Glaucoma surgery

What is glaucoma?

Glaucoma is a chronic eye disease, most often bilateral, associated with increased intraocular pressure over the level supported by the optic nerve that causes its damage over time. If the intraocular pressure remains high, it can reach blindness. There exists also a form of glaucoma with normal tension, in this case the condition being more difficult to diagnose and treat. Glaucoma can occur at any age, even at children, but is more common with people over 40 years. Also, people who have a family history of glaucoma have a more common risk of developing the disease. It is a progressive disease that lasts a lifetime, for which there is no cure yet known to treat it. Yet, with the right treatment, vision may be preserved for lifetime. When drug therapy fails, the surgery of glaucoma is recommended.

Classification of glaucoma:

Congenital glaucoma – is a rare disease (1/10.000 births), bilateral in 75% of cases, affecting more frequently male persons. It is associated with genetic abnormalities. It must be monitored carefully because it can lead frequently to severe visual handicap;
Primitive open angle glaucoma (POAG) – 60% of cases. It is associated with values of the intraocular pressure (IOP) higher than 21 mm Hg, presence of specific alterations of the visual field and open angle of the anterior chamber at gonioscopy in the absence of other causes of glaucoma;
Primitive closed angle glaucoma (PCAG) – 20% of cases (anatomical conformation = smaller eye, having the angle of the anterior chamber under 25 degrees, frequently patients with hypermetropy). The evolution and clinics of the primitive closed angle glaucoma is more dramatic compared to the POAG, as there exist 2 forms of the closing of the angle: acute attack of glaucoma and malignant glaucoma;
Secondary glaucoma with open angle: of ocular causes (exfoliation, pigment, inflammatory, post-traumatic, associated with intraocular tumors, ocular hemorrhage, induced cristalinian), or iatrogenic (caused by the corticosteroid treatment, postlaser));
Secondary glaucoma with closed angle: with pupillary block (determined by the intumescent cataract) or without pupillary block (neovascular glaucoma, post-inflammatory);

How is glaucoma manifested?

Glaucoma is a sly disease, which most often shows no sign to the patient, such as when the patient finds or becomes aware of a worsening of vision, it is most often too late. Any loss of vision which was produced until the time of diagnosis and starting of treatment is irreversible.

The causes of glaucoma are not known exactly, but among the risk factors we can mention: age (often 45-50 years), heredity, myopia, black race, c / d ratio of increased or asymmetric optic nerve.

Since glaucoma does not present sympthoms, the only way to find this disease early is to perform regular checkups and specific ophthalmologic investigations. Due to the technological evolution we have available various equipments and modern methods to diagnose glaucoma in time. Such an example is the visual field exam that shows how the optic nerve works. Optic nerve tomography allows us to check with the help of the laser the state of the nerve fibers of the optic nerve. Thus, we can diagnose glaucoma before it has clinical manifestations and can have a predictability of the risk of developing glaucoma. If glaucoma is already diagnosed, optic nerve tomography helps us to know how the optic nerve is affected, whether the treatment is effective, it simply helps us to monitor properly the disease.

Investigations necessary for diagnosing and monitoring the evolution of glaucoma

Fortunately, today there are effective methods to diagnose glaucoma on time, provided that any person who has more than 40 years goes to the eye doctor regularly and conducts investigations such as: measurement of intraocular pressure, fundus examination, examination of the field of vision, optic nerve tomography (evaluation of the status of nerve fibers of the optic nerve), pachimetry, pentachloro, etc.

For the diagnosing and monitoring of the evolution of glaucoma the following investigations are necessary:

Measurement of intraocular pressure (IOP) (preferably by Goldmann aplanotonometry), normal values are between 10-21 mmHg;
Pentacam – with this device we can check if the eye anatomy favors the appearance of glaucoma or i the value of the ocular pressure fits that eye;
Gonioscopy – which evaluates the anterior chamber angle (open or closed) and the presence of changes, because the treatment is different for the two forms of glaucoma (open angle or closed angle);
Fundus evaluation (FE) which determine the ratio c / d, the appearance of retinal blood vessels, the presence of hemorrhage on the optical disk. This investigation is done with pupil dilation drops;
Fundus stereophotography – to monitor changes in the optical disk;
Computerized perimetry (visual field) – shows functional changes of the optic nerve. Glaucoma starts in nasal peripheral area (the area where in binocular vision the visual fields of the two eyes overlap) and initially the patient does not perceive them. Subsequently, glaucoma progresses and in the final stages, it remains only a temporary vision island;
Corneal pachimetry – which measures the thickness of the cornea. Thin cornea is a risk factor for progression of galucoma;
Optic nerve imaging: Optical Coherence Tomography laser (OCT) of the optic nerve or of the retina. These investigations allow to detect structural changes of the optic nerve fibers, which precede the functional ones by 3-5 years.

Early and correct diagnosis of glaucoma is very important, as well as preventing the disease progression by repeated eye tests. Intraocular pressure and fundus examination should be carried out during all checks. Equally, 6 exams are required in the first 2 years after diagnosis of the visual field (VF), then every 6 months. Optical coherence tomography (OCT) and Pentacam is performed according to the doctor recommendation. It is very important that the results of the investigations (VF, OCT) are seen by an ophthalmologist, they must be interpreted in the clinical context and do not replace, in any way, the ophthalmologic consultation.

Treatment of glaucoma

The purpose of the antiglaucomatos treatment is to preserve the visual function and patient’s quality of life. The treatment should be individualized according to the disease stage, severity of the functional impairment, as well as depending on the patient’s age at the moment of the diagnosis. The treatment should be continuously evaluated based on the rate of disease progression.

The most important risk factor for glaucoma is believed to be elevated intraocular pressure, therefore the purpose of treatment is decreasing its value by reaching the target „intraocular pressure” (that value of IOP at which the glaucoma disease no longer advances or changes are minimal) but we also must keep in mind improving the microcirculation of the optic nerve and its neuroprotection.

Choosing the best treatment for each patient depends on the type of glaucome of the evolution stage of the disease:

Local medical treatment (drops) – at primitive open angle glaucoma and secondary open-angle glaucoma. The drops should be administered daily at fixed hours according to the doctor’s recommendation (every 8 hours, 12 hours or 24 hours) during the entire lifetime;
General medical treatment – upon the acute glaucoma attack, and pre- or post- operative. There should be administered tablets or vein infusions in order to lower intraocular pressure;
Laser
In case of primitive closed angle glaucoma (iridotomy, iridoplasty). Iridotomy must be practiced at the eye congener to the one developing the glaucoma attack, in order to prevent a possible attack of glaucome at this eye
In case of primitive open angle glaucoma (trabeculoplasty, iridoplasty);
Surgical
In case of congenital glaucome (first intention),
In case of acute glaucoma attack (does not respond to laser and medical treatment),
In case of primitive open angle glaucoma (uncompensated medical treatment, as well as to noncompliant patients or those with almost normal IOP values, but to which glaucoma continues to advance).

Medical treatment

It is important to know that most drugs are effective in reducing intraocular pressure. Most drugs of this type are in the form of eye drops. They are easy to administer, once or several times a day. If the ophthalmic solutions do not control enough the disease, laser treatment and then surgery are used.

You must understand that in order to have a good result in the best possible preservation of vision, there must exist an increased seriousness of the patient. The patient must strictly comply with the prescribed treatment and go to regular check-ups at the ophthalmologist. Checks will be made at different periods of time, depending on the case, in order to measure the intraocular pressure and do an examination of the fundus, and every six months there will be performed an examination of the visual field.

It should be noted that glaucoma can worsen without the patient realizing it, so it is very important a daily administration of the treatment. Patient with glaucome should be registered in the registry of the family doctor. He must know when to send immediately a patient to an ophthalmologist, considering that, for example, during the glaucoma attack, besides the ocular symtoms (blurred vision which may decrease rapidly, colored halos around light sources, ocular and periocular pain) there can appear also general symptoms that can dominate the picture (nausea, vomiting, adinamy, bradycardia, cold hands and feet), making differential diagnosis difficult.

Anti-glaucoma treatment is expensive, but registration with family doctors ensure for the patient access to subsidized drugs, most anti-glaucome drugs are free.

If medication or laser treatment does not work on lowering intraocular pressure, surgery is needed. After glaucoma surgery, lower intraocular pressure is expected, but medication can still be needed after surgery.

COMPLICATIONS AND RECOMMENDATIONS

See necessary tests

COMPLICATIONS (FORTUNATELY VERY RARE):

inflammations
infections
endophthalmitis
red eye
cataract
depigmentation of the choroid
ocular pain
ocular hypotonia (soft eye)
ocular or conjunctival hemorrhage
ineffective trabeculectomy (does not lower intraocular pressure)

RECOMMENDATIONS AFTER GLAUCOMA SURGERY

exposure to dust, wind is forbidden
swimming is forbidden (pool, lake, sea) for 6-8 weeks.
during the first 2 weeks after the surgery it is recommended to get help when washing your head in order not to get water in our eyes.
it is forbidden to wear make up for 6 weeks
it is forbidden to rub your eyes (it must be avoided for 3-4 months)
local trauma, strenuous efforts are forbidden especially in the first 6-8 weeks

Checks the next day and a week after the glaucoma surgery are free. Consultation is to be paid 6 weeks after the surgery. Mandatory checks after the surgery are: first day after surgery, after 6 weeks and then 2 times a year. These data may change depending on the case. About complications, risks, outcomes, the patient is informed during the preoperative consultation. For any questions or information contact one of our assistants.

Conclusion: glaucoma is an “insidious” disease, without noisy events, with an increasingly high incidence which if it is not treated in a correct way leads to permanent and irreversible blindness. Regular visits to the ophthalmologist, complete and accurate investigations, fair treatment administered according to the case made seriously by the patient can prevent unwanted effects of this disease.

Dr. Andrei Filip
Primary Doctor, Ophthalmologist specialist
Medical Science Doctor
Ama Optimex Ophthalmology clinic

Dr. Carmen Dragne
Primary Doctor
Ophthalmologist specialist
Ama Optimex Ophthalmology Clinic