Glaucoma

glaucomaGlaucoma is a condition where there is characteristic damage to the optic nerve at the back of the eye resulting in loss of visual fields.

It is a condition often related to high intraocular pressure although it can occur even if the eye pressures are normal.

Treatment of glaucoma involves lowering the intraocular pressure. Initial treatment often involves eye drops.
If medical therapy is insufficient other treatment options are available.

Laser Therapy

Laser Therapy

Laser is used to enhance the outflow system of the eye in order to lower intraocular pressure. Selective laser trabeculoplasty(SLT) and micro pulse laser trabeculoplasty(MLT) are two types of laser that are used in a clinic setting to enhance outflow through the natural drainage system. It is a pain free, quick procedure carried out as an outpatient which often produces an effective lowering of intraocular pressure.

Angle surgery

Angle surgery

There are now many surgical options in the treatment of glaucoma. Many of them focus on enhancing the outflow system through the natural drainage channels. The obstructions to the drainage system can be removed by means of an ab internal goniotomy using a Kahook dual blade(KDB). The resistance can also be bypassed by inserting a small titanium stent in the form of the Glaucos iStent or the Ivantis Hydrus stent. The internal drainage channel can also be dilated using a technique called ab internal canaloplasty(Abic). All of these procedures fall under the umbrella of minimally invasive glaucoma surgery(MIGS) with good effectiveness and a low risk profile. The reduction in intra ocular pressure is often sufficient for patients suffering from mild to moderate glaucoma.
These procedures can be performed on its own but more often are combined with cataract surgery to achieve the maximum pressure lowering effect.

Suprachoroidal stents

Suprachoroidal stents

The suprachoroidal space is a potential space within the wall of the eye. Micro stents have been developed (Alcon CyPass micro stent) to be inserted into the suprachoroidal space which allows communication between the anterior chamber and the suprachoroidal space. Fluid from the eye can then drain into the suprachoroidal space, lowering the eye pressure. This new way of stenting has demonstrated good pressure lowering effect, reduction in glaucoma medication and can be performed as a stand-alone procedure as well as combined with cataract surgery to achieve better results.

Ciliary body treatment

Ciliary body treatment

The ciliary body is the structure that produces the fluid in the eye which maintains the pressure. In glaucoma patients the pressure is normally raised due to obstructed outflow. One can tackle the high pressure by reducing the production of fluid, similar to turning down the tap on a bath that is overfilling.

Ciliary body treatment is often reserved for glaucoma in the later stages and more complicated glaucoma. It can be performed using the traditional continuous wave style laser or the latest micro pulse diode laser.

Both types of laser have been shown to be effective in pressure lowering with the micro pulse laser offering a slightly better safety profile.


Filtration surgery

Filtration surgery

Often when a significant pressure lowering is required (for example in moderate to severe glaucoma) one would require a filtration operation. Filtration surgery works by creating an extra outflow channel in the eye allowing the fluid to escape to the subconjunctival space. The Allergan Xen implant is a newly developed collagen gel stent that can be inserted into the eye to allow the fluid to do just this. It is a quick 10 minute procedure which achieves a significant pressure lowering effect.

Trabeculectomy

Trabeculectomy

Trabeculectomy has been the gold standard in glaucoma drainage operations for many years. It remains one of the most powerful glaucoma operations in terms of pressure lowering and percentage of success. It is particularly useful in patients with more advanced disease where a low target pressure is required and subsequent use of glaucoma drops is deemed to be undesirable. In a trabeculectomy a drainage channel is created at the top of the eye under a scleral flap. The flap is then secured using very fine sutures. During the post-operative visits one can remove these sutures to gradually open the drainage flap and titrate the pressure down to the target level. Surgery takes 30-45 minutes and is usually performed under local anaesthetic. Post operatively patients are monitored initially on a weekly basis in order to adjust the pressure down to the desired target.

Tube surgery

Tube surgery

Glaucoma tube surgery is designed to combat the more complicated types of glaucoma. It is often used when previous glaucoma surgery has failed. Baerveldt tube and Ahmed valves are two such devices designed to shunt fluid from inside the eye to the subconjunctival space. This procedure is often performed under general anaesthesia.

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