Consultant Ophthalmologist
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patient information

glaucoma

Questions to ask your doctor

If you have been diagnosed with glaucoma, obtaining treatment and following your treatment plan are essential to preserving your eyesight. 

As a newly diagnosed patient with glaucoma, you may need to have your eye pressure checked every week or month until it is under control. Even when your eye pressure is at a safe level, you may need to see your doctor several times a year for checkups. 

It is important that your doctor listens and responds to your concerns and questions, is willing to explain your treatment options, and is available for calls and checkups. If you do not feel confident and comfortable with your doctor, remember, you always have the right to seek a second opinion. A good working relationship with your eye doctor facilitates effective treatment.

The most recent diagnostic and treatment advances won’t help if you don’t obtain and follow the instructions from your doctor. Don’t be afraid to ask questions!

Ask questions about the medications, results and possible side effects. If side effects are intolerable, let your doctor(s) know as soon as possible so they can work on finding a more suitable medication.

Here are some specific questions you can ask to help you gather all of the information you need.

 

The basics of glaucoma

  • What type of glaucoma do I have?

  • Did something cause my condition? And if so, what?

  • How will my vision be affected now and in the future?

  • Is it hereditary? What should I tell my family about my condition?

  • What is my expected prognosis?

Treatment

  • What are my treatment options?

  • Which ones are most appropriate for me? Why?

  • What are the possible risks and side effects of this treatment?

  • What could happen without treatment?

  • What medications do you recommend? Will they interact with any other medications or dietary supplements I am taking?

  • How long will this treatment last?

  • How will I know if the treatment is working?

  • How often will I need checkups?

Lifestyle Changes

  • Should I follow a special diet?

  • What type of exercise could help my condition?

  • What special precautions should I take when working or driving?

  • Which activities should I avoid?

Support

  • Can you recommend any glaucoma support groups?

More tips for working with your doctor

  1. Make sure you have the information you need. Detailed regimens can be hard to remember. Ask the doctor to write out the treatment plan in large clear letters, and if necessary, color-code the medications and instructions.

  2. Bring a friend to your appointment. Ask a friend or family member to come with you to your appointment and help you capture all the details. This can be especially helpful if your diagnosis is recent, since the diagnosis may create a shock-like state that makes it hard to absorb all the information the doctor provides.

  3. Write things down. In addition to taking your own notes at the doctor's office, keep a journal of drug reactions, their timing, etc. so you won't have to rely on memory at your next appointment.

  4. Utilize the medical support team. Trained staff at your doctor's office, such as nurses and technicians, can be an enormous support to helping you manage your disease. These knowledgeable professionals can often give you the information, time, and attention that can make a big difference.

 


Understanding your diagnosis

Glaucoma is not a rare condition, with 2% of people over 40 having glaucoma and nearly 25% of all the follow ups in the eye clinic relating to glaucoma.

The diagnosis of glaucoma is made when your eye doctor notices damage in the optic nerve known as “cupping.” This diagnostic finding usually occurs with high pressure inside the eye, but not always. Around ten per cent of patients have normal pressure and the cause of the optic nerve damage is still debated.

A normal intraocular pressure (IOP) ranges between 11 and 21 mmHg (millimeters of mercury, a measurement of pressure). While it is more likely that you will have or develop glaucoma if your eye pressures are high, many people with high eye pressures never develop glaucoma. Furthermore, some people with glaucoma never have high eye pressures. Glaucoma with eye pressure in the normal range is known as “normal-tension glaucoma.”

Diagnostic Exams in glaucoma

During an exam, your doctor will use a machine called a "tonometer" to measure the pressure in your eyes. This requires putting yellow drops into the eyes - which consist of fluorescein and a local anaesthetic. In addition to checking your eye pressure, your eye doctor may use drops to dilate the pupil to examine your optic nerve.

Your doctor may also use a diagnostic machine such as the OCT  to visualize and assess damage to the optic nerve. This can sometimes show damage in eyes before it is suspected by the doctor’s examination. 

If damage is severe enough, vision changes can be detected on a peripheral vision test known as a Visual Field Test. Often the patient won’t notice peripheral vision changes until there is significant vision loss.

Once the glaucoma diagnosis is made either by optic nerve examination or visual field testing, treatment is initiated.

“Will I Go Blind?”

When faced with a new diagnosis of glaucoma there is one question that is foremost in every patient’s mind: “Will I go blind?” 

Fortunately for most patients the answer is no. Blindness does occur from glaucoma but with proper treatment, it is a relatively rare occurrence.

Loss of vision can occur even with the best treatment. Despite that sobering fact, correct treatment and follow-up will stabilize the vast majority of patients with glaucoma. A major factor in the treatment of your glaucoma is you. By correctly using your eye drops and being consistent in their use, a favorable outcome will be more likely.

Treatment for glaucoma

Today the only treatments available are those which lower the intraocular pressure. Lowering eye pressure can be accomplished using medicines, laser, or surgery. Treatment needs to be carried out for life. Glaucoma can be controlled, but there is currently no cure. 

When medication is chosen, eye drops are usually prescribed. Some of the drops need only be used once daily while some require twice or three times a day dosing. 

The SLT laser has been shown to be as effective a first treatment as eye drops. This is a simple, mostly painless, quick procedure that can control eye pressure for a period of up to 5 years in some patients. 

YAG peripheral iridotomy (PI) is designed to make a hole in the iris in order to allow fluid to take a different route around the eye - effectively an 'overflow valve.' This can prevent a sudden rise in pressure, otherwise known as an 'attack of glaucoma.' See the video below for more information.

Many surgeries are available and newer ones are being constantly developed and evaluated. Most of these are reserved for patients with more advanced glaucoma, but some newer surgeries are safe enough for use earlier in the disease. 

Choice of treatment depends on many factors which are unique to each patient and should be discussed with your doctor. Correct and timely treatment usually will protect against further vision loss. 

Glaucoma drops

Currently, in the UK, eye drops are often the first choice for treating patients. For many people a combination of medications and laser treatment can safely control eye pressure for years. 

Eye drops used in managing glaucoma decrease eye pressure by helping the eye’s fluid to drain better and/or decreasing the amount of fluid made by the eye. 

Drugs to treat glaucoma are classified by their active ingredient. These include: prostaglandin analogs, beta blockers, alpha agonists, carbonic anhydrase inhibitors, and rho kinase inhibitors. In addition, combination drugs are available for patients who require more than one type of medication. An older class of medications, the cholinergic agonists (such as pilocarpine) are not commonly used these days due to their side effects. 

 
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Types of Glaucoma Eye Drops

Prostaglandin analogs include Xalatan® (latanoprost), Lumigan® (bimatoprost), Travatan Z® (Travoprost), and Saflutan™ (tafluprost), and they work by increasing the outflow of fluid from the eye. They have few systemic side effects but are associated with changes to the eye itself, including change in iris color and growth of eyelashes. Depending on the individual, one of these preparations may be more effective and produce fewer side effects. Latanoprost is now available in generic form. Tafluprost and Latanoprost are available as a preservative-free prostaglandin analog.

Beta blockers such as timolol are the second most often used class of medication and work by decreasing production of fluid. They are available in generic form and, therefore, may be less expensive. Timolol is also available in a preservative-free formulation. Systemic side effects of beta blockers can be minimized by closing the eyes following application or using a technique called punctal occlusion that prevents the drug from entering the tear drainage duct and systemic circulation. 

Alpha agonists [Alphagan®P (brimonidine), Iopidine®] work to both decrease production of fluid and increase drainage. Alphagan is available in a generic form. 

Carbonic anhydrase inhibitors (CAIs) reduce eye pressure by decreasing the production of intraocular fluid. These are available as eye drops [Trusopt® (dorzolamide), Azopt® (brinzolamide)] as well as pills [Diamox (acetazolamide)]. Except for brinzolamide, all CAIs are available in generic form. 

Rho khinase inhibitors [Rhopressa® (netarsudil)] increase the drainage of intraocular fluid. This new class of glaucoma drug has been available in the US since April 2018 although have yet to become available in the UK

Combined medications can offer an alternative for patients who need more than one type of medication. In addition to the convenience of using one eyedrop bottle instead of two, there is decreased exposure to preservatives. There may also be a financial advantage, depending on your insurance plan. Cosopt® is a combination of a beta blocker (timolol) and a carbonic anhydrase inhibitor (dorzolamide) and is available in generic form and also as a preservative-free formulation (Cosopt® PF). Combigan® combines an alpha agonist (brimonidine) with a beta blocker (timolol). Simbrinza® is a beta blocker-free combination medication consisting of brinzolamide and brimonidine.

Preservative Free Medications are mow much more widely available. Preservative free versions of most of the above drops are now available and they are of particular benefit if you have ocular surface disease such as dry eye.

 
 
Short video by the International Glaucoma Association showing the correct way to instill eye drops.
 
 

laser treatments in glaucoma

 

If you are told that you have narrow angles, it may predispose you to having a sudden rise in eye pressure. This is also known as an 'attack of glaucoma.' This risk can be reduced by performing a YAG laser peripheral iridotomy or a lens extraction. Mr Modi will advise you which of the two would be better for your eyes.

 
 
 

Learn about treating glaucoma with laser trabeculoplasty. This areatment is for patients with open angles who need reduction in eye pressure.

 

Minimally Invasive and Standard Glaucoma Surgery

There are now a number of treatment options

  • Endoscopic cyclophotocoagulation is a laser treatment that can be performed at the same time as cataract surgery and through the same small incision. It takes only a few minutes and can reduce the production of the aqueous humour into the eye, thus reducing the eye pressure.

 
The picture on the right shows the laser probe pointing at the ciliary processes and they blanche with application of laser This is seen on a screen by the surgeon so it is a form of micro-laparoscopic laser surgery.

The picture on the right shows the laser probe pointing at the ciliary processes and they blanche with application of laser This is seen on a screen by the surgeon so it is a form of micro-laparoscopic laser surgery.

 
 
  • iStent inject is a small titanium stent that can be inserted into the drainage angle in the eye to improve the outflow of aqueous fluid from the eye. It can also be inserted at the same time as cataract surgery through the same micro-incision.

 
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Two iStents positioned in the drainage angle viewed through a gonioscope.

Two iStents positioned in the drainage angle viewed through a gonioscope.

 
 
  • Xen Gel Stent - this is a fine collagen tube that is again inserted through the drainage angle but this passes all the way through the eye into the subconjunctival space. An anti scarring drug (Mitomycin - C) is used at the same time to help stop the drainage pathway from scarring over and to maintain flow from the eye. It can be performed alongside cataract surgery.

This show insertion of the Xen gel stent through the trabecular meshwork all the way into the subconjunctival space where it will remain and drain fluid from inside the eye.

This show insertion of the Xen gel stent through the trabecular meshwork all the way into the subconjunctival space where it will remain and drain fluid from inside the eye.

 

What You Can Do to Manage Your Glaucoma?

Keeping track of glaucoma medications along with your other schedules and responsibilities can be challenging. 

By getting informed, making healthy choices, and keeping organized, you can establish a health routine that works for you. We hope you find the following tips helpful in managing your glaucoma.

Know Your glaucoma Medications

  • Tell everyone on your health care team, including your family doctor and other specialists, that you have glaucoma and what medications you are taking. This will help them in prescribing treatments that won’t interfere with your glaucoma medications. Be especially careful about using any medication that contains cortisone.

  • Some medications may cause you to experience strong side effects. Be sure to tell your doctor about any side effects you experience once you have started your medication. The intensity of your side effects may mean you need a different type of medication.

  • Let your doctor know if, for any reason, your medications are not working for you, or if your daily routine has changed. Your doctor may be able to solve such problems by changing the type or timing of your medications.

  • Report any changes to your doctor, especially eye irritation, watering, blurring or scratchiness, unusual discharge in the corner of your eye, temporarily cloudy vision, or rainbows around lights at night.

glaucoma Medication Tips

  • Make your medications part of your daily routine, perhaps by taking them when you get up, at mealtimes, and/or at bedtime. Use an alarm on your watch or phone to remind you when to take your medication.

  • If you forget to take your prescribed medication, take your medication when you remember, then get back on your regular schedule.

  • Get an extra supply of medication in case you misplace a bottle of eye drops or pills. Take an extra prescription along with you on trips away from home.

Stay Organized

  • Keep a record of each medication you are taking. Write down the name, dosage, and the number of times it should be taken each day. Keep it in your purse or wallet. This reminder can help you remember how often to use your medications.

  • Schedule your next checkup before you leave the doctor’s office, and put the appointment on your calendar or smartphone.

  • Go for a checkup before you go on a long trip or start a long-term, demanding project.

  • Write down any questions you have about your eyes, vision, or medications before you see your doctor. During your checkup, bring this list of questions, and write down your doctor’s answers.

Stay Healthy

  • Try to keep your eyes clean and free of irritants. Patients should be careful about eye cosmetics, use non-allergenic brands and replace them often.

  • Don’t rub your eyes, even though some glaucoma medications might make them feel itchy or blurry.

  • Wear goggles when swimming, and wear protective glasses when doing yard work or when playing contact sports.

  • Take care of the rest of your body. Keeping in good general health is just as important as taking care of your eyes.

  • Eating healthy foods, getting enough exercise, not smoking, not ingesting too much caffeine, and staying at a healthy weight are important. Check with your doctor before you start any strenuous exercise program.

  • Space out your fluid intake, and lower your salt intake. This will help prevent fluid retention.

  • Reduce the day-to-day stress in your life. Be sure to make time for fun and relaxation.

 

New technologies that are showing value in glaucoma management

 

Patients often ask if there is anything they can do themselves and with innovations in technology, self monitoring is becoming possible. Icare mHOME adds a new dimension to IOP monitoring. mHOME combines Icare HOME tonometry with the Icare CLINIC, Icare EXPORT and Icare PATIENT softwares that make transfer, storage and reporting of long term IOP data easy. It helps to understand IOP variations throughout the day, during the normal activities.