What glaucoma treatment options are there after medication resources have been exhausted?
Glaucoma Surgery Options
If intraocular pressure cannot be adequately controlled with oral or topical medications, glaucoma surgery may be needed. These are all outpatient procedures most commonly performed under monitored anesthesia care using, topical anesthesia, and a local anesthetic block. Please feel free to discuss which option your OCLI surgeon recommends.
Trabeculectomy is a surgical procedure used in the treatment of glaucoma to reduce intraocular pressure. It is the most common glaucoma surgery performed and allows drainage of aqueous humor from within the eye to just underneath the conjunctiva where it is absorbed by the adjacent structures.
Tube Shunt Surgery
Devices known as shunts, or tube-shunts are thin flexible plastic tubes connected to a silicone plate drainage surface. The tube drains the aqueous fluid present within the eye to the plate on the scleral surface beneath the conjunctiva. A space overlying the plate forms which allows fluid to exit, lowering the intraocular pressure.
This type of surgery may be performed if other surgeries fail. Other surgeries may be contraindicated due to risk factors for failure, causing tube shunt surgery to be chosen as the primary glaucoma procedure. Typically, one of two types of tube-shunt devices are used (Baerveldt, Ahmed).
Minimally Invasive Glaucoma Procedures (MIGS)
iStent is a microscopic titanium stent that drains aqueous fluid into the eye’s internal drainage canal (Schlemm’s canal). Pressure within the eye is lowered to prevent further glaucoma-related vision loss.
Presently the stent is implanted only during cataract surgery. Many people with glaucoma also suffer from cataracts. Because cataract surgery is usually a stitch-less procedure, the stent is implanted through the cataract surgery incision.
iStent is the first MIGS device that improves the eye’s natural fluid outflow to safely lower eye pressure by creating a permanent opening in the trabecular meshwork. “Glaucoma is often controlled with eye drops, which can very burdensome to patients. By using the iStent we have a solution that may reduce a patient’s dependency on glaucoma eye drop medication following cataract surgery”. – Dr. Caronia
Goniotomy is a surgical procedure in which the doctor uses a lens (goniolens) to see the structures in the front part of the eye (anterior chamber). An opening is made in the trabecular meshwork, the group of tiny canals located in the drainage angle, where fluid leaves the eye lowering intra ocular pressure.
Several methods for performing goniotomy are performed by our doctors including Trabectome, Kahook dual blade goniotomy, Canaloplasty, and ABIC (Ab Interno Canaloplasty).
A trabectome is an electro-surgical device that uses electrocautery to open the trabecular meshwork into Schlemm’s canal (Ab interno trabeculotomy) for management of adult, juvenile and infantile glaucoma. It may be combined with cataract surgery.
Kahook Dual Blade™
The Kahook Dual Blade (KDB) removes trabecular tissue through a clear corneal micro incision. This can be performed in conjunction with cataract surgery.
Canaloplasty is the dilation and/or unroofing of Schlemm’s Canal, the exit passageway of aqueous fluid from the eye. This can be performed externally by incising outer tissues to reach Schlemm’s canal.
A newer method where this is performed internally (Ab Interno Canaloplasty) uses a fine cannula to unroof the canal allowing intraocular pressure to be lowered. ABiC™ can be combined with cataract surgery, or as a stand-alone procedure.
This flexible plastic stent diverts aqueous fluid from the anterior chamber into the supra-choroidal vascular space inside the eye, lowering intraocular pressure. This procedure is combined with cataract surgery.
Inserting this soft microscopic bio-gel stent diverts aqueous fluid from the anterior chamber into the sub-conjunctival space, lowering intraocular pressure. This procedure is indicated for glaucoma where a trabeculectomy or tube shunt may be considered. It is a stand-alone procedure, or it may be combined with cataract surgery. More than ten thousand of these procedures have been performed worldwide for refractory glaucoma.
CycloPhotocoagulation (ECP) is a laser procedure which targets the fluid producing tissues (ciliary body) of the eye. By selectively treating this structure intraocular pressure can be reduced
Trans Scleral CycloPhotocoagulation (TSCPC)
TSCP is performed using a laser probe externally to the eye procedure which targets the fluid producing tissues (ciliary body) inside of the eye. By selectively treating this structure intraocular pressure can be reduced when other forms of glaucoma surgery are not indicated.
ECP is performed using a video camera guided laser probe inside the eye to selectively target the ciliary body. It is usually performed in eyes having cataract surgery or eyes that have previously undergone cataract surgery. Endoscopic CycloPhotocoagulation has proven to be highly effective in reducing or eliminating the need to continue using glaucoma medications in the majority of patients who receive this treatment. Studies have shown that the ECP procedure has significant success rate with a relatively low complication risk.