Glaucoma

The Leading Cause of Preventable Blindness

What is Glaucoma?

Glaucoma is a group of diseases that damage the eye’s optic nerve and can result in vision loss and blindness. However, it is important to note that loss of sight from glaucoma could be prevented with early treatment.

Glaucoma Symptoms

In beginning, open-angle glaucoma has no symptoms. It causes no pain or vision changes. Without treatment, people with glaucoma will slowly lose their peripheral (side) vision. As glaucoma remains untreated, people may miss objects to the side and out of the corner of their eye. They seem to be looking through a tunnel. Over time, central (straight-ahead) vision may decrease until no vision remains.

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Who is at risk for open-angle glaucoma?

Anyone can develop glaucoma. Some people, listed below, are at higher risk than others:

  • African Americans over age 40
  • Everyone over age 60
  • People with a family history of glaucoma

A comprehensive dilated eye exam can reveal more risk factors, such as high eye pressure, thinness of the cornea, and abnormal optic nerve anatomy.

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The optic nerve

The optic nerve is a bundle of 1.2 million nerve fibers. It connects the retina to the brain. The retina is the light-sensitive tissue at the back of the eye. A healthy optic nerve is necessary for good vision.

Several large studies have shown that eye pressure is a major risk factor for optic nerve damage. In the front of the eye is a space called the anterior chamber. A clear fluid flows continuously in and out of the chamber and nourishes nearby tissues. The fluid leaves the chamber at the open angle where the cornea and iris meet. (See diagram below.) When the fluid reaches the angle, it flows through a spongy meshwork, like a drain, and leaves the eye.

In open-angle glaucoma, even though the drainage angle is "open", the fluid passes too slowly through the meshwork drain. Since the fluid builds up, the pressure inside the eye rises to a level that may damage the optic nerve. When the optic nerve is damaged from increased pressure, open-angle glaucoma-and vision loss—may result. That’s why controlling pressure inside the eye is important.

Another risk factor for optic nerve damage relates to blood pressure. Thus, it is important to also make sure that your blood pressure is at a proper level for your body by working with your medical doctor

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Will I develop glaucoma if I have increased eye pressure?

Not necessarily. Not every person with increased eye pressure will develop glaucoma. Some people can tolerate higher levels of eye pressure better than others. Also, a certain level of eye pressure may be high for one person but normal for another. Whether you develop glaucoma depends on the level of pressure your optic nerve can tolerate without being damaged. This level is different for each person. That’s why a simple pressure check is not enough in the diagnosis of glaucoma. A comprehensive dilated eye exam is very important.

Can I develop glaucoma without an increase in my eye pressure?

Yes. Glaucoma can develop without increased eye pressure. This form of glaucoma is called low-tension or normal-tension glaucoma. It is a type of open-angle glaucoma.

Can glaucoma be cured?
No. There is no cure for glaucoma. Vision lost from the disease cannot be restored.

Glaucoma Treatments

Immediate treatment for early-stage, open-angle glaucoma can delay progression of the disease. That’s why early diagnosis is very important.

Glaucoma treatments include medicines, laser trabeculoplasty, conventional surgery, or a combination of any of these. While these treatments may save remaining vision, they do not improve sight already lost from glaucoma.

Medicines. Medicines, in the form of eyedrops or pills, are the most common early treatment for glaucoma. Taken regularly, these eyedrops lower eye pressure. Some medicines cause the eye to make less fluid. Others lower pressure by helping fluid drain from the eye.

Before you begin glaucoma treatment, tell your eye care professional about other medicines and supplements that you are taking. Sometimes the drops can interfere with the way other medicines work.

Glaucoma medicines need to be taken regularly as directed by your eye care professional. Most people have no problems. However, some medicines can cause headaches or other side effects. For example, drops may cause stinging, burning, and redness in the eyes.

Many medicines are available to treat glaucoma. If you have problems with one medicine, tell your eye care professional. Treatment with a different dose or a new medicine may be possible.

Because glaucoma often has no symptoms, people may be tempted to stop taking, or may forget to take, their medicine. You need to use the drops or pills as long as they help control your eye pressure. Regular use is very important.

Make sure your eye care professional shows you how to put the drops into your eye. For tips on using your glaucoma eyedrops, see the inside back cover of this booklet.

Laser trabeculoplasty. Laser trabeculoplasty helps fluid drain out of the eye. Your doctor may suggest this step at any time. In many cases, you will need to keep taking glaucoma medicines after this procedure.

Laser trabeculoplasty is performed in your doctor’s office or eye clinic. Before the surgery, numbing drops are applied to your eye. As you sit facing the laser machine, your doctor holds a special lens to your eye. A high-intensity beam of light is aimed through the lens and reflected onto the meshwork inside your eye. You may see flashes of bright green or red light. The laser makes several evenly spaced burns that stretch the drainage holes in the meshwork. This allows the fluid to drain better.

Like any surgery, laser surgery can cause side effects, such as inflammation. Your doctor may give you some drops to take home for any soreness or inflammation inside the eye. You will need to make several follow-up visits to have your eye pressure and eye monitored.

If you have glaucoma in both eyes, usually only one eye will be treated at a time. Laser treatments for each eye will be scheduled several days to several weeks apart. Studies show that laser surgery can be very good at reducing the pressure in some patients. However, its effects can wear off over time. Your doctor may suggest further treatment.

Conventional surgery. Conventional surgery makes a new opening for the fluid to leave the eye. (See diagram on the next page.) Your doctor may suggest this treatment at any time. Conventional surgery often is done after medicines and laser surgery have failed to control pressure. Conventional surgery, called trabeculectomy, is performed in an operating room. Before the surgery, you are given medicine to help you relax. Your doctor makes small injections around the eye to numb it. A small piece of tissue is removed to create a new channel for the fluid to drain from the eye. This fluid will drain between the eye tissue layers and create a blister-like "filtration bleb."

For several weeks after the surgery, you must put drops in the eye to fight infection and inflammation. These drops will be different from those you may have been using before surgery.

Conventional surgery is performed on one eye at a time. Usually the operations are four to six weeks apart.

Conventional surgery is about 60 to 80 percent effective at lowering eye pressure. If the new drainage opening narrows, a second operation may be needed. Conventional surgery works best if you have not had previous eye surgery, such as a cataract operation.

Sometimes after conventional surgery, your vision may not be as good as it was before conventional surgery. Conventional surgery can cause side effects, including cataract, problems with the cornea, inflammation, infection inside the eye, or low eye pressure problems. If you have any of these problems, tell your doctor so a treatment plan can be developed.

New surgical developments

What are some other forms of glaucoma and how are they treated?

Open-angle glaucoma is the most common form. Some people have other types of the disease.

In low-tension or normal-tension glaucoma, optic nerve damage and narrowed side vision occur in people with normal eye pressure. Lowering eye pressure at least 30 percent through medicines slows the disease in some people. Glaucoma may worsen in others despite low pressures. A comprehensive medical history is important to identify other potential risk factors, such as low blood pressure, that contribute to low-tension glaucoma. If no risk factors are identified, the treatment options for low-tension glaucoma are the same as for open-angle glaucoma.

In angle-closure glaucoma, the fluid at the front of the eye cannot drain through the angle and leave the eye. The angle gets blocked by part of the iris. People with this type of glaucoma may have a sudden increase in eye pressure. Symptoms include severe pain and nausea, as well2 as redness of the eye and blurred vision. If you have these symptoms, you need to seek treatment immediately. This is a medical emergency. If your doctor is unavailable, go to the nearest hospital or clinic. Without treatment to restore the flow of fluid, the eye can become blind. Usually, prompt laser surgery and medicines can clear the blockage, lower eye pressure, and protect vision.

In congenital glaucoma, children are born with a defect in the angle of the eye that slows the normal drainage of fluid. These children usually have obvious symptoms, such as cloudy eyes, sensitivity to light, and excessive tearing. Conventional surgery typically is the suggested treatment, because medicines are not effective and can cause more serious side effects in infants and be difficult to administer. Surgery is safe and effective. If surgery is done promptly, these children usually have an excellent chance of having good vision.

Secondary glaucomas can develop as complications of other medical conditions. For example, a severe form of glaucoma is called neovascular glaucoma, and can be a result from poorly controlled diabetes or high blood pressure. Other types of glaucoma sometimes occur with cataract, certain eye tumors, or when the eye is inflamed or irritated by a condition called uveitis. Sometimes glaucoma develops after other eye surgeries or serious eye injuries. Steroid drugs used to treat eye inflammations and other diseases can trigger glaucoma in some people. There are two eye conditions known to cause secondary forms of glaucoma.

Pigmentary glaucoma occurs when pigment from the iris sheds off and blocks the meshwork, slowing fluid drainage.

Pseudoexfoliation glaucoma occurs when extra material is produced and shed off internal eye structures and blocks the meshwork, again slowing fluid drainage. Depending on the cause of these secondary glaucomas, treatment includes medicines, laser surgery, or conventional or other glaucoma surgery.

Dr. fridman Photo author

Dr. Gretta Fridman