Treatment

1. I have glaucoma. What are my treatment options?

Initially, your doctor will perform a test called gonioscopy to decide your glaucoma subtype: open angle or closed angle.

For open angles, you will be prescribed eye drops to be used as directed by your doctor. Your doctor will thereafter check their efficacy over time, adding or substituting eye drops as required. He/ she may also offer you a laser treatment called selective laser trabeculoplasty.

In case of closed angle glaucomas, you will be offered a laser procedure called laser peripheral iridotomy. In case your doctor believes that the laser alone is not enough, you will be prescribed eye drops subsequently like open angle glaucoma patients.

In case the above treatment modalities are not adequate, especially in advanced glaucomas and certain other complicated sub-types of glaucoma, your doctor will advise glaucoma surgery.

Eyedrops

2. What are the common glaucoma medications?

The common glaucoma medications are listed in the table below, the list is by no means exhaustive.

Class	Drug name	Action	Half life	Dosage	Brand names
Prostaglandin Analogues	Latanoprost	Outflow	Long	Once at bedtime	Xalatan, Latoprost RT
	Travoprost	Outflow	Long	Once at bedtime	Travatan
	Bimatoprost	Outflow	Long	Once at bedtime	Lumigan
Beta blockers	Timolol	Inflow	Moderate (longer in gel form)	Twice a day	Iotim, Glucomol, Timolol GFS
	Levobunolol	Inflow	Moderate	Twice a day	Betagan
	Betaxolol	Inflow	Moderate	Twice a day	Betoptic
Alpha-agonists	Brimonidine	Inflow/ Outflow	Moderate	Thrice a day	Alphagan
Carbonic Anhydrase Inhibitors	Acetazolamide (tablet)	Inflow	Short	Thrice a day/ SOS	Diamox, Iopar SR (sustained release)
	Dorzolamide	Inflow	Shorter	Thrice a day	Dorzox
	Brinzolamide	Inflow	Shorter	Twice a day	Azopt
Miotics	Pilocarpine	Outflow	Short	Thrice a day	Pilocarpine

 

3. My eye pressures are no longer high after medication. Why do I have to still take medication?

If you stop taking glaucoma medication, the eye pressure will go back up to what it was before treatment. It is absolutely necessary to continue your eye drops as prescribed. Glaucoma is a chronic disease like diabetes or high blood pressure, we can only control your eye pressures with medication, and not treat it once and for all.

4. I have been prescribed eye drops. Can I switch to a generic medicine?

In general, we presume that the effectiveness of generic medication is the same as that of the branded product. Generics contain the same active ingredient, and in the same concentration and have been tested in laboratories to be the same chemically. However, the manufacturers of the generics are not required to prove the therapeutic effect of the drug.

Equivalence of eye drops is difficult to assess because blood levels cannot be monitored or considered to be an index of effectiveness.  Minor differences can affect absorption, and the comfort of the eye drop. Other concerns of importance include safety of packaging and drop size. In case the bottle dropper is such that the drop size is larger, the drug will prove to be more expensive per month.

That said, it will be erroneous to dismiss generics as unacceptable, and you must discuss with your doctor if you may use a generic product under supervision, provided your comfort is not compromised, and your doctor is assured of the product’s efficacy.

5. I have been prescribed eye drops. What are the side effects?

Listed below are the most common side effects of the common anti glaucoma medication. You can develop a hypersensitive reaction, or allergy to any medication. Almost all medications can potentially cause dryness of the eyes. The specific side effects of the usual groups of prescribed medications include:

• Prostaglandin Analogs: Change in eye color (especially for those with light eyes), pigmentation of eyelid skin, stinging, blurred vision, redness, itching, burning.
• Beta Blockers: Reduced pulse rate, fatigue, shortness of breath (especially in asthmatics), reduced libido, depression.
• Alpha Agonists: Stinging, fatigue, headache, drowsiness, dryness of the mouth and nose.
• Carbonic Anhydrase Inhibitors:

Eye drop: stinging, altered taste

Oral tablet: tingling hands and feet, stomach upset, confusion, depression, metabolic imbalances

6. I have been prescribed eye drops. How do I put them?

Remember to follow your doctor’s orders about dose and frequency. Please wash your hands before putting in your eye drops, and ensure that the tip of the dropper does not touch any part of your eye or hand.

If you have been prescribed more than one type of drop, make sure you wait five minutes before putting the next drop in.

Initially you may want to practice putting in your eye drops in front of a mirror. Tilt your head backward while sitting down. Fold a clean paper tissue into four and place it just below your lower lid. With your index finger gently pull down your lower lid to form a pocket.

Look up and squeeze one drop into the lower lid, and try and avoid blinking. Keep your eyes closed for two minutes and gently press on the inside corner of your closed eyes with your index finger. Blot around your eyes to remove any excess.

In case your hands shake, try approaching your eye from the side, while resting your hand on your face.

In case you are unable to grip or squeeze the eye drop bottle due to arthritis, ask your doctor for an assistive device.

7. I keep forgetting to put in my eye drops. What can I do to help?

You are not alone; lots of patients struggle to remember. That said, it’s important to put your eye drops as advised. A recurrent alarm on the phone usually helps, provided you respond to it immediately.

Unless your eye drop requires refrigeration (Xalatan does but only until you open it and start using it), you can keep it on your bedside and link it to an activity like taking off your glasses at bedtime.

Your smart phone has several apps that you can download, which have reminder facilities.

For Ios phones-

https://itunes.apple.com/us/app/eyedrops/id525362921?mt=8

For Android phones –

https://play.google.com/store/apps/details?id=com.eyedropsfree&hl=en

You can do the same for your doctor visits. You can also ask a friend or relative to also help you remember or schedule doctor appointments.

Laser:

8. I have been advised a laser iridotomy. What is that?

A laser peripheral iridotomy, or LPI, is advised by your doctor in order to make an alternate channel for drainage of the fluid in the eye, in case the drainage angles are compromised.

Your doctor will instil drops to make your pupil smaller, and thereafter a local anesthetic agent, so you feel no pain.

As in a gonioscopy, a lens will be placed in your eye so your doctor can see your iris better. You will be asked to focus on a red light, while the doctor will use the laser to make a small hole in the iris.

The process is slightly uncomfortable, and some patients report pain which is not intolerable. Your vision remains blurred for a maximum of three days after surgery, and your doctor will usually prescribe steroid drops for upto a week.

9. I have been advised selective laser trabeculoplasty. What is SLT?

Selective laser trabeculoplasty or SLT is a laser procedure that helps in increasing the outflow from the drainage angle of the eye. The doctor applies a low energy laser to the drainage angle, and immune modulators within the eye increase the outflow through this channel. It is usually prescribed for open angle glaucomas.

The doctor will instil some eye drops to close the pupil up to three times, so as to increase the visibility of the drainage angle. A drop of eye pressure lowering agent may also be instilled an hour before the procedure.

Just before SLT, the doctor will instil a drop of local anaesthetic, which may sting a little. After this, the doctor will ask you to sit comfortably with your face close to the headrest, with your chin in chinrest of the laser machine. He/ She will then insert a lens in the eye, as for your gonioscopy. You will be asked to look at a blinking red light while the doctor adjusts the focus of the laser. You might feel the laser as a small brief twinge or stinging.

After the procedure, you will be advised either steroid drops or non-steroidal anti-inflammatory eye drops, as needed, for up to a week. You will also  be asked to continue your glaucoma medication as before, and the doctor will want to measure your eye pressures an hour after your procedure. Most doctors will ask for a review after one week..

Peak effects of SLT take up to one to three months, and often the effect of SLT is temporary. It is therefore extremely important to remain under constant follow up after the procedure.

See more: https://www.youtube.com/watch?v=ZPuzM19KiRY

Surgery:

10. What is trabeculectomy? Why do I need trabeculectomy?

Trabeculectomy is a surgery performed to decrease the eye pressures. In case your doctor is not satisfied with the pressure control achieved in your eyes with drops, you will be advised a trabeculectomy.

Trabeculectomy involves creating a small pathway in the white part of the eye (sclera) so that the fluid inside the eye can drain out, under the conjunctiva. The drained fluid forms a bleb, a small elevation that you will be able to see just under your upper lid if you look into a mirror.

11. What is an Ahmed Glaucoma Valve?

An Ahmed Glaucoma Valve is a small silicone valve that is implanted in the eye to promote drainage of fluid from inside your eye to the space under your conjunctiva. Your doctor might also implant a small piece of donated sclera (white part of eye) to cover the tube and stop it from extruding.

12. Why am I getting an Ahmed Glaucoma Valve (AGV) implant and not a trabeculectomy?

Clinical trials all over the world have established that both procedures are equally effective and safe in the long term. If you have not had a previous surgery, your doctor can help you choose from either of the procedures, depending on what will suit you best.

In case you have had a failed trabeculectomy, your doctor will consider the Valve implantation, since the chances of success with a repeat trabeculectomy are lower.

In certain cases such as inflammatory, neovascular, and post VR surgery glaucomas, as also scarred corneas, the Valve implantation often has a better surgical result. Most doctors consider is prudent to use the Valve as a reserve procedure because of its higher cost.

13. What do I feel during the surgery?

Typically you will be given an injection to make the eye numb, and another intravenous injection to bring down your  eye pressures.

You will be made to lie on your back in the operating room, and a drape will be placed over your face after cleaning the area to be operated.

In case you are asthmatic, or feel claustrophobic, do let your doctor know and the anaesthetist will provide you with oxygen piped under it. There will a clip placed in the eye to make sure you don’t blink during surgery. You will see a bright light of the microscope, and your vision will get blurred as the surgery progresses.

You might feel some discomfort during the procedure, most of which gets exaggerated due to apprehension, but the surgery is mostly painless.

The surgery can take between 45 minutes to an hour, and you should be back with your friends and family in a couple of hours, depending on hospital policy.

14. What is recovery period like?

Most patients experience a drop in their central vision post-surgery, which slowly recovers back to normal. You might need a change of glasses, which your doctor will discuss with you.

You will be seen by your doctor on the day after your surgery; most doctors need you to wear an eye patch on the day of the surgery, to be opened on the morning after. Thereafter, depending on the status of your eye, you will be required to visit the doctor again after 3-7 days. Initially most doctors prefer to see you more frequently, and once your eye is stable, less regularly.

You will be required to use antibiotic drops, and steroid drops as prescribed by your doctor. You may also be asked to continue with some or all of your glaucoma medications during the early post-operative period.

15. Do I need to restrict my activity after trabeculectomy or AGV implantation?

You can resume gentle exercise like walking soon after surgery, in fact your doctor will encourage you to take lots of oral fluids and walk around soon after surgery. You will be advised to wear an eye shield for up to a week after surgery, while sleeping.

You can resume work in about two weeks, but strenuous weight lifting should be avoided for at least a month. Swimming also should be avoided for this duration.

16. What are risks of glaucoma surgery?

When your doctor has advised that you get your eyes operated for glaucoma, he has obviously considered the risks and benefits of surgery in your case, and decided that it is best to go ahead with surgery.

The important ones that you need to be aware of include:

Decreased Vision: The decrease in central vision may last for up to a few weeks due to inflammation, fluctuating eye pressures and bleeding within the eye.

Cataract: Your chances of getting cataract increase, and if you already have cataract the process might be accelerated.

Infection: There is an increased risk of infection, as after every surgery. With trabeculectomy, the increased risk is permanent.

Second surgery: There might be a need to perform an additional procedure or surgery to ensure optimal pressure control.