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Treatment of glaucoma, both medically and surgically

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Glaucoma is one of the leading causes of loss of vision in the United States, especially for people over the age of 65. Significant loss of sight is often preventable with early detection and treatment. However, once significant loss has occurred prior to detection, there is no way to reverse the condition.

Glaucoma is basically a disease of the optic nerve. The optic nerve carries the images seen by the eye to the brain. Damage to the optic nerve results in gradual increase of pressure within the eye, leading to the progressive and irreversible loss of vision if it is not treated. The optic nerve is made up of roughly 1.2 million small nerve fibers that originate from the retinal tissue of the eye and can be related to the film in a camera. It receives the image that the eye sees and
transmits the image to the brain.

Glaucoma is basically excessive pressure within the eye. A clear liquid called aqueous humor circulates within the anterior chamber (the area between the cornea and the pupil). It is necessary for the proper nourishment and health of the anterior structures of the eye. Under normal circumstances, the constant production of this clear liquid and the drainage of the liquid from the eye through a microscopic drainage system are balanced. If the drainage is compromised for any reason, excessive fluid buildup occurs, resulting in increased pressure and eventual damage to the optic nerve. This damage can lead to blindness if not treated.

There are numerous types of glaucoma. The most common form is called chronic open angle glaucoma and is a direct result of aging. For whatever reason, the drainage angle of the eye gradually loses its ability to filter the fluid out of the eye. Thus, increasing pressure within the eye can result in damage to the optic nerve. Of the adult population with glaucoma in the United States, 90% will have this form of glaucoma.

Angle closure glaucoma is a form of glaucoma that comes on suddenly in the vast majority of people, resulting in a rapid increase of pressure within the eye. It is caused by closure of the drainage angle, resulting in severe pain, headache, redness of the eye, decreased vision, and in most cases nausea and vomitting. It is not uncommon for a person having an acute angle closure glaucoma episode to be treated for a gastro-intestinal problem, with the eye never being addressed until days later. A person with these symptoms need to contact an Ophthalmologist immediately. Unless the episode is treated quickly, blindness can result.

There are numerous other forms of glaucoma. Diagnosis is made possible only by a thorough eye examination, which would involve measuring the intraocular pressure, inspecting the drainage angle of the eyes, evaluating the health of the optic nerve, and conducting a visual field test, if indicated, to measure peripheral vision. Elevated eye pressure alone does not mean a patient has glaucoma.

Who would be at risk for developing glaucoma? If a person has a positive family history of glaucoma, he or she would be predisposed to the disease. A person over the age of 65 as well as a person of African-American ancestry are at increased risk. Past injury to the eye is another risk factor. An annual examination for such a person would be highly recommended. If glaucoma is diagnosed or suspected, periodic examinations are vital to monitor damage to the optic nerve.

Treatment depends on the type of glaucoma present. A number of eye drop medications designed to maintain the proper pressure in the eye as well as rarely used pills can be prescribed. Laser and surgical options are available to help prevent further damage. A person diagnosed with chronic open angle glaucoma will have examinations every three to four months to monitor the disease and discuss options.

Eye drop medications are the first approach in controlling the glaucoma in most patients. Once these medications can no longer hold the progression at bay, surgical options are discussed. The topical eye drops are designed to either decrease the production of the fluid, increase the outflow facility, or a combination of both. The frequency of use will depend on the type of eye drop prescribed. It is quite important for the patient to understand that compliance is mandatory in order for the medication to work properly and effectively. Failure to comply with the instructions given for use of the medication can result in further loss of vision. Some patients may experience side effects for a brief period of time. These would include a stinging or burning sensation, redness to the eyes, changes in pulse or heart rate, changes in energy levels, blurred vision, headaches, difficulty breathing in patients with chronic obstructive pulmonary diseases such as asthma and emphysema. That is why it is important, before prescribing any of the topical medications, to have a thorough medical history and a list of medications including the dosage on hand.

When medication no longer controls the intraocular pressure in a normal and safe zone, laser surger can be effectively performed in some individuals with glaucoma. In patients with chronic open angle glaucoma, laser surgery can be used to open the drainage channels. This procedure is called laser trabeculoplasty and is quite effective. It is not a substitute or replacement for topical medications, and in most patients the procedure is an additive for reducing the intraocular pressure and keeping it at a safe level.

Patients with acute angle closure glaucoma are treated with a laser that creates a hole in the iris, or colored part of the eye, to improve the flow and re-establish normal flow from the back of the eye where the fluid is made into the front of the eye where the fluid flows out. This procedure is called a laser iridotomy, and is quite effective and safe.

These laser surgeries are non-invasive. There are no incisions or sutures involved. In the event that a patient is no longer controlled on topical medications and/or laser surgery, an operative procedure would become necessary. The surgical procedure of choice at Moulton Eye Clinic is the placement of a glaucoma shunt, that effectively filters fluid from the anterior (front) chamber of the eye through a small tube underneath the mucous membrane of the eye and into a drainage area, where the fluid is absorbed by the body. Once again, this is an additive therapy for helping control the pressure and is not necessarily a substitute for eye medications.

It is very important to note that the patient has the ultimate responsibility in helping control their glaucoma after they leave our office. Patients should never stop taking their medication or changing them without first consulting their eyecare professional. Examinations every three to four months are critical to help monitor the pressure within the eye and any progressive loss of vision.
Other forms and less common forms of glaucoma are either secondary glaucoma or congenital glaucoma. Secondary glaucoma is a result of an underlying condition of the eye such as inflammation or tumor, past surgical procedures, injury and advanced cataracts. One of the more devastating forms of secondary glaucoma is due to the formation of new blood vessels in the anterior segment of the eye where the fluid is filtered from the eye. These abnormal blood vessels are most commonly seen in patients with advanced forms of diabetic retinopathy, vascular occlusive disease of the eye such as central retinal vein occlusions, advanced forms of carotid artery disease and patients with a history of retinal detachment.

Congenital glaucoma is that form of glaucoma that is present at birth and is quite rare. Newborns that have enlarged eyes, excessive tearing and light sensitivity need to be examined as soon as possible, as these are symptoms of congenital glaucoma. This form of glaucoma is treated best by pediatric ophthalmologists. We would refer such patients to Arkansas Children’s Hospital in Little Rock for proper care.

Glaucoma is known as the sneak thief of sight because people usually do not know that they have glaucoma because they do not notice the gradual blurring of vision and loss of peripheral vision until significant damage has been done or until the glaucoma has been detected by a full comprehensive eye examination. If the progression is severe enough, the optic nerve is destroyed and blindness is total and irreversible. Obviously, early detection and proper treatment, either medical or surgical, is the key to maintaining sight.