Ideal Medical-Surgical Management

For Chronic Closed-Angle Glaucoma

Diagnostic Tests
• Contrast Sensitivity Tests

• Lenses

• Optic Nerve Imaging

• Optical Coherence Tomography (OCT)

• Pachymeters

• Spectral Domain OCT

• Tonometer

• Visual Field Test

Medical Therapy
No cure is available for glaucoma, but the disease can be controlled. Even with effective treatment,
patients must have regular eye examinations. Treatment often continues for the patient's lifetime.
Although burdensome, lifelong treatment is preferable to vision loss.

Lowering the IOP is the focus of treating patients with glaucoma. Lowering IOP is done to a level that is
not likely to cause further optic nerve damage; this level is referred to as the target pressure and is
determined by the ophthalmologist. High IOP may damage the optic nerve, which can lead to vision loss.
The level differs for each patient, and a patient's target pressure may change during the course of a
lifetime.

For open-angle glaucoma (the most common type), the ophthalmologist may prescribe medication to
lower IOP. Topical or oral medications, inserts (waferlike strips of medication that are put in the corner of
the eye), or eye ointments can be used.

Topical medications include the following:

• Miotics - Increase the outflow of aqueous humor from the eye

• Epinephrine compounds - Increase the outflow of aqueous humor from the eye
• Beta-blockers - Reduce the amount of aqueous humor produced in the eye
• Carbonic anhydrase inhibitors and alpha-adrenergic agonists - Reduce the amount of aqueous
humor produced in the eye
• Prostaglandin analogs - Work near the drainage area of the eye to increase the secondary route
of aqueous humor outflow to lower IOP

Oral medication can control IOP. Carbonic anhydrase inhibitors, which slow the production of aqueous
humor in the eye, are the most common.

Many of the same medications used to treat patients with open-angle glaucoma are used to treat patients
with angle-closure glaucoma. Angle-closure glaucoma can cause IOP to rise quickly. To rapidly lower the
pressure to prevent vision loss, the ophthalmologist may administer a sugar-based medication, called a
hyperosmotic agent, by either mouth or injection. The effects of this drug last only 6-8 hours; therefore, it
is not used for the long-term management of glaucoma.

Any medication, including eye drops, may have adverse effects. Most adverse effects are not serious and
usually resolve, and not every patient experiences them. However, patients with glaucoma must carefully
adhere to their prescribed treatments and discuss any adverse effects with their ophthalmologist. If an
adverse effect is serious enough or intolerable, the patient and the ophthalmologist may decide to change
the medication or the type of treatment.

Possible adverse effects associated with glaucoma medication include the following:

• Stinging or redness of eyes

• Blurred vision
• Headache
• Changes in pulse, heartbeat, or breathing
• Changes in sexual desire
• Mood changes
• Tingling of fingers and toes
• Drowsiness
• Loss of appetite
• Change of iris color (in patients with light-colored eyes taking prostaglandin analogs)

Surgical Therapy
For some patients, surgery might be the best option. Surgery may be performed first or after attempts to
lower IOP with medication are tried. Several types of surgery are available to treat patients with
glaucoma. The type and the severity of the glaucoma, the patient's other eye problems, and the patient's
health condition are all considerations in selecting the type of operation. Surgery may be performed by
using a laser or with more conventional approaches, such as incisional surgery, viscocanalostomy, or
shunt placement.

Laser surgery

Iridotomy is a laser surgery that is frequently used to treat patients with angle-closure glaucoma. The
laser makes a small hole in the iris to allow the aqueous humor to flow more freely within the eye. The iris
does not plug up the trabecular meshwork.

In cyclophotocoagulation (CPC), a laser is used to freeze selected areas of the ciliary body (the part of
the eye that produces the aqueous humor) to reduce fluid production. This procedure may be used to
treat more advanced or aggressive cases of glaucoma.

Most laser surgeries can be performed in the ophthalmologist's office or in an outpatient surgical facility.
Because patients usually have little discomfort, eye drops are used to numb the eye and are often the
only anesthetics needed for the duration of the procedure. Little recuperation is required. Patients may
have local eye irritation, but they can usually resume their normal activities within 1-2 days.

Incisional surgery

When vision loss is rapid or when medication and/or laser surgery fails to sufficiently lower the IOP,
incisional (conventional) surgery is the best option.

Filtering surgery is usually performed in a hospital or in an outpatient surgical center with local anesthesia
and sometimes sedation. Using delicate instruments, the ophthalmic surgeon removes a tiny piece of the
sclera, leaving a tiny hole. The aqueous humor can drain through this hole, thereby reducing IOP. The
bloodstream then reabsorbs the aqueous humor.
Some patients require the placement of an aqueous shunt (eg, Ahmed, Molteno, Baerveldt) in the eye
through a tiny incision in the sclera. It allows the fluid to flow out from the interior of the eye, where it can
be reabsorbed. This procedure may be performed under local anesthesia in the ophthalmologist's office
or in an outpatient surgical center.

Recuperation from incisional surgery is generally short. An eye patch is usually worn for a few days after
surgery. Activities that expose the eye to water (eg, showering, swimming) should be avoided. To avoid
complications, refraining from heavy exercise, straining, or driving for a short time may be recommended.

Viscocanalostomy

Viscocanalostomy was developed as an alternative to trabeculectomy. Although many viscocanalostomy

techniques are available, the procedure basically involves production of superficial and deep scleral flaps,
excision of the deep scleral flap to create a scleral reservoir, and unroofing of Schlemm canal. A high-
viscosity viscoelastic, such as sodium hyaluronate, is used to open the canal and create a passage from
a scleral reservoir to the canal. The superficial scleral flap is then sutured to become watertight, trapping
the viscoelastic until healing takes place.

According to a recent study (O'Brart, 2004), in terms of complete success and number of
antiglaucomatous medications required postoperatively, IOP control appears to be better with
trabeculectomy than with this procedure. However, viscocanalostomy is associated with fewer early
transient postoperative complications.

Shunt placement

The Ex-PRESS shunt is a 3-mm device that is inserted at the edge cornea. It is a microscopic conduit that
drains excess fluid out of the eye and into the tissues that surround the eye, where it cannot do any harm.

Standard glaucoma surgeries can take from 30 minutes to 1.5 hours, but surgery with this new shunt
takes 10 minutes.

According to 1 study (Wamsley, 2004), the incidence of complications after the implantation of an Ex-
PRESS shunt directly under the conjunctiva was unacceptably high, despite a significant reduction in the
IOP.