Everything in life has risks! Our doctors would only treat glaucoma if they believe that the risks of not being treated and going blind are greater than the risks of any therapy. Our doctors take into account at least the following when deciding upon the appropriate course of action:
- How advanced the glaucoma is in each eye
- Family history of eye problems
- Other eye problems excluding glaucoma
- Life expectancy
- Life style
- Visual needs
- Medical history
- Medications for other diseases
- Allergies to medications
- The degree of damage from glaucoma
- The rate at which the glaucoma has progressed or is progressing
- The degree of damage caused by glaucoma which is already present in the eye before the beginning of therapy
The doctor will then decide what is the best option. We will discuss the alternatives with you as any decision is a team decision, between both you, your family, and the doctor. We will discuss the appropriate options, both the positive and negative aspects of each. We take all options seriously, knowing that there are risks and benefits to all therapies.
Choices for Therapy
Your initial choice of therapy will most likely be between medical (eye drop) and laser therapy, although if the first one does not work, you can always try the other. It is important that you understand both types of therapy so that you can make the best decision for yourself.
How Serious Are Eye Drops For Glaucoma?
Eye drops for glaucoma should be taken seriously. They are not just a special water, but are actually similar to pills (medications) used to treat other health conditions. Do not overuse eye drops in an attempt to get an "added effect", as this could be hazardous.
How Can You Minimize the Side Effects of Eye Drops?
There are two tricks which may help you keep much of the eye drop's effect within your eye and not in the rest of your body. The object of both of these tricks is to maximize the amount of time an eye drop stays in contact with your eye and minimize the amount of drop which goes down into your tear duct which then becomes absorbed by your blood stream.
The first is called Forced Eye Lid Closure. It means that you should tightly close your eye, after instilling the drop, for approximately five minutes after each eye drop. The second is called Nasal Lacrimal Occlusion. This requires the placing one of the fingers of your hand upon the side of your eye lid, near your nose. This is where the punctum is located (the area of your eye lid which lets tears drain into your nose). You can use your finger to "close this area off" so that the amount of the drop which gets into you general circulation is minimal. Please ask one of the doctors to show you a video on how to do this or ask for specific instructions.
Is It Important to Remember to Always Use Your Eye Drops?
Compliance, or strict adherence with therapy, is one important reason why people do not lose vision while on therapy! Do not forget to use your eye drops. Eye drops only last a number of hours (ranging from 6 to 24).
If you don't use your eye drop regularly, you are only hurting yourself. Every time you miss an eye drop, there is a time when your eye pressure may be rising again. If you are to take any eye drop three times daily, and you regularly miss one of the three drops, over the course of a year, you might be missing one third of the eye drops you need. This is equivalent to missing eye drops for four months every year!
Almost all medical therapies for glaucoma are eye drops. Most eye drops may sting or burn when placed in the eye. This does not mean that they are not working or that they are bad for you. It just means that some people may find a specific eye drop more comfortable than others.
Eye drops are sometimes hard to put in the eye. It is okay to have a friend or family member help you instill an eye drop. It does not matter which part of the eye that the eye drop touches, as long as it gets onto the eye (being on the eye lid is NOT enough)! Sometimes people find eye drops so comfortable that they don't actually know if the eye drop has touched their eye or not. If you are having trouble with this, you may decide to put the drop in your refrigerator. Drops do not require refrigeration, but it may be easier to determine whether a cold eye drop has actually touched your eye or not compared to an eye drop which is at room temperature.
People often worry about how many eye drops they should put into their eyes. All you need is one. The space between your lower lid and eye ball usually only holds one-half of an eye drop, so that it is normal for some part of an eye drop to roll down your cheek.
Glaucoma usually involves both eyes. However, the doctor may start treatment with a drop in only one eye. This does not mean that you may need drops in only one eye, but it is a way of seeing whether a specific drop works for you. If the pressure in the eye receiving the drop is much lower than the pressure of the eye on no drop, it lets us know that this medication is actually working. We will start you on the medication in both eyes, only after we are sure that there has been a successful effect from the drop in the one treated eye.
You have at least a 50% chance of needing more than one type of eye drop to adequately lower your eye pressure. Different classes of eye drops have additive effects to other classes of eye drops. Some individuals take up to five different types of eye drops at the same time to adequately lower the eye pressure. If you require more than one type of drop, either eye drop can be used first. You should wait at least 5 minutes between each drop to insure that you do not wash out the first drop when you instill the second drop. If you think that you are having any side effects from a medication, please mention this to your doctor.
What Types of Eye Drops are Available for Therapy?
There are currently five different types of eye drops most commonly used for the medical treatment of glaucoma.
Prostaglandin analogs (Latanoprost (Xalatan), Travoprost (Travatan, Travatan Z), Bimatoprost (Lumigan)) (teal tops) are first-line therapy in the medical management of glaucoma, and are used once daily, usually at bedtime. They reduce intra-ocular pressure by enhancing the removal of fluid (aqueous humor) from the eye. In studies, prostaglandin analogs were able to reduce eye pressure by 30% to 35%; an additional drop in pressure is possible when these medicines are taken in combination with other medicines. Possible side effects associated with this family of medications are dry eyes, eye redness, elongation and darkening of eyelashes, iris darkening, periocular skin pigmentation, and inflammation of the front of the eye.
Beta-blockers (betaxolol, timolol, timoptic, betoptic, optipranolol, carteolol) (usually yellow or blue tops) are another common medication. They lower eye pressure by decreasing the amount of fluid made within your eye. They are either used once or twice daily. They can lower your eye pressure about 20% to 25% on the average. Complications associated with these medications are rare if used correctly, but should be understood so that you do not take a medication which is not appropriate for you. They should not be used in the following patients: those who have asthma, severe heart failure, blockage of their carotid arteries, a slow pulse, severe lung or heart disease, or are prone to depression. Additionally, males with a history of sexual dysfunction may want to ask their doctors about the advisability of this class of medications.
There are two different types of beta-blockers. There are selective beta blockers (Betoptic©) which are not quite as strong in lowering your eye pressure, but are safer in that they have less effect on your pulse rate, heart, and lungs. Non-selective beta blockers lower your eye pressure slightly more than do selective blockers. They may also make an individual's blood lipids (fats in the blood stream which can predispose one to heart disease) change in such a way as to increase your risk of heart attack or stroke.
Alpha-agonists (Brimonidine, Alphagan-P, Iopidine©) (white or purple tops) are used twice or three times daily. Eye pressure is lowered by decreasing the amount of aqueous humor produced. It usually takes a month to determine how well this type of medication works to lower your eye pressure. It is quite unusual to have systemic complications when this medication is used. However, it is not unusual for your eyes or eye lids to become red and swollen. (This will stop and go back to normal if the eye drop is stopped). Infrequently, you may develop a dry sensation in your mouth or nose.
Carbonic Anhydrase Inhibitors (Diamox©, Neptazane©, acetazolamide, methazolamide). (white or orange pill) or Azopt or Trusopt© (orange top bottle) can either be a pill or a drop. Dosing varies from twice to four times daily. These all work by decreasing the amount of aqueous humor made. They are all sulfa drugs -- so if you are allergic to SULFA you probably should not take these medications. This class of medication was first used clinically in the 1950's. Only approximately 50% of individuals who take carbonic anhydrase inhibitor pills can tolerate the side effects. These include fatigue, loss of appetite, kidney stones, depression, a funny taste in the mouth. This, like all sulfa drugs, can cause a type of anemia which is extremely rare and can be fatal in a very small number of patients. The first eye drop with this formula was introduced in mid-1995. The eye drop Trusopt© can also burn in one out of four individuals who take it, and with Azopt, while there is not as much burning, tends to cause a blurring of vision because it is a thicker solution.
Miotics (pilocarpine, carbachol, phospholine iodide, pilopine ointment) (usually green tops) are the oldest class of medications used for glaucoma. They work by increasing the amount of fluid which leaves the eye and are given at various dosing intervals varying between once weekly to four times daily. We have used this class of medication for over a century. Most side effects are limited to the eye. All side effects are temporary and are reversible when the medication is stopped. They make your pupil smaller which can make your vision seem dimmer. They can also cause your vision to seem blurry or cause a headache.
Can Laser be used to Treat Glaucoma?
Lasers were first introduced in the therapy of glaucoma in approximately 1978. A laser is a special form of light energy. Laser procedures are done in the office. A numbing drop, similar to the drop used to measure your eye pressure is used to anesthetize your eyes. A special type of lens is used to help keep your eye lids separated and aim the laser beam with greater magnification into the angle of the eye.
The laser treatment is quite safe. It only takes a few minutes to do. You will sit at a slit lamp and see a green or red light focused on your eye. It will only go where directed. 50 to 100 laser spots are aimed at the trabecular meshwork. The light is bright, but not painful. You might occasionally feel "a pin-prick" sensation associated with a laser spot.
After the laser procedure, we will check your eye's pressure again in about 30-45 minutes to insure that the eye pressure has not gone up (this happens in only approximately 1% of cases). We will prescribe an eye drop to decrease inflammation. You will need to use these four times a day. Your vision might be slightly blurry for about an hour. Your eye might feel scratchy or feel like something is in it for about a day or two. Your eye might also be blood shot for a few days.
The laser procedure does not take effect for about four to six weeks. The laser works adequately to lower the eye pressure in approximately 80% of people one year later. At five years, the effect continues in 50% of people.
The laser has proven to be safe and effective. Many ophthalmologists feel that it is safer than many types of medications. Laser surgery for glaucoma is being done at an earlier stage of the disease for some individuals. In a National Eye Institute evaluation, laser therapy for glaucoma was compared to medical therapy of glaucoma as the initial treatment, and was found to be as safe and effective as eye drops.
Can Surgery be Performed for Open-Angle Glaucoma?
Large multi-center nationally-based studies have concluded that offering eyedrops, laser or surgery to patients is the standard of care for glaucoma treatment. Eye surgery for glaucoma involves the creation of a partial thickness hole in the wall of your eye. Special anti-scarring chemicals are often used to keep this hole open as it is the body's natural tendency to try to heal any holes. This hole is like a trap door and acts like a safety valve. Fluid (aqueous humor) now has a new place to escape. A blister (or "bleb") is created under your eye lid. This acts as a reservoir for the fluid.
The surgery, called a trabeculectomy, can be performed on an outpatient basis. An anesthetist or anesthesiologist will give you medicine to put you into a “twilight” sleep. During this time, numbing medication will be injected surrounding your eye. This will keep your eye from feeling anything, seeing the surgery, and moving during surgery.
You will wear a patch over your eye until the following day. Following that, you will need to protect your eye with either a plastic shield (which you will be given), or your glasses.
Your vision may be blurry for several weeks following surgery. Unfortunately, we can not set a thermostat within your eye to achieve an exact pressure. In many cases, the success rate of glaucoma surgery is over 90%. However, sometimes the pressure is either below or above our desired goal, and further surgery may be required.
Glaucoma surgery would not be suggested unless it was felt that the risk of no surgery was worse than the risks involved with surgery itself. The main risks associated with glaucoma surgery are:
- Loss of vision due to hemorrhage or infection (extremely infrequent)
- Infection at any time after surgery (extremely infrequent)
- Cataract formation or progression (Infrequent)
- Need for further surgery (less than 1 out of 5)
- Discomfort (rare)
Most people need no medications following glaucoma surgery. They also usually do not need a change in their spectacle correction.