FREQUENTLY ASKED QUESTIONS

Surgery

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Q: What is the limit to the number of glaucoma surgeries a person can have over their lifetime?
A: The answer depends upon the type of surgery. With a trabeculectomy [the most common form of traditional surgery], it depends upon the patient and his/her condition. Only a doctor who is familiar with the patient’s history can answer this question. With a trabeculoplasty [the most common laser surgery], the limit is two per eye.

Patients are often unaware of the fact that there are a number of different laser treatments applicable to glaucoma, and this serves as a major source of confusion. Angle-closure glaucoma is an anatomic disease. The drain of the eye (the trabecular meshwork) is forced against it, usually by fluid pressure behind the iris, similar to putting a stopper over the drain of a sink. Laser iridotomy is the definitive treatment for angle-closure glaucoma. Medications should be used only as a temporary measure or if the intraocular pressure is still elevated after laser iridotomy has been performed. A second laser procedure, peripheral iridoplasty, is indicated in a small percentage of patients who have a more complicated from of angle-closure glaucoma known as plateau iris, when laser iridotomy is insufficient to eliminate the blockage of the trabecular meshwork by the iris.
In open-angle glaucoma, the trabecular meshwork is functionally impaired. Argon laser trabeculoplasty is the treatment applicable to the various diseases, which fall under the category of open-angle glaucoma. The most common of these are chronic (primary) open-angle glaucoma, exfoliation syndrome, and pigmentary glaucoma. It is still controversial as to what point to intervene with laser trabeculoplasty in open-angle glaucoma. When the procedure was first developed, it was regarded as a step between maximally tolerated medications and surgical intervention. However, over the past 15 years, it has become realized that, whereas some patients tolerate medications extremely well with no side effects whatsoever, others are seriously hampered in their quality of life. At the same time, surgical techniques have advanced and complications have diminished. The Glaucoma Laser Trail, a national multi-institutional prospective study sponsored by The National Eye Institute, shows that initial laser trabeculoplasty, performed in newly discovered chronic open-angle glaucoma patients prior to the institution of any medical therapy, compared favorably over a two year follow-up over eyes treared initially with medications. However, at the present time, most glaucoma specialists do not perform laser trabeculoplasty as the primary mode of therapy, but rather only if medical therapy is insufficient to control the disease. New medications approved for use in the past two years include apraclonidine (lopidine) and dorzolamide (Trusopt). Patients who have no detectable optic nerve or visual field damage are not candidates for laser trabeculopasty at the present time.

There is no specific intraocular pressure at which laser trabeculoplasty is indicated. The pressure, which is too high for an eye, is that pressure at which glaucoma damage progresses and this is usually in the 20’s or 30’s. If the pressure is in the 40’s, laser trabeculoplasty is unlikely to control the disease and surgery is indicated in most cases. I personally do not believe that laser trabeculoplasty is very useful in nomal tention glaucoma. Laser traeculoplasty is by and large a safe prolonged elevation of intraocilar pressure or severe inflammation.

Ideally, life for the patient should return to normal approximately six weeks after this surgical procedure. Clearly, caution should be used to avoid any trauma to the eye and it is advisable to wear goggles when swimming.

There is no blanket indication for a second opinion. Some insurance companies require one, some patients feel better having one, and some ophthalmologists feel better getting one. It all depends on the situation. In straightforward, uncomplicated glaucomas, it is probably not usually necessary, and in more complicated glaucoma it can be beneficial.

There are two types of laser procedures used for treating the most common forms of glaucoma. Argon laser trabeculoplasty is performed in treating open angle glaucoma. It is usually quite effective and generally used after topical medication is unsuccessful in controlling intraocular pressure. In open angle glaucoma, picture a sink with the stopper in and the water continuing to run. Eventually, the sink will overflow. Laser sugary opens the drain so the fluid has a way to drain from the eye. In narrow angle glaucoma or angle closure glaucoma, a laser iridectomy is used to pull the iris (the colored part of the eye) away from the drain from the eye. This procedure is successful in preventing damage from angle closure glaucoma.

Q: I was diagnosed with acute angle closure glaucoma in my left eye and have had laser surgery. I also have macula degenerative eye disease and cataracts. Since I depend mostly on my left eye to see, I have been very apprehensive about cataract surgery on this eye. Is there increased danger? I use Pilocar .01% four times daily. Should I get a second opinion?
A: It depends on the exact findings of your condition. You should get a second opinion from a glaucoma specialist to determine the risk factors.

Q: I have received two different opinions about glaucoma treatment – one favoring an operation and the other favoring the use of medicine as much as possible due to the complications of surgery – and I am interested in your opinion. If medication keeps the glaucoma in control, but the side effects are awful or make your quality of life not very pleasant, is an operation a better option? Will there eventually be a medicine or operation for glaucoma that will not have all the side effects? What should a person look for in a good eye doctor as far as treating glaucoma for life? The future just looks a little bleak if you have glaucoma, especially if you get it when you are under the age of fifty.
A: Open angle glaucoma with onset under the age of 50 is usually pigmentary glaucoma or juvenile open-angle glaucoma. Angle-closure glaucoma with onset under the age of 50 is usually caused by plateau iris. It can certainly be psychologically devastating to the patient to receive a diagnosis of glaucoma, but with appropriate treatment and timely intervention, a lifetime of continued functional vision is certainly possible. As with all chronic diseases, one should look for a physician in whom one has confidence and to whom one can relate.
It is certainly not unusual to receive differing opinions about the treatment of glaucoma. Most of us who are glaucoma specialists today probably would have been theologians in the 12th century. There are two important trends in the approach to treatment, which have developed over the past several years that should be taken into account.
Surgical intervention was formerly done as a last resort. It was fraught with complications and the success rate was not all that high. In the past decade, the use of anti-metabolites, such as 5-fluorouracil and mytomycin-C, in conjunction with glaucoma filtration surgery, has markedly increased the rate of success. At the same time, tighter would closure and post-laser suture lysis to titrate intraocular pressure has significantly reduced the complication of a flat anterior chamber, which used to be quite common. In essence, glaucoma surgery is safer and more effective than ever before. Routine trabeculectomy for uncomplicated open-angle glaucoma when performed as an initial surgical procedure in a patient who has not had previous intraocular surgery is a highly effective procedure. The chance of complications or surgical failure increases with previous intraocular surgery, complicated glaucoma, reoperations for glaucoma, and high myopia.
Quality of life is an important fact in the treatment of any chronic disease. Particularly if you have many years left to live, it is important to make a decision as to whether you want to spend those years with side effects, which make you miserable. You should first consider whether there is a way to eliminate the side effects of the medications you are presently taking. For instance, if you are taking pilocarpine eye drops which cause blurred vision and induced myopia, you could consider pilocarpine ocuserts which are extremely well tolerated by younger patients. Simple nasolacrimal occlusion can reduce or eliminate side effects of beta-blockers. If you are taking an oral carbonic anhydrase inhibitor, such as Diamox or Neptazane, you might ask your ophthalmologist about dorzolamide (Trusopt), a recently released topical carbonic anhydrase inhibitor. If none of this is effective and you are still suffering from intolerable side effects, or if your glaucoma is uncontrolled, then surgery is not an unreasonable option.

Q: How long should I expect to take off work if I need surgery for pigmentary glaucoma?
A: Laser surgery: 1 day
Trabeculectomy: at least one week, often 2 weeks, possibly longer.