Glaucoma Treatment and Laser Surgery

Glaucoma is a family of diseases that damage the optic nerve. The optic nerve is the nerve that connects the eye and the brain.

Often the pressure in the eye with glaucoma is elevated. The eye is filled with fluid that is made and drained in the eye. A mismatch between fluid production and fluid drainage causes the pressure to be elevated.

Not all cases of glaucoma are caused by elevated pressure. There is a large percentage of glaucoma cases–about 40%– where pressures are not elevated.

Often the first signs of glaucoma are visible by looking at the optic nerve. The changes – called optic nerve cupping – are often seen years before a patient loses vision.

Normal Optic Nerve

The optic nerve cup on the image below is quite large. The “belly button” is abnormally big. The finding results from loss of the nerve fibers. There are usually about 1.2 million nerve fibers here. This one has less. A nerve that looks like this would make the doctor suspicious of glaucoma. The patient may be seeing well at this point. But further tests should be done.

Enlarged Optic Nerve

On the other hand, having elevated pressures does not necessarily mean that you have glaucoma. It can just be an indicator of high eye pressure or ocular hypertension. Sometimes an eye with a thick wall or cornea can fool the pressure measuring device into reading higher than it actually is. Often when the pressure is high, we measure the corneal thickness to be sure that we aren’t being fooled.

A note of caution, if the eye is not dilated, seeing this finding might be missed. That is one reason why dilation should not be skipped at your eye exam.

The vision loss due to glaucoma is measured by a computerized test called a visual field. A visual field test measures how dim a light needs to be before you don’t see it anymore. It measures this at several points in your field of vision and compares it to your prior tests and to a normal person’s results of the same age, sex, and glasses prescription. The field loss is usually subtle and not something you can see by waving a hand on the side of your head–at least early in the disease. The changes actually occur in the nose side of the vision first. This is often the same area served by the center vision of the other eye. So, it is easily missed.

There are other tests like optic nerve or ganglion cell layer OCT that measure thinning of the optic nerve layers. These can often help follow the disease early on.

Glaucoma treatment usually consists of lowering the pressure, whether the initial pressure is high or not. If low blood pressure or sleep apnea co-exist, they should be treated as well.

We can lower the eye pressure by 2 main methods: Reducing the fluid production in the eye or increasing the drainage out of the eye.

To do this, we have more than 10 different options of eye drop medications, 4 different kinds of laser treatments, and many surgical options. The surgical process has become much faster, with better results over the last 10 years.

Here are a few of the specialty glaucoma surgeries Dr. Mahootchi offers

• Laser Trabeculoplasty (ALT, SLT, and MLT)
• Micropulse Trans-scleral Laser Therapy (TLT)
• Hydrus
• I-stent (all versions)
• Goniotomy
• Canaloplasty
• XEN Gel Stent (we have done more of these than any doctor in the US for 2019 and 2020)
• Trabeculectomy (getting rarer as other options are available)
• Tube Shunts (getting rarer as other options are available)
• Laser Iridotomy and Iridoplasty
• ECP (endoscopic cyclo-photocoagulation)

Many of the surgical options can be done at the time of cataract surgery. This is important because many of these options are not paid for if not done with cataract surgery. These opportunities should not be missed.

Drops are nice but are not without long-term side effects. If you need two medicines, it’s probably time to consider what comes next. There are few good reasons to be on 3 medications as this rarely works and can make future options less successful.

The traditional glaucoma surgeries that can help fluid get out of the eye and lower the pressure are getting less common. Trabeculectomy has lost popularity to the XEN Gel Stent. It is the #1 surgical option for glaucoma in our practice and is chosen 99% of the time over trabeculectomy.

Glaucoma is a lifelong disease. Different Glaucoma treatments often work well at first but need to change later. So, follow-up is key.

Dr. Mahootchi has over 25 years of experience with glaucoma specialty surgery and care. Thousands of Tampa patients have trusted their eyes to his care. He is consistently rated a top doctor in Tampa and Florida.