Glaucoma is a group of eye diseases that lead to the progressive degeneration of the optic nerve and can cause gradual, irreversible vision loss if not detected and treated early. In a healthy eye, fluid circulates within the eye and drains out through a tissue called the trabecular meshwork, which is located at the angle between the iris and the cornea.
If the fluid does not drain properly, as in glaucoma, it builds up in the eye and raises the pressure inside. This elevated pressure damages the optic nerve, a bundle of nerve fibers located at the back of the eye that carries visual information from the eye to the brain. As the optic nerve fibers gradually deteriorate, the visual field constricts, and vision is eventually impaired.
Glaucoma symptoms vary depending on the primary cause of the disease. It is often referred to as the “silent thief of sight” because changes in vision usually go undetected until the disease reaches an advanced stage.
Treatments Available for Glaucoma
Glaucoma is treated by lowering the pressure inside the eye. Several treatment options are available
Medications
Prescription eye drops are a common treatment for glaucoma. These drops aim to increase fluid drainage from the eye or decrease fluid production, thereby reducing intraocular pressure (IOP) and preventing optic nerve damage. Oral medications may also be prescribed if eye drops alone are ineffective. While drops and pills effectively lower the pressure, they have multiple side effects, making them less ideal for long-term use. Moreover, they affect the quality of life
(Selective Laser Trabeculoplasty (SLT
Laser trabeculoplasty temporarily increases the eye’s ability to drain fluid efficiently and is an early option for patients with open-angle glaucoma. Using a small laser beam, this treatment allows the reopening of the clogged trabecular meshwork and restores its natural function. It is effective and safe
Incisional Surgery
When IOP cannot be controlled with laser treatment or medications, surgery is recommended. Additionally, glaucoma surgery is a good option to combine with cataract surgery. The two primary types of glaucoma surgery are minimally invasive glaucoma surgery (MIGS) and traditional glaucoma surgery
Minimally Invasive Glaucoma Surgery- (MIGS)
MIGS is a surgical option developed in the last two decades to lower intraocular pressure. Professional literature highlights excellent results among hundreds of thousands of patients worldwide. MIGS procedures are less invasive than traditional surgeries, have an excellent safety profile, and are often combined with cataract operations
The three common types of MIGS are:
Preserflo
Preserflo MicroShunt is a tiny, soft, flexible stent that helps drain excess fluid from the eye. It has consistently shown effective IOP reductions, averaging ≤15 mmHg in multiple clinical studies, and helps prevent further vision loss. The device is implanted during an outpatient surgical procedure under topical anesthesia, bypassing the clogged drainage system and creating an alternative pathway for fluid. The procedure is less invasive, more elegant, and way more predictable than traditional glaucoma surgeries
Goniotomy (GATT) or Kahook Dual Blade
Goniotomy is a highly efficient, minimally invasive glaucoma surgery. It involves opening the filtration system, often in combination with cataract surgery. The procedure is short and hardly adds to the complication rates of cataract surgery. By removing clogged tissue from the filtration systems with minimal damage to the surrounding tissues, the procedure allows for a reduction in eye pressure and restores normal drainage in the eye. The Kahook Dual Blade, a specifically designed blade, allows an elegant trabeculectomy at the angle. This is the less invasive procedure of the MIGS for its being done at the angle under gonioscopy without opening the conjunctiva and doesn't leave a device in the eye.
The success rates of Goniotomy surgery
The success rates of goniotomy surgery are high, up to 85%. Depending on factors such as the type of glaucoma, age, the extent of the disease, the structure of the eye, and the surgeon's experience. Patients may still need anti glaucoma drops after the surgery.
The success of the surgery is measured by the ability to significantly reduce the intraocular pressure and maintain visual quality over time.
Is it possible to go home on the day of the surgery?
The goniotomy is a surgical procedure that does not require hospitalization. The patient returns home on the day of the surgery and comes back for a follow-up the next day to rule out infection or inflammation. The patient is not allowed to drive on the day of the surgery due to medications that may cause drowsiness, so they must arrive with an escort.
When is it possible to return to nornal activity after a Goniotomy surgery?
As in any other eye surgery, it is necessary to avoid lifting heavy objects and engaging in strenuous physical activity for at least a week. It is possible that the acuity of the vision will not be optimal in the first few days after the surgery. Stabilization of the visual acuity may take several weeks.
iStent
The iStent inject creates a bypass pathway through the trabecular meshwork. The trabecular meshwork is the main source of resistance for aqueous fluid outflow, resulting in a multi-directional flow through Schlemm’s canal. It is the smallest medical device known to be implanted in the human body. It can effectively lower intraocular pressure and may reduce your reliance on glaucoma medications
Safety of MIGS
Although MIGS procedures are generally safe, some side effects may occur, including temporary vision reduction in case of bleeding, particularly for Goniotomy GATT or KDB. This reduction can last for a few hours to a few days, and resolves spontaneously. Other side effects include discomfort, red eye, blurred vision, or a sensation of a foreign body sensation in the eye. These side effects typically resolve within days to weeks after surgery
Traditional Glaucoma Surgeries
KDB\Goniotomy
Trabeculectomy is a type of glaucoma surgery that creates a new pathway for fluid inside the eye to be drained. During the procedure, a surgeon creates a flap in the sclera (the white part of the eye) beneath the upper eyelid. This flap allows fluid to drain, lowering intraocular pressure. The flap is then placed loosely back down against the sclera to protect the drainage pathway, and the entire surgery site is covered up using the conjuctiva. The procedure results in a small fluid blister, called a bleb, beneath the eyelid on the surface of the eye. The fluid in the bleb is absorbed by blood vessels and does not cause excessive tearing. The bleb is hidden by the upper eyelid and is not noticeable to others
Tubes
There are several types of glaucoma drainage implants, all have a soft and flexible tube connected to a small plate. The tube that is attached to the plate is inserted in the front part of the eye so that the aqueous fluid flows out of the eye through the tube. The fluid then collects into a pool over the plate and is naturally absorbed by the body. This surgery is intended for patients in whom all other techniques have failed
In summary, to protect your vision, you need to be diagnosed early enough and followed thoroughly with regular visits where your pressure is measured and progression is assessed with regular visual field and oct examinations.
Dr. Kaplan Messas has been trained extensively in glaucoma surgery and advanced anterior segment. She is a pioneer in the field of MIGS and is teaching numerous techniques in the US for many years at the “Association for Cataract and Refractive Surgery” (ASCRS). Our clinic is equipped with the most advanced technologies. For more than 20 years, we have performed the most complex surgeries with care and outstanding results.
