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Vision Special Report

Your Glaucoma Treatment Options

Eyedrops are the most common treatment for glaucoma, a vision-threatening disorder that affects more than two million Americans. But for about 10% of patients, eyedrops are not sufficient. In those cases, laser therapy or surgery is usually recommended to prevent further vision loss.

While a number of risk factors are associated with glaucoma, the clearest cause of the disease is increased pressure in the eye -- intraocular pressure, or IOP -- that damages the optic nerve and can lead to blindness. Among people who have open-angle glaucoma, which accounts for 90% of all glaucoma cases, the damage progresses slowly and produces no obvious symptoms until its late stages.

Three treatments are currently available for glaucoma: Medications (eyedrops and, less commonly, oral medications), laser therapy, and surgery.

Eyedrops for glaucoma. Eyedrops lower IOP by either blocking excess production of aqueous humor (eye fluid) or increasing fluid drainage out of the eye. In many glaucoma patients, eyedrops can be just as effective as surgery.

Some people do not respond to eyedrop medication. However, a more common problem is that many patients do not use their eyedrops as prescribed. Because glaucoma produces no vision loss at first, some forget -- or don't bother -- to take drops regularly. Some glaucoma patients (for example, those with painful arthritis or essential tremor) have difficulty getting drops into the eye. Others stop using drops to avoid side effects, such as eye redness or burning. Cost also can be a reason to skip medications that must be taken for the rest of a patient's life.

Laser trabeculoplasty for glaucoma. When eyedrops do not reduce IOP, glaucoma patients typically turn to laser trabeculoplasty, a noninvasive procedure that uses a laser to increase drainage of aqueous humor. But for many, the effects don't last: About 40% of people who undergo laser trabeculoplasty require additional medication or some form of surgery within five years.

Trabeculectomy or filtration surgery for glaucoma. If a laser procedure does not help, the next step is surgery. Most doctors first use a procedure called trabeculectomy, also called filtration surgery. During trabeculectomy, the surgeon removes a small piece of the eye wall (the white of the eye, or sclera) to create a fluid-drainage channel. Excess fluid is then absorbed by blood vessels around the eye. The surgeon can use adjustable sutures on a drainage flap created during surgery to control IOP.

Glaucoma implants. Glaucoma implants are another surgical option. In this procedure, a plastic drainage tube, or "shunt," is placed in the front chamber of the eye. Fluid drains through the shunt and onto a small plate that is sewn onto the side of the eye. Surrounding tissues absorb the fluid from the plate. Implant surgery is effective, but there is reluctance to use shunts in patients who might instead benefit from trabeculectomy.

A doctor will consider implants if a patient has already had one or more trabeculectomies or other eye surgeries and their IOP is not controlled -- or if other eye problems (including scarring from previous eye surgeries) make trabeculectomy less likely to work.

Posted in Vision on March 12, 2010

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