Tiered Approach to Treating GLAUCOMA

My goal is to help you optimize your vision at all times and help you understand your diagnosis.  It can be scary if your I or any eyeMD says you are a suspect for glaucoma or that you have glaucoma.

In general Glaucoma is a disease that damages the eye’s optic nerve and can lead to loss vision loss. The definition of true Glaucoma has changed over the years as we have been able to pick up early nerve damage better than ever before. Thus there is a range of Glaucoma Suspects (range: low risk, moderate, high risk) and Glaucoma Patients (early, moderate, severe). These terms help us determine together how closely we need to follow you (with visual fields or special testing) and when and how to treat you if needed. Most often such decisions depend on your risk factors (ie, family history, history of smoking, trauma, anatomy, highest pressures, diabetes). The below information is meant to help you. Good site for answers to questions is: http://effectivehealthcare.ahrq.gov/ehc/products/183/1395/glaucoma-treatment.pdf

The optic nerve is the cable that connects the eye (retina) to the brain (like a tv cable). The retina is a layer of light-sensitive tissue lining the back of the eye and is made up of many nerve fibers, like an electric cable is made up of many wires. It is the optic nerve that sends signals from your retina to your brain, where these signals are interpreted as the images you see.

Glaucoma is a change of the Optic Nerve usually diagnosed over time. Glaucoma if left untreated can lead to progressive, irreversible vision loss. Glaucoma is the second leading cause of blindness.

There are 5 main types:
1. Open Angle: Angle is open and Maximum corrected for corneal thickness eye pressure >21mmHg
2. Normal Tension: (normal eye pressure 8-21mmHg)
3. Narrow Angle or Angle closure: Narrow angle can cause pressure spikes and/or nerve damage
4. Congenital: develops after birth
5. Secondary: (ie, due to trauma, steroid medications, inflammation, prior eye surgery)

Risk Factors:
1. Age: increased age        5. African or Hispanic descent
2. Family History        6. Eye issues: Narrow Angles, Past eye injury
3. High eye pressure        7. Farsighted or nearsighted
4. Thin Cornea (pachymetry)    8. Blood flow anomalies from Diabetes, Migraine, Low blood pressure

Tiered Approach: GLAUCOMA Treatment START at  STEP 0 & 1; steps skipped if need lower pressure. 10. Glaucoma Drainage Implant: Ahmed, Baerveldt, Molteno: increased risk
9. Trabeculectomy: used to be gold standard for glaucoma surgery but has high complication rates (partial thickness scleral flap made & sutured loosely back in place allow fluid to flow out of the eye to form a bleb; chemotherapeutic adjuvants (ie. mitomycin C (MMC) or 5-fluorouracil (5-FU) may be used.
8. Stents: 1mm stents creates new channels to stay open in the TM. Less complications occur compared to Trabeculectomy.
7. Trabectome: Intraocular surgery device incises Trabecular Meshwork (TM), drain in eye, to decrease eye pressure. Less complications vs. #9, 10
6. New Laser Technology: Selective laser trabeculoplasty (SLT), helps decrease eye pressure with little to no pain, few side effects; uses 532-nm, frequency-doubled, Q-switched Nd:YAG laser, to selectively target melanin pigment in the trabecular meshwork cells. Studies show SLT is as effective as ALT (older laser type: Argon laser trabeculoplasty). SLT may be repeated three to four times, whereas ALT can usually be repeated only once.
5. Other Drops: rarely used due to side effects, older drops(ie, Miotic agents-pilocarpine (parasympathomimetics) & Echothiophate

  4. Combination Drop: helps compliance (ease of use) if already on 2 drops
Combigan: Alphagan & Timoptic; Tell us if you have any new side effects.
Cosopt: Trusopt & Timoptic; Tell us if you have any new side effects.

3. Third Line: If Second line drops do not work well enough: add or replace with Trusopt: (put it in the refrigerator as it can cause itchiness, redness; itchy, rash, swelling); Timoptic works well but side effects can occur (depression, difficulty breathing, wheezing, asthma, chest tightness, decreased heart rate, feeling like might pass out, muscle weakness, confusion, hallucinations, decreased libido.) If side effects are significant, call eyeMD before stopping them.

2. Second Line: If first line drops do not work well enough: add or replace with Alphagan 2x/d or Rescula 2x/day: put it in the refrigerator as it can often cause itchiness, redness; if side effects are intolerable, call eyeMD before stopping them

1. Eye Drops to lower pressure: First Line: Usually Start with most effective one with least side effects: Prostaglandin Analogs like Lumigan, Xalatan, Travatan (side effects: redness, itching, long eyelash, darkening of light iris color). With all drops, do PUNCTAL OCCLUSION after drop placed. If a Narrow Angle is noted, we may need to do a Laser Pupil Iridotomy (LPI) to open the angle.
1A. Recommendations: a. Do not smoke or be around smokers b. Avoid yoga positions where pressure is exerted on head/eye; c. Avoid eye trauma. d. Avoid if possible use of Steroids (ie, by mouth, topically around eye, drops). d. Eat well: Not proven yet, but eating a diet low in carbohydrates, rich in Omega 3s,green leafy veggies help eye health and may help decrease glaucoma progression. If you have Narrow Angles, check with Primary MD to eliminate offending systemic medications: ie. acetazolamide (Diamox), hydrochlorothiazide (Dyazide), cotrimoxazole (Bactrim, Septra), topiramate (Topomax).  Patients with headaches, Raynaud’s syndrome (cold extremities): tell us!                                                                                         

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