Glaucoma Treatment Guidelines

1. What is glaucoma?

Glaucoma is one of the blinding diseases of the eye. Unlike another blinding disease of the eye such as infections and ulcers of cornea, retinal diseases, age-related problems, diabetic and hypertensive retinopathy, with timely recognition and management, glaucoma can be slowed down so that a person will not become blind in his lifetime. however, the vision that is lost can be reversed with any treatment strategy.

Glaucoma is the disease of the optic nerve, affecting the visual field in which certain risk factors play an important role like intraocular pressure, age, myopia, hypertension, and racial factors.

Glaucoma may start without any symptoms, some patients may feel pain around the eyes, haloes in the room, deterioration in the visual field, watering from eyes, and redness in the eyes.

Glaucoma treatment starts with medications in the early stages. Compliance is the key factor in the regulation of glaucoma treatment. certain other procedures like laser trabeculectomy and glaucoma surgery e.g., trabeculectomy can be performed if the disease is in an advanced stage or the patient has a compliance problem oris having multiple drug therapy.

Symptoms of Glaucoma:

2. What are the warning signs and symptoms of glaucoma?

These includes reduced

Visual acuity reduction

Reduction in the peripheral visual field

Eye ache or headache

Watering, redness of eye

Haloes and smoke in the room.

Some types of glaucoma may go unnoticed by the patient such as chronic glaucoma and normal tension glaucoma

3. What is the pathophysiology of glaucoma?

Certain factors are postulated to cause glaucoma. These includes

Direct mechanical damage:

The retinal nerve fibers pasting through lamina cribrosa may receive direct mechanical damage.

Ischemic damage:

Ischemic damage is caused due to compression of blood vessels supplying the optic nerve.

Common pathway:

Both mechanisms can result in a reduction of axoplasmic flow, interference with the delivery of nutrients or removal of metabolic products, oxidative injury, or immune-mediated damage.

Glaucoma Risk Factors:

4. Who might get glaucoma?

These includes

Raised intraocular pressure

Increased age

Race factor, African of Hispanic descent

Diabetes and hypertension

First degree relative with glaucoma

Use of contraceptive pills

Thin corneal thickness

Raynaud’s disease or migraine

Reduced ocular perfusion pressure

Diagnosis and Tests:

5. How is glaucoma diagnosed?

Glaucoma is a silent blinding disease, in the early stages you might not know that you are actually having glaucoma, however keeping in mind the risk factors, a regular ophthalmic checkup will help to diagnose it and start treatment well on time. The ophthalmologist will perform the following test to diagnose glaucoma

Visual equity.

Visual functions include RAPD and color vision.

Slit lamp examination of cornea, lens, anterior chamber depth measurement, and iris assessment.

Gonioscopy for the assessment of open or closed angles

Tonometry for the measurement of intraocular pressure.

Optic disc and fundus examination.

Types of Glaucoma:

6. What are the types of glaucoma?

The types of glaucoma can be widely divided into open angle glaucoma and angle closure glaucoma.

Open angle glaucoma: It is one the most common cause of glaucoma. In this type of glaucoma there is no iridotrabecular contact, hence the angels are open. The main pathology lies at deposition of tiny particles in the draining canals of the eye and leading to building up of pressure. The particles may include pigment, lens particles, pseudoexfoliation material etc.

Angle closure glaucoma:In angle closure glaucoma the angle between the iris and trabecular meshwork is occluded. This may be caused due to pupillary block or due to posterior anterior synechaes. This type of glaucoma can present with acute symptoms of sever pain, tearing, watering, red eyes and can leave certain marks of acute damages such as corneal edema, infarction in epithelium of lens and optic disc changes.

Normal tension glaucoma: in normal tension glaucoma, the intraocular pressure is under normal limits. There is decline in the visual field and optic disc damage like other types of glaucoma.

7. What are the treatment options of glaucoma?

There is no permanent or reversible treatment of glaucoma, however, the health professional will make an effort to slow down the damaging process.

Treatment of glaucoma includes

Medical treatment

Glaucoma Medicines:

The initial management of glaucoma includes topical and oral medications. The type of medication depends on your health and other co-morbidities.

8. What types of eye drops can help glaucoma?

Latanoprost and other prostaglandins for example tafluprost, travoprost, and bimatoprost are considered the first-line topical medications.

Beta-blockers such as timolol, levobunolol, and carteolol are contraindicated in heart diseases and asthmatic patients.

Alpha 2 agonists include brimonidine and apraclonidine. It is contraindicated in patients under the age of 9 years. The major complication is CNS depression.

Carbonic anhydrase inhibitors are available in oral and topical form. These medications are used in cases where extensive lowering of pressure is required. However, CAI are contraindicated in patients with renal stones and renal failure.

Mannitol and glycerol are used in an acute attack of glaucoma. Mannitol is administered via intravenous route and glycerol is given orally.

Laser procedures:

Laser is used in the treatment of glaucoma keeping in mind its indications and benefits. Two types of LASERs are used for glaucoma treatment, Argon, and Nd: YAG. The indications for lasers include primary glaucoma, multiple drug therapy, primary congenital glaucoma, and unresponsive to medical treatment.

9. How long will I need to use glaucoma eye drops? click here for more

If the intraocular pressure and the ongoing damage to the optic nerve is under control, the patient is advised to use glaucoma drops for life long.

Surgeries and Other Therapies:

Surgical procedures:

When LASERs and medical treatment can’t maintain the intraocular pressure and slow down the ongoing damage, then surgical procedures are performed. These include trabeculectomy and glaucoma valve implantation.

In trabeculectomy, a fistula is created under the cover of the sclera for the passage of aqueous humor from the anterior chamber into the subtenon space.

The novel procedure is the implantation of a glaucoma valve. In this procedure, a passage is made between the anterior chamber and sub tenon space with the help of a valve. Indication for glaucoma valve surgery includes eyes with conjunctival scarring, uncontrolled glaucoma, neovascular glaucoma, or when the conventional trabeculectomy has failed.

In non-penetrating glaucoma surgery, the anterior chamber is not entered and the trabecular meshwork is preserved. The surgery is technically challenging and involves meticulous dissection of scleral flap.

Cycloablation procedure is the treatment option for blind and painful eye, where there are least chances of vision restoration.

10. Glaucoma effects one or both eyes?

It depends upon the cause of glaucoma. Normal-tension or primary open-angle glaucoma is usually in both eyes, while angle-closure glaucoma can occur in one only. If the cause of neovascular glaucoma is a tumor, only one eye will be involved.

11. Glaucoma medication is used lifelong or not?

Yes, the glaucoma medications are used for life long even if the patient experience no symptoms and if the intraocular pressure is under normal range.

12. When should I call doctor?

You should call your health care provider if you experience the following conditions

severe acute pain in the eyes or headache

haloes or flashes

reduced vision

vision loss

13. Which age group is affected by glaucoma?

All age groups can be affected with glaucoma. In primary congenital glaucoma, glaucoma will start in intrauterine life, while in the juvenile type of glaucoma, it will start at 15 years of age.

Complications Of Glaucoma:

14. What are the complications of glaucoma?

One of the debleating complications of glaucoma is blindness, if not treated on time or if the treatment option is not chosen properly, then the patient will gradually become blind. Other complications of glaucoma include

Recurrent attacks of pain

Hyphema inside the anterior chamber

Early development of cataract

Corneal edema leading to scaring

Choroidal affusion

Periphery visual field loss encroaching the center with the passage of time.

Blindness

Tips for Living With Glaucoma:

The patient should know in-depth about the disease. The main features in coping with glaucoma include lifestyle modification

Eye drops should be used regularly and as described by the consulting doctor.

Regular exercise should be advised on regular basis to keep the intraocular pressure under normal limits

Regular schedule of eye checkup should be maintained

Maintain blood pressure and diabetes under normal limits

Eat healthy food, rich in omega 3 fatty acid and anti-oxidants.

Avoid smoking

Elevate your head end during sleep.

Patient who drive should get regular visual field checkup for the peripheral visual fiels.

15. What questions should I ask my doctor?

What is the type of glaucoma I am suffering?

Compatibility of drugs I have been given with co morbidities that I have, e.g asthma, cardiovascular disease, renal disease etc.

What are the timings of my eye drops?

What are the complications of medicines that I have been advised?

When to call immediate help?

What are the life style modifications I need?

When to come for regular eye checkup?

What are the other treatment options, if my glaucoma is not controlled with eye drops/ medications?