and pain free. The procedure generally takes 10 – 20 minutes.

Medications - You may need to use drops both before and after the laser treatment. As the pressure in the eye may temporarily go up after laser treatment, you will likely need to have your pressure measured after the laser surgery. If the pressure does elevate, you may need additional medicines to lower the pressure, which will be administered in the office. Rarely, the pressure in the eye could elevate to a level that may require surgery in the operating room to relieve the glaucoma. You need to use drops after the laser to help the eye heal correctly. In most cases you will be asked to continue your other glaucoma medications after the laser surgery. Your surgeon will notify you if there are exceptions to continuing your medications.

Risks and complications - Glaucoma laser surgery may be followed by complications. Most patients notice some blurring of their vision after laser surgery. This generally clears within a few hours. The chance of your vision being permanently affected by this laser is very, very small. Although rare and unusual, there may be bleeding within the eye, inflammation, cataract and increase in the pressure in the eye requiring different and more extensive treatment. It will take several weeks to determine how much of your eye pressure will be lowered with this treatment. You may require additional laser surgery to lower the pressure.

Treating Glaucoma with Micro-stent

Micro-invasive Treatment Approach with OMNI® (Canaloplasty and Goniotomy)

Plumbing Analogy for the Outflow System That Drains Fluid From The Eye:

A sink "drain" has:

Cover- Trabecular Meshwork
Pipes Under The Sink- Schlemm’s Canal
Pipes Heading Out Of The House- Distal Collector Channels

*Just like in a clogged sink, in Glaucoma, there can be resistance in any or all of the 3 parts of the drain

Treats Three Points of Resistance:
Trabecular Meshwork, Schlemm’s Canal, Distal Collector Channels

Dr. Del Negro will inform you which procedure below you are a candidate for (or both) and either use a pre-existing incision if the procedure is being done at the time of cataract surgery or he will simply make a small incision in the cornea to access the “natural drain.”

Two Implant-Free Procedures

Viscoelastic Delivery:

Dr. Del Negro will use the cannula of the OMNI device to insert a thin tube (microcatheter) into the main pipe of the drain (Schlemm’s Canal) to deliver a small amount of elastic fluid (viscoelastic).

Trabeculotomy:

Dr. Del Negro can also thread the tube (microcatheter) into the main pipe (Schlemm’s Canal) and remove the first layer of potential resistance, Trabecular meshwork which is the top of the drain.