Glaucoma Surgery

Overview

The optic nerve is a network of nerve fibers at the back of the eye that transmits visual messages from the retina to the brain. Glaucoma is a gradual, persistent degeneration of the visual nerve. Glaucoma is typically caused or exacerbated by intraocular pressure (pressure within the eye) that is too high for the nerve's sustained health.

Although there is no cure for glaucoma, most patients may successfully manage their disease using eye drops, laser therapy, surgery, or a combination of all three.

What is Glaucoma?

Glaucoma is a condition caused by an increase in intraocular pressure. It is a dangerous condition that can cause blindness in a huge number of persons over the age of 60. The pressure buildup prevents fluid from draining from your eye. This impairs your eyesight by causing damage to your optic nerve. This condition can be treated in a variety of ways. Surgery is one among them, however it is typically the final resort if other therapies have failed.

The most common kind of glaucoma is open angle glaucoma, which occurs when the drainage pathways of the eye get gradually blocked over time. People experience little symptoms in the early stages. As a result, they are frequently not identified until their illness has progressed and they become aware of their impaired vision. Glaucoma, if left untreated, can result in blindness.

The goal of all glaucoma treatments is to reduce intraocular pressure (IOP) within the eye in order to avoid optic nerve degeneration, which leads to vision loss. Treatment differs from person to person, so please consult with your ophthalmologist to determine the best course of action for you.

While therapy helps prevent vision loss, it cannot restore sight that has already been lost due to glaucoma, which is why early identification is critical. 

How is glaucoma treated?

• Eye Drops
  In practice, eye drops are typically the first line of therapy, with patients undergoing surgery if their glaucoma is not sufficiently managed. Because of the possible hazards of surgery and a lack of data to warrant it, many ophthalmologists are hesitant to start with surgery, especially in advanced illness.
  
  The researchers sought to know if surgery or eye drops were better for avoiding vision loss and lowering glaucoma symptoms. They also wanted to know which was the safest and least expensive.
  
  
• Oral Medications
  Open-angle glaucoma can be treated with oral medication. This medicine is normally only used for a limited length of time since its efficacy diminishes with time and it frequently causes negative effects.

Do I Need Glaucoma Surgery?

It is used to treat glaucoma. A transparent fluid generally bathes the interior of the eye. The fluid enters and exits the front chamber of the eye. In most cases of glaucoma, this fluid exits the eye too slowly. The fluid accumulates and raises the pressure inside the eye. If this pressure is not regulated, it can cause eye injury and visual loss.

The purpose of this procedure is to reduce the amount of pressure in the eye. Reduced pressure may be required to avoid additional eyesight loss. While glaucoma surgery may save your residual eyesight, it does not enhance or restore sight.

Some of the surgical treatments available for glaucoma include:

• Laser Surgery
• Electrocautery 
• Drainage Implant Surgery
• Tube Implantation
• Microinvasive Glaucoma Surgery

Laser Surgery

Laser surgery is the most often used surgical option for many surgeons for treating glaucoma. Laser surgery is a procedure that can be performed in a clinic or at your doctor's office. Its benefit is that it is a technique that does not necessitate overnight hospitalization. This means you may undergo the treatment and then safely return home to resume your life.

Laser surgery uses a strong laser beam to remove fluid from your eyes. There are several types of laser therapy. They are as follows:

• Cyclophotocoagulation
  This occurs when your doctor directs a laser beam into a structure in your eye. Its objective is to relieve ocular strain. When other laser treatments have failed, this is typically the final resort
  
  
• Argon Laser Trabeculoplasty (ALT)
  ALT removes whatever is preventing fluid from flowing from your eyes. This is a standard therapy, although it does not work for everyone with glaucoma.
   
• Laser Peripheral Iridotomy (LPI)
  This is a laser beam that aids in the formation of a tiny hole in your iris. When the area between the iris of the eye is very narrow, this is excellent.
   
• Selective Laser Trabeculoplasty (SLT)
  This is when your doctor directs low-level laser beams only at the pressure spots in your eye. When ALT does not relieve the pressure, this is the next step. The majority of doctors recommend this as the initial option for laser glaucoma therapy.

What is a Glaucoma Drainage Implant?

Glaucoma drainage implants are tiny devices that are implanted in the eye to treat glaucoma. Glaucoma causes aqueous fluid to drain improperly from the front of the eye. The optic nerve is damaged when pressure builds up in the eye. Glaucoma can cause blindness if not addressed. A drainage implant (also known as an aqueous shunt or tube shunt) alters the way aqueous fluid drains from the eye. This aids in the reduction of ocular pressure.

When eyedrops and laser treatments have not sufficiently reduced your eye pressure, your ophthalmologist may propose a drainage implant. There is no therapy that can repair the optic nerve damage that has already occurred. However, drainage implants can assist prevent additional glaucoma damage.

How Is Glaucoma Drainage Implant Surgery Performed?

Glaucoma drainage implant surgery is performed in a hospital or an outpatient surgical facility. The operation typically takes an hour or less. What occurs is as follows:

• You will be given anaesthetic to numb the region around your eyes as well as medication to help you relax.
• There are several kinds of glaucoma drainage implants. A soft, flexible tube connects each to a tiny plate. That plate is very thin and contoured to fit snugly against your eyeball.
• A pocket will be created underneath the clear conjunctiva by your eye surgeon. The plate will be inserted into this pocket and will rest on the sclera. The thin tube connecting to the plate will be introduced into the anterior portion of your eye. This tube drains aqueous fluid from your eye, decreasing ocular pressure. The fluid forms a pool over the plate (called a reservoir or bleb). Your body naturally absorbs that fluid.
• Your eye may be patched after the treatment, and you may be required to wear the patch overnight. Make arrangements for someone to drive you home following the procedure. For few days to a few weeks, your eyesight may be hazy.
• Your ophthalmologist will prescribe medications that you must take for several weeks following the operation. These medications aid in the prevention of infection, pain, and scarring.
• As you recuperate, avoid bending over, straining, or lifting large things. Your eye doctor will give you precise advice and inform you when you may resume doing these activities.
• Most patients who have a glaucoma drainage implant will still need to take some glaucoma drugs. Your ophthalmologist will advise you on which drugs to discontinue or continue.
• In the weeks following surgery, you will need to see your ophthalmologist a few times for follow-up treatment. Make every effort to keep these appointments.

Microinvasive Glaucoma Surgery

Currently, trabecular microbypass stenting is a type of microinvasive glaucoma surgery in which a small stent, or tube, is put in the eye's natural drainage system, increasing fluid flow and lowering eye pressure. Patients who have this procedure may require less drugs to treat their glaucoma.

Trabecular microbypass stenting is often performed in conjunction with cataract surgery, a very popular outpatient treatment to remove the clouded lens of the eye. This combination method allows surgeons to address two problems with a single tiny incision. The recovery, safety, and complication rate of normal cataract surgery are unaffected by microinvasive glaucoma surgery.

Tube Implantation

Tube implantation is a technique in which a very small plastic tube is inserted into the eye to aid in the removal of fluid. During this procedure, you will be given a sedative to calm you, and your surgeon will use eye drops to numb your eyes. A short tube attached to a circular, flat plate is the principal equipment used in this technique.

Your surgeon will place the plate behind the eye, behind the top eyelid and against the eye itself. He or she then gently inserts the little tube that is attached to it into the front chamber of your eye, generally just in front of the iris (the colored part of your eye).

The idea is for the eye fluid to drain via the tube towards a collection region near the implant in the back of the eye, where it will be collected and reabsorbed into the circulation.

This treatment is quite successful in lowering ocular pressure, and the benefits are usually long-lasting. The operation can occasionally cause impaired vision, hemorrhage, pain, and low ocular pressure. As a result, the surgery is not available unless the eye is at danger of serious vision loss due to glaucoma.

What to Expect After Surgery?

Your eye is normally taped shut after glaucoma surgery, and a hard shield is placed over it. To allow for optimal healing, you put a dressing over the eye the first night following surgery and an eye shield at bedtime for the next four weeks.

It is recommended that you keep water out of your eye for a week following surgery and avoid any activities that strain it, such as reading, bending, or carrying heavy objects. If your eye becomes inflamed or uncomfortable as a result of the treatment, your doctor might prescribe medicine to make you feel better.

Your doctor may prescribe eye drops for many weeks to avoid infection and irritation. These drops are not the same as the ones you were using before to surgery. Your doctor may recommend a follow-up visit within a few days following surgery to monitor your eye pressure and search for symptoms of infection or inflammation.

If you use contacts or glasses, you may be recommended to acquire new ones since any procedure that decreases your eye pressure might change the shape of your eye and, as a result, your prescription.

Post-procedure Care

After the procedure, you may be given:

• An eye exam
• Eye drops
• An eye patch

Be sure to follow your doctor's instructions.

• Wear any eye patches or bandages as instructed.
• Use the eye drops exactly as directed. These drops are frequently used to prevent infection and irritation.
• Swimming and other activities that expose your eyes to water should be avoided.
• Inquire with your doctor about how to properly wash your face and when it is appropriate to shower or bathe.
• Refrain from hard lifting, straining, or driving until your doctor has cleared you.
• Follow your doctor's recommendations for resuming exercise and other activities.

Contact your doctor if any of the following occurs:

• Sudden and/or severe eye pain
• Loss of vision or other eyesight changes
• Signs of infection, including fever and chills
• Nausea or vomiting
• Redness, swelling, increasing pain, excessive bleeding, or any discharge from the eye
• Pain that you cannot control with the medicines you have been given
• Cough, shortness of breath, or chest pain

Benefits V.S Risks of Surgical Treatment

Glaucoma surgery, like any other operation, carries dangers. This page outlines several hazards so that you may have an open conversation with your eye surgeon (ophthalmologist). However, it is crucial to highlight that surgery has a very high success record in significantly delaying the course of glaucoma. The benefits of surgical surgery for advanced glaucoma cases often exceed the dangers. Discuss the following (rare) glaucoma surgery risks or side effects with your doctor:

• Vision Loss
  Glaucoma surgery momentarily impairs your eyesight following your procedure. It is critical to recognize that permanent eyesight can be decreased or perhaps lost entirely as a result of any of these glaucoma surgeries; nevertheless, vision loss is not a typical long-term adverse effect. As a result, surgery is more likely to help your eyesight in the long run.
  
  
• Bleeding
  Even with the greatest surgical methods, problems can arise with any of these operations. Bleeding inside the eye, infection, and fluid pockets behind the retina owing to extremely low ocular pressures are all uncommon or unusual consequences. Bleeding within the eye can be a major problem, so see your ophthalmologist if you are using blood thinners and follow his/her advice on whether to continue or discontinue the medication prior to surgery.
  
  
• Infection
  To avoid infection, eye specialists use medicines before, during, and after surgery, as well as strict sterile practices. However, infection inside the eye can develop on extremely rare instances, which can be quite dangerous and jeopardize vision. Infections can develop weeks, months, or even years after surgery. As a result, even if it's years later, if you see early indicators of infection, such as redness, discomfort, or excessive tearing, you should contact your ophthalmologist right away to treat the infection before it gets serious. Most infections can be effectively treated with antibiotic drops if detected early.
  
  
• Low Eye Pressure
  Eye pressures that are excessively low, often known as hypotony, can occur as a result of surgery. This is particularly typical right after surgery. Fluid may gather behind the retina (choroidal detachment) in hypotony, causing a shadow in your peripheral or side vision. This is usually only transient, as the pressure recovers to the desired levels. Sometimes, however, hypotony continues and surgery is required to correct the condition.
  
  
• Scarring
  These glaucoma procedures, which are more prevalent than eye pressures that are too low, may fail over time owing to the natural healing or scarring tendencies of the eye, resulting in ocular pressures that are greater than planned. Sometimes the scarring is so severe that the procedure fails to decrease the pressure and you must resume your glaucoma drugs, undergo clinic modifications, or repeat surgery in the operating room.
  
  
• Cataract
  Cataract production will most certainly be hastened by glaucoma surgery, although cataracts are quite straightforward to treat medically. If your ophthalmologist believes that the cataracts are having a moderate to major influence on your vision, glaucoma surgery may be coupled with cataract surgery. However, for some glaucoma procedures, it is preferable to do the glaucoma surgery first and then treat the cataract in a subsequent operation.

Safer Procedures on the Horizon

minimally invasive glaucoma surgery (MIGS) is a series of modern treatments that are typically paired with cataract surgery to reduce ocular pressure to the mid-teens range. The safety profile of these operations is often higher than that of the more typical glaucoma surgeries discussed above. This improved safety profile, however, is offset by a relatively moderate reduction in ocular pressure. As a result, for patients with early- to moderate-stage glaucoma, these treatments are generally paired with cataract surgery. MIGS operations are less likely to achieve the required low ocular pressures in individuals with advanced glaucoma.

Conclusion

Although glaucoma surgery can prevent additional vision loss and, in rare cases, enhance vision, glaucoma damage is considered irreversible and is not currently reversible with medication, laser surgery, ocular stents, or MIGS. While it is critical to understand the dangers described above, many of which are uncommon, it is equally critical to note that the great majority of glaucoma procedures are effective in halting the course of the disease and reaching the desired eye pressure. As a result, we recommend working with your ophthalmologist to investigate choices when the timing is opportune, rather than delaying treatment unnecessarily.