Treatment at Mass. Eye and Ear

Dr. Sola shows patient how to use glaucoma eye drops

Board-certified and specialty trained in glaucoma, our physicians are well-equipped to treat the full spectrum of glaucoma disorders, including complex conditions, such as keratoprosthesis-related glaucoma.

The goal of treatment is to slow or stop the progression of vision loss. Depending on many factors, such as your age and the type and severity of your glaucoma, treatment may include medications and/or surgery.

Prompt diagnosis and treatment are important because once vision is lost from glaucoma, it cannot be restored. If you have difficulty performing normal daily activities because of glaucoma-related vision loss, you may benefit from vision rehabilitation.

Medications

Prescription eye drops are often the first line of treatment for glaucoma. Examples include:

  • Prostaglandins work near the drainage area of the eye to improve fluid outflow
  • Beta blockers, carbonic anydrase inhibitors, and miotics reduce the amount of fluid produced
  • Alpha adrenergics reduce the eye's resistance to fluid drainage
  • Combination eye drops include two medications in one bottle

Self-Care

Having glaucoma requires close attention and self-management. You need to follow a long-term medication schedule and have regular appointments to monitor the disease. It is important that you discuss any new drugs you are taking with your physician(s).

Surgery

If your glaucoma progresses and is no longer controlled by medications, surgery may be necessary. Examples include:

Laser Peripheral Iridotomy (LPI)

This laser procedure opens or widens the drainage structures in the eye.

It is generally used as a preventative measure for patients with narrow-angle glaucoma.

It can also be used as a treatment for patients who already have angle-closure glaucoma. Sometimes other medications or surgery may be needed to control eye pressure.

What to expect: This outpatient procedure can usually be done in the eye doctor's office and typically takes a few minutes. You will be seated at a slit-lamp with your forehead resting against a headpiece and your chin on a chinrest. After numbing eye drops are applied, a lens will be placed on your eye to prevent you from blinking and moving your eye. The laser is then directed into the eye.

Most people experience minimal discomfort during the procedure. Afterward, you may experience some eye irritation and some blurry vision, but this is largely resolved within a day or two. Usually, you will have your eye pressure checked one hour after the procedure. Then, you are seen the day after the laser procedure and/or the following week. The number and frequency of visits may vary depending on the condition of your eye. Most people will need to take an eye drop four times daily for one week to help the eye heal. 

What are the risks? Risks include, but are not limited to, bleeding, inflammation, eye pressure elevations, and vision loss. Some people may see bright lights or flashes. In general, serious risks are not common. However, you are encouraged to discuss the benefits and risks with your doctor.

Laser Trabeculoplasty

This laser procedure is used to open the drainage site of the eye in patients with open-angle glaucoma that continues to progress, despite the use of medications. Although less common, it may also be recommended prior to trying medical treatment. These decisions vary, depending on the type and stage of glaucoma, as well as other factors.

What to expect: This outpatient procedure can usually be done in the eye doctor's office and typically takes a few minutes. You are seated at a slit-lamp with your forehead resting against a headpiece and your chin in a chinrest. After numbing eye drops are applied, a lens will be placed on your eye to prevent you from blinking. The laser is then directed into the eye. 

Most people experience minimal discomfort during the procedure. Afterward, you may have some eye irritation and blurry vision for a day or two.

You will usually have your eye pressure checked one hour after the procedure. You are then usually seen the day after the laser procedure and then the following week. The number and frequency of visits thereafter will vary, depending on your type of glaucoma and on the judgment of your doctor.

Most people will need to apply an eye drop four times a day for one week to help the eye heal. This new eye drop is taken in addition to your regular glaucoma drops. Because only half of the trabecular meshwork is treated at one time, you may need another laser procedure.

Are eye drops still needed after surgery? You will need to continue your glaucoma eye drops for at least a few weeks after the procedure, until the effects of treatment are known. The long-term need for eye drops after this treatment varies greatly, depending on your type of glaucoma and how quickly it is progressing. Even if you still take the same glaucoma medications, the procedure is considered successful if your eye pressure is lowered.

What are the risks? Risks include, but are not limited to, inflammation, eye pressure elevations, and vision loss. In general, loss of vision after a laser treatment is usually from progression of the glaucoma and not from the procedure itself. Although serious risks are not common, you are encouraged to discuss the benefits and risks with your doctor. Sometimes the laser procedure needs to be repeated.

Does trabeculoplasty work for everyone? It is successful for most, but not all, patients. It tends to be more successful in patients with primary open-angle glaucoma, pigmentary glaucoma, and pseudoexfoliation glaucoma. Even if the laser procedure is successful, its effect is usually not permanent. Sometimes the laser treatment can control pressure for up to three to five years.

Minimally Invasive Glaucoma Surgery (MIGS)

This new group of minimally invasive glaucoma surgeries is designed to lower intraocular pressure, usually in patients with mild-to-moderate glaucoma. Surgeons use microscopically sized equipment to make tiny incisions, which results in fewer complications and faster recovery time compared to traditional surgery. Most MIGS procedures can be used in combination with cataract surgery.

Although MIGS has become a promising intermediate treatment option between medication and major surgery, it may not be as effective as traditional surgery. MIGS is usually not appropriate for those with advanced glaucoma.

Mass. Eye and Ear offers several types of MIGS procedures. Examples include:

iStent®: This implantable device helps fluid drain by bypassing the trabecular meshwork—the main drainage system of the eye.

CyPass®: Using a tiny tube, the front of the eye (where fluid is produced) is connected to the back of the eye to improve drainage.

Trabectome®: A specialized device destroys part of the drainage system to improve the outflow of fluid.

New laser procedures: Endoscopic cyclophotocoagulation (ECP), micropulse cyclophotocoagulation, and diode cyclophotocoagulation (CPC) are laser procedures that reduce the amount of fluid that is produced.

Trabeculotomies/canaloplasties: New devices, such as iTrack®, are used to open the drainage system further.

Kahook dual blade: This tiny blade is used to open up the trabecular meshwork and improve fluid drainage.

Trabeculectomy

During trabeculectomy surgery (also called glaucoma filtration surgery), a new opening under the outer covering (the conjunctiva) of the eye is created for fluid to drain.

Trabeculectomy may be recommended if your glaucoma continues to progress, despite the use of medications and/or laser treatments. In some cases, it may be recommended before trying other treatment options. These decisions vary, depending on the type and stage of glaucoma, as well as other factors. Sometimes this surgery can be combined with cataract surgery.

What to expect: The procedure is done under local anesthesia in the operating room. Some surgeons may also give you sedatives to keep you completely comfortable. After numbing eye drops are applied, a sterile drape will be placed over your face and body, leaving only your eye uncovered. This keeps the area of the operation clean and sterile. Your eye will be held open with a lid speculum.

After the surgery, a patch and shield will be placed over your eye. This will be removed the day after surgery, on your first postoperative visit. You should expect to be seen frequently by your surgeon until the eye completely heals. For many people, this may take up to two or three months. During this time, you will be applying multiple eye drops, frequently.

Postoperative care varies greatly and may include suture removal, injections with supplemental medications, or other procedures to guide the healing process. During this time, you will need to restrict yourself from strenuous activities.

Preventing scarring: The main reason trabeculectomy surgery can fail is that the new drainage site scars and closes up. Some patients may need to take special medications, called antimetabolites, to prevent scarring. However, because antimetabolites can increase the risk of some complications after surgery, they are only reserved for patients who have an increased risk for trabeculectomy failure. This may include patients who have had an unsuccessful trabeculectomy surgery in the past, younger patients who have had eye surgery, and patients with uveitis.

Are eye drops still needed after surgery? The need for eye drops after tube shunt surgery varies greatly, depending on your type of glaucoma and the rate it is progressing. You will definitely need eye drops for two or more months after the surgery. Some people do not have to take eye drops after that period, but many people will eventually need some glaucoma eye drops to keep their pressure under control. In some cases, people will be taking fewer eye drops than they were before the surgery.

What are the risks? Risks include, but are not limited to, bleeding, infection, very low eye pressure, scarring, swelling, retinal detachment, droopy eyelid, double vision, loss of vision, or even loss of the eye. Sometimes the tube fails and needs to be replaced. In general, many of the risks are uncommon, but you are encouraged to discuss the benefits and risks with your surgeon.

Tube Shunt Surgery

A small tube, or shunt, is surgically implanted into the eye to allow extra fluid to drain and reduce the pressure in the eye. Glaucoma shunts come in many different varieties. Most, if not all, of the device will not be visible after surgery.

Tube shunt surgery may be needed if you have glaucoma that is not controlled by medications, after a previous trabeculectomy surgery (or surgeries) have failed, or in certain types of glaucoma where traditional trabeculectomy surgery is likely to fail. Examples of such patients are those with neovascular glaucoma, and patients who have corneal transplants.

What to expect: The procedure is done under local anesthesia in the operating room. Some surgeons may also give you sedatives to keep you completely comfortable. After numbing eye drops are applied, a sterile drape will be put over your face and body, leaving only your eye uncovered. This keeps the area of the operation clean and sterile. Your eye will be held open with a lid speculum.

After the surgery, a patch and shield will be placed over your eye. This will be removed the day after surgery, on your first postoperative visit. You should expect to be seen frequently by your surgeon until the eye completely heals (usually six to eight week). During this time, you will be applying multiple eye drops, frequently.

Postoperative care varies greatly and may include suture removal and/or other minor procedures to maximize the outcome of the surgery. During this time, you will need to avoid strenuous activities.

Are eye drops still needed after surgery? The need for eye drops after tube shunt surgery varies greatly, depending on your type of glaucoma and the rate it is progressing. You will definitely need eye drops for two or more months after the surgery.

What are the risks? Risks include, but are not limited to, bleeding, infection, very low eye pressure, scarring, swelling, retinal detachment, droopy eyelid, double vision, loss of vision, or even loss of the eye. Sometimes the tube fails and needs to be replaced. In general, many of the risks are uncommon, but you are encouraged to discuss the benefits and risks with your surgeon.

Diode Laser Transscleral Cyclophotocoagulation (Diode CYC)

This laser procedure reduces the eye’s ability to produce fluid in the eye.

It is usually only recommended after other, more conservative, surgeries (such as trabeculectomy or tube shunt surgery) have failed and vision is already very poor.

What happens during the procedure? This outpatient procedure is done in the eye doctor’s office. After the eye is numbed with eye drops, a laser beam partially destroys part of the ciliary body, where the eye’s fluid is produced. Multiple treatments may be needed.

What to expect: The whole procedure takes only one or two minutes. Most people experience only minor discomfort during the procedure. Afterward, you may have some blurry vision or eye soreness, but it usually resolves within a few days.

You will usually have follow-up visits the day after the procedure and the following week. The number and frequency of postoperative visits vary, depending on your type of glaucoma and the discretion of your doctor. Most people will need to take two eye drops up to four times daily for a few weeks to help the eye heal after the procedure. If your pressure is not sufficiently lowered with one treatment, repeat treatments may be needed.

Are eye drops still needed after surgery? You may need to continue your eye drops for at least a few weeks after the procedure, until the effects of treatment are known. The long-term need for eye drops after this treatment varies greatly, depending on your type of glaucoma and the rate at which it is progressing. But many patients are able to reduce the number of eye drops they are taking. Even if you still take the same glaucoma medications afterward, the procedure is considered successful if your eye pressure is lowered.

What are the risks? Risks include, but are not limited to, failure of treatment, pain, inflammation, loss of vision, very low eye pressure, and even loss of the eye. However, because of the risk of some decrease in vision, this procedure is usually only done if a person’s vision and visual prognosis are already poor. You are encouraged to discuss the benefits and risks with your surgeon.

Does the laser procedure work for everyone? Unfortunately, this procedure does not bring everyone’s pressure down into an acceptable range with one treatment. Multiple treatments may be needed. Alternative treatments, such as Nd:YAG laser or cryotherapy, may be discussed with your physician. However, they are less commonly used because of either decreased effectiveness or increased complications.