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Glaucoma

Treatment

If your doctor determines that you have elevated intraocular pressure , an excavated optic disk and loss of visual field, you'll likely be treated for glaucoma. If you have only slightly elevated eye pressure, an undamaged optic nerve and no visual field loss, you may not need treatment, but your doctor may advise more frequent examinations to detect any future changes. If you have signs of optic nerve damage and visual field loss, even if your eye pressure is in the normal range, you may need treatment to lower eye pressure further, which may help slow the progression of glaucoma.

Glaucoma can't be cured, and damage caused by the disease can't be reversed. But with treatment, glaucoma can be controlled. Eyedrops, oral medications and surgical procedures can prevent or slow further damage.

Having glaucoma means you'll need to continue treatment for the rest of your life. Because the disease can progress or change without your being aware of it, your treatment may need to be changed over time. Regular checkups and adherence to a treatment plan may seem burdensome, but they're essential to prevent vision loss.

Keeping your eye pressure under control can prevent further damage to the optic nerve and continued loss of your visual field. Your eye doctor may focus on lowering your intraocular pressure to a level that's unlikely to cause further optic nerve damage. This level is often referred to as the target pressure and will probably be a range rather than a single number. Target pressure differs for each person, depending on the extent of the damage and other factors. Your target pressure may change over the course of your lifetime.

Topical medications are the most common early treatment for glaucoma. Standard practice has been to move on to surgery if medications are ineffective. However, surgery is also an option as a relatively safe and effective initial treatment.

Eyedrops
Glaucoma treatment often starts with medicated eyedrops. Doctors prescribe several types of drops. Be sure to use the drops exactly as prescribed to control your intraocular pressure . Skipping even a few doses can cause damage to the optic nerve to worsen. Some drops need to be applied several times each day, and others must be used just once a day. Inform your doctor of all other medications you're taking, to avoid any undesirable drug interactions.

Because some of the eyedrops are absorbed into your bloodstream, you may experience side effects unrelated to your eyes. To minimize this absorption, close your eyes for one to two minutes after putting the drops in. Press lightly at the corner of your eye near your nose to close the tear duct, and wipe off any unused drops from your eyelid. Your doctor may prescribe more than one type of eyedrop. If you're using more than one, ask your doctor how long to wait between applications.

The types of eyedrops that doctors most commonly prescribe include:

• Beta blockers. These reduce the production of aqueous humor. Examples include levobunolol (Betagan ), timolol (Betimol, Timoptic ), carteolol (Ocupress), betaxolol (Betoptic) and metipranolol (OptiPranolol ). Possible side effects include difficulty breathing, slowed pulse, hair loss, lower blood pressure, impotence, fatigue, weakness, depression and memory loss. If you have asthma, bronchitis or emphysema, or if you have diabetes and use insulin, medications other than beta blockers are options.

• Alpha-adrenergic agents. These reduce the production of aqueous humor. Examples include apraclonidine (Iopidine) and brimonidine (Alphagan). Possible side effects include increased blood pressure; dizziness; red, itchy or swollen eyes; dry mouth; and allergic reactions.

• Carbonic anhydrase inhibitors. These medications, which include dorzolamide (Trusopt), reduce the amount of aqueous humor. Possible side effects include frequent urination and a tingling sensation in the fingers and the toes, but these occur more frequently when a carbonic anhydrase inhibitor is taken orally. If you're allergic to sulfa drugs, this type of medication shouldn't be used unless no alternative is possible, and then only with great care.

• Prostaglandin analogues. These eyedrops increase the outflow of aqueous humor. These hormone-like substances, which include latanoprost (Xalatan), may be used in conjunction with a drug that reduces production of aqueous humor. Possible side effects include mild reddening and stinging of the eyes and darkening of the iris, changes in the pigment of the eyelid skin, and mild swelling of the central retina (a condition known as cystoid macular edema).

• Prostamides. These include bimatoprost (Lumigan). They increase the outflow of aqueous humor. Possible side effects include mild to moderate reddening of the eyes and itchy eyes.

• Miotics. Miotics, such as pilocarpine (Isopto Carpine, Pilocar) increase the outflow of aqueous humor. Possible side effects include pain around or inside the eyes, brow ache, blurred or dim vision, nearsightedness, allergic reactions, a stuffy nose, sweating, increased salivation and occasional digestive problems.

• Epinephrine compounds. These also increase the outflow of aqueous humor. Possible side effects include red eyes, allergic reactions, palpitations, an increase in blood pressure, headache and anxiety.

• Anxiety

• Asthma

• Bronchitis

• Depression

• Emphysema

• fatigue

• Headache

• Impotence

Oral medications
If eyedrops alone don't bring your eye pressure down to the desired level, your doctor may also prescribe an oral medication. Carbonic anhydrase inhibitors, such as acetazolamide and methazolamide, are commonly prescribed oral medications for glaucoma. Take these pills with meals to reduce side effects. You can help to minimize the potassium loss that these medications can cause by adding bananas and apple juice to your diet.

When you first start taking these oral medications, you may experience a frequent need to urinate and a tingling sensation in your fingers and your toes. After several days, these symptoms usually disappear. Other possible side effects of carbonic anhydrase inhibitors include rashes, depression, fatigue, kidney stones, lethargy, stomach upset, a metallic taste in carbonated beverages, impotence and weight loss.

• Depression

• fatigue

• Impotence

Surgery
You may need surgery to treat glaucoma if you can't tolerate medications or if they're ineffective. Doctors use several types of surgery to treat glaucoma:

• Laser surgery. In the last couple of decades, a procedure called trabeculoplasty (truh-BEK-u-lo-plas-te) has been used increasingly in the treatment of open-angle glaucoma. The doctor uses a high-energy laser beam to shrink part of the trabecular meshwork, which causes other parts of the meshwork to stretch and open up. This helps aqueous humor drain more easily from the eye.

• This type of laser surgery is an office procedure that takes 10 to 20 minutes. You'll be given an anesthetic eyedrop, seated at a slit lamp and fitted with a special lens on your eye. The doctor aims the laser through the lens at the trabecular meshwork and applies burns to it. You will see bright flashes of light.

• After the surgery you can immediately resume normal activities without discomfort. The doctor will usually check your eye pressure one to two hours after the procedure and several times in the following weeks. He or she may prescribe anti-inflammatory eyedrops for you to use for a few days following trabeculoplasty. It may take a few weeks before the full effect of the surgery becomes apparent.

• In almost all cases, laser surgery for glaucoma initially lowers intraocular pressure. However, its effects may wear off over time.

• Conventional surgery. If eyedrops and laser surgery aren't effective in controlling your eye pressure, you may need an operation called a filtering procedure, usually in the form of a trabeculectomy (truh-bek-u-LEK-tuh-me). This procedure is done in a hospital or an outpatient surgery center. You'll receive medication to help you relax and eyedrops and usually an injection of anesthetic to numb your eye. Using delicate instruments under an operating microscope, your surgeon creates an opening in the sclera — the white of your eye — and removes a small piece of the trabecular meshwork. The aqueous humor can now freely leave the eye through this hole. As a result your eye pressure will be lowered. The hole is covered by the conjunctiva, so there's not an open hole in your eye.

• Your doctor will check your eye in several follow-up visits. You'll use antibiotic and anti-inflammatory eyedrops for some time after the operation to fight infection and scarring of the newly created drainage opening. Scarring is a particular problem for young adults, blacks and people who have had cataract surgery. This procedure works best if you haven't had any previous eye surgery.

• Although glaucoma surgery may preserve current vision, it can't restore already lost vision. Sometimes a single surgical procedure may not lower eye pressure enough, in which case you'll need to continue using glaucoma drops or have another trabeculectomy operation.

•  Drainage implants. Another type of operation, called drainage implant surgery, may be an option for people with secondary glaucoma or for children with glaucoma.

• Like the trabeculectomy, drainage implant surgery is performed at a hospital or an outpatient clinic. You'll be given medication to help you relax and eyedrops and an anesthetic to numb the eye. Then the doctor inserts a small silicone tube in your eye to help drain aqueous humor.

• After the surgery you'll wear an eye patch for 24 hours and use eyedrops for several weeks to fight infection and scarring. Your doctor will check your eyes several times in the weeks that follow.

• Cataract

Complications from glaucoma surgery may include infection, bleeding, eye pressure that remains too high or too low, and, potentially, loss of vision. Having eye surgery may also speed up the development of cataracts. Most of these complications can be effectively treated.

Treating acute angle-closure glaucoma
Acute angle-closure glaucoma is a medical emergency. When you come in with this condition, doctors may administer several medications to reduce eye pressure as quickly as possible. You'll also likely have a laser procedure called iridotomy. In this procedure, a laser beam creates a small hole in your iris to allow aqueous humor to flow more freely into the anterior chamber where it then has normal access to the trabecular meshwork. Once aqueous humor can reach the trabecular meshwork again, the fluid can drain as it normally does. Many doctors recommend an iridotomy on the other eye at a later date because of the high risk that it too will have an attack within the next few years.

Prevention

Until recently, there was no proven way to prevent glaucoma. But in June 2004, a large multi-center trial, supported by the National Eye Institute, found that when glaucoma eye drops were given daily to people with elevated eye pressure (above 24 mm Hg), they reduced eye pressure an average of 22 percent. More important, the researchers discovered that daily use of eye drops can reduce the risk of developing glaucoma by nearly half in blacks with elevated eye pressure.

Another study, published in the Archives of Ophthalmology in June 2004, found that cholesterol-lowering medications reduced the risk of open-angle glaucoma, especially for people who already have cardiovascular disease. While this may be an added benefit for those already taking these medications to reduce their cholesterol levels, more studies need to be done to confirm the reduction in risk of glaucoma.

Regular checkups can help detect the disease in its early stages before irreversible damage has occurred. As a general rule, have eye exams every two to four years if you're between the ages of 40 and 65, and every one to two years if you're older than 65.

Your doctor will likely recommend more frequent monitoring if you're at increased risk of developing glaucoma. For example, a family history of glaucoma puts you at increased risk for developing glaucoma and is a reason for more frequent monitoring. You may also need even more frequent checkups if you have received a diagnosis of abnormally high intraocular pressure or have a history of serious eye injury.

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