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Newly diagnosed with Glaucoma, what are my treatment options?

dxglaucoma

Newly Diagnosed with Glaucoma, what are my treatment options?


There are several different variations of Glaucoma and what we will discuss mostly today is what we call Primary Open Angle Glaucoma.  This means that there is no specific underlying cause for the Glaucoma like inflammation, trauma or a severe cataract.  It also means that the drainage angle where fluid is drained from the inside of the eye into the blood stream is not narrow or closed.  Closed or Narrow Angle Glaucoma is treated differently from Open Angle Glaucoma.   We will deal with Narrow Angle Glaucoma in a future Blog post. 

In the US, Primary Open Angle Glaucoma (POAG), is by far the most common type of Glaucoma we treat.  Glaucoma is a disease where the Optic Nerve in the back of the eye deteriorates over time and that deterioration has a relationship to the Intraocular Pressure (IOP).  Most people diagnosed with Glaucoma have an elevated IOP but not everyone with Glaucoma does.  Some people have fairly normal IOP’s but show the characteristic deterioration in the Optic Nerve.  Regardless of whether or not the pressure was high initially our primary treatment is to lower the IOP.  Usually we are looking to try to get the IOP down by about 25% from the pre-treatment levels.

A video description of Open Angle Glaucoma is below:

View Video

The two mainstays of initial treatment for POAG in the US are medications or laser treatments.  There are other places in the world where Glaucoma is treated initially with surgery.  Surgery can often lower the pressure to a greater degree than either medications or laser treatments but that comes with a higher rate of complications.  Most US eye doctors elect to go with the more conservative approach and utilize either medications most often in the form of eye drops or a laser treatment.

Drops

There are several different classes of medications used to treat Glaucoma.  The most common class used are the Prostaglandin Analogues or PGA’s.  The PGA’s available in the US are Xalatan (latanaprost), Travatan (travapost), Lumigan (bimatoprost) and Zioptan (tafluprost).  The PGA’s are most doctor’s first line treatment because they generally lower the IOP better than the other classes, they are reasonably well tolerated by most people and they are dosed just once a day while most of the other drugs available have to be used multiple times a day.  The other classes of drugs include beta-blockers used once or twice a day, carbonic anhydrase inhibitors (CAI’s ) which come in either a drop or pill form and are used either twice or three times a day, alpha agonists used either twice or three times a day and miotics used three or four times a day.  All of these other medications are typically used as either second line or adjunctive treatment when the PGA’s are not successful keeping the pressure down as single agents.  There are also several combination drops available in the US that combine two of the second line agents (Cosopt, Combigan, and Symbrinza).


A video description of the eye drops is below:

View Video

Laser


The second option as initially treatment is a laser procedure.  The two most common laser treatments for Open Angle Glaucoma are Argon Laser Trabeculoplasty (ALT) or Selective Laser Trabeculoplasty (SLT).  These treatments try and get an area inside the eye called the Trabecular Meshwork, where fluid is drained from the inside of the eye into the venous system, to drain more efficiently.  These treatments tend to lower the pressure to about the same degree as the PGA’s do with over 80% of patients achieving a significant decrease in their eye pressure that lasts at least a year.  Both laser treatments can be repeated if the pressure begins to rise again in the future but the SLT works slightly better as a repeat procedure compared to the ALT.


You can watch the video describing SLT below.

View Video
Whichever treatment you and your doctor decide to start with the key is to get the pressure down and keep it down and in many patients that initial treatment doesn’t work forever and additional therapy is often needed.

Click for more of our blog post on Glaucoma

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Sunday, 19 January 2020

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