Glaucoma means optic nerve damage which can lead to blindness. Many forms of glaucoma are preventable.
The key treatment options are:
1. Drops: there are many types of drops: see below *
2. Pills by moth: not a great long term option: Diamox
3. Laser surgery: see **
4. Intraocular Eye Surgery:
a. Minimally Invasive Glaucoma Surgery (MIGS): require less post-op care and less risky than Trabeculectomy or Tube/Shunt/Drainage device placement.
3). Cypass: off the market due to corneal endothelial concerns.
4). Express implant
b. Trabeculectomy/Filtering surgery: a connection is physically placed between the inside of the eye and the outside of the eye with a Bleb or an area under the conjunctiva (the clear covering above the sclera), above the eye which acts as a reservoir so the fluid in the eye can start to gently ooze to the back of the eye safely; more invasive requiring a lot of post-operative visits; risk of eye infection is real
c. Tube/Shunt: a connection is physically placed between the inside of the eye and the outside of the eye with a plastic reservoir placed above the eye, under the conjunctival, close to the area under the orbital bone. This is more invasive with more risks. Glaucoma eye drops are well known to worsen dry eye disease and the corneal epithelial surface.
d. NEW: Implantable solid polymer sustained-release drug delivery system: FDA-approved, biodegradable, in-the-eye-implant indicated to reduce intraocular pressure in patients with open angle glaucoma or ocular hypertension via a sustained-release drug delivery system.
1. *Preservative-Free Glaucoma Drops: There are lovely but some patients’ eye pressure does not decrease with these drops or the patient has an allergy.
Here is a list of Preservative-Free Glaucoma Drops:
Zioptan (tafluprost ophthalmic solution 0.0015%)
Cosopt PF (dorzolamide-timolol ophthalmic solution 2%/0.5%)
Timoptic in Ocudose (timolol maleate ophthalmic solution 0.25% and 0.5%).
XELPROSTM is the only FDA-approved BAK-free version of Latanoprost. It joins three other FDA-approved topical glaucoma medications completely free of preservatives:
3. Laser therapy. Selective Laser trabeculoplasty (truh-BEK-u-low-plas-tee) SLT: uses a laser beam to poke new holes in the trabecular meshwork (sort of like poking holes in your kitchen drain). This can be used as a First Line Treatment, meaning a patient can have SLT instead of first using drops depending on insurance coverage. SLT is very safe. I have never seen a complication yet from this other than it needing to be repeated or it does not lower the pressure enough.
4a. Minimally invasive glaucoma surgery (MIGS): require less postoperative care & has less risk than trabeculectomy or installing a drainage device; often combined with cataract surgery.
4b. Filtering surgery: trabeculectomy (truh-bek-u-LEK-tuh-me), or “Trab” for short: we create an opening in the white of the eye (sclera) and removes part of the trabecular meshwork.
4c. Drainage tubes: surgeon inserts a small tube shunt in your eye to drain away excess fluid to lower your eye pressure.
4D. DURYSTA™ (bimatoprost implant) may be a game-changer. It is an implantable drug that is indicated for the reduction of intraocular pressure (IOP) in patients with open-angle glaucoma (OAG) or ocular hypertension (OHT). Whether your eye surgeon offers this will sadly depend on how the company works with the surgeon to make it easier for the insurance to cover and decrease the surgical team’s paperwork.
This is the positive of DURYSTA:
1. No preservative
2. Does not worsen dry eye
3. No need for drops
4. Won’t forget to use the drops or miss the eye trying to get the drop in the eye.
These are the Negatives:
1. Cost: will insurance cover it?
2. What are long term risks to corneal endothelium? We may not know for years. The company says it is safe but it is a concern.
3. Risk of infection/ endophthalmitis/ loss of eye from an infection: this is rare but the risk is not 0%
4. Long term effect is still unknown: will it need to be repeated?