Glaucoma Treatment
Goals of Treatment
The main goal of glaucoma treatment is to preserve vision and quality of life by preventing further damage to the optic nerve, which can lead to irreversible blindness. This is particularly important as glaucoma often results from elevated intraocular pressure. Since glaucoma damage is permanent, treatment strategies—such as minimally invasive glaucoma surgery and selective laser trabeculoplasty—focus on slowing or halting progression rather than restoring lost vision.
Lowering Intraocular Pressure (IOP)
The only proven method to slow or prevent glaucoma progression is to reduce intraocular pressure (IOP), regardless of the initial pressure or type of glaucoma. Target IOP is individualized based on disease severity, rate of progression, and patient factors such as age, health, and life expectancy. Typically, the target IOP is set 20–50% below the baseline IOP and adjusted over time, often incorporating treatments like minimally invasive glaucoma surgery or selective laser trabeculoplasty when necessary.
Preventing Optic Nerve Damage and Visual Field Loss
Regular monitoring with optic nerve imaging (OCT) and visual field testing is essential to track progression, especially in managing intraocular pressure. The aim is to maintain stable optic nerve appearance and visual fields over the patient’s lifetime, which may involve treatments such as minimally invasive glaucoma surgery or selective laser trabeculoplasty.
Selective Laser Trabeculoplasty (SLT)
SLT, or selective laser trabeculoplasty, is a gentle, in-office laser treatment that specifically targets the eye’s natural drainage system, known as the trabecular meshwork. This helps fluid exit more easily, thereby lowering intraocular pressure.
Why it’s often first:
- Effective for many patients with open-angle glaucoma or ocular hypertension.
- Reduced daily medication burden demonstrated in the LiGHT Study.
- Minimal recovery time; the procedure is usually painless.
- Can be repeated if the effect fades over time, depending on the initial response.
- Not suitable for every patient, and some risks do exist.
What to expect:
- A quick 2-3 minute laser session per eye.
- Temporary light sensitivity or redness may occur.
- Pressure will be rechecked the same day or within a week.
- Benefits may become noticeable over a period of 1-2 months.
Risks:
There may be a short-term pressure spike, inflammation, or limited response. While serious complications are rare, they are still possible.
EYE DROPS
Main Classes of Glaucoma Drops
Prostaglandin analogs (e.g., latanoprost, bimatoprost, travoprost)
How they work: Increase fluid outflow to help manage intraocular pressure.
Typical use: Once nightly
Common side effects: Redness, eyelash growth, darker iris/skin around eyes, mild irritation.
Beta-blockers (e.g., timolol, betaxolol)
How they work: Decrease fluid production, thereby aiding in the reduction of intraocular pressure.
Typical use: Once or twice daily
Common side effects: Burning/stinging, dry eyes.
Systemic cautions: Can slow heart rate, lower blood pressure, worsen asthma/COPD, or certain heart conditions—always inform your doctor about your medical history.
Alpha-agonists (e.g., brimonidine)
How they work: Decrease production and increase outflow to manage intraocular pressure effectively.
Typical use: Two to three times daily
Common side effects: Redness, dry mouth, fatigue; rare allergies may present with redness/follicles.
Carbonic anhydrase inhibitors (CAIs)
Drops: dorzolamide, brinzolamide (2–3× daily)
Oral: acetazolamide, methazolamide (short-term or special cases)
How they work: Decrease fluid production, which is crucial in controlling intraocular pressure.
Common side effects (drops): Burning/metallic taste; (oral): tingling fingers/toes, frequent urination, fatigue, kidney stone risk, electrolyte changes—typically associated with short-term use.
Rho-kinase (ROCK) inhibitors (e.g., netarsudil)
How they work: Increase outflow through the trabecular meshwork to help lower intraocular pressure.
Typical use: Once daily at night
Common side effects: Redness, small corneal deposits, mild irritation.
Combination drops (two medicines in one bottle)
These drops improve convenience, increase compliance, and may reduce preservative exposure, making them a preferred option for many patients considering minimally invasive glaucoma surgery or selective laser trabeculoplasty.
Minimally Invasive Glaucoma Surgery (MIGS)
A family of procedures known as minimally invasive glaucoma surgery (MIGS) enhance the eye’s natural drainage, typically through a small opening and with a lower risk profile. These procedures are designed to help manage intraocular pressure (IOP) effectively.
Who it’s for:
Mild to moderate open-angle glaucoma patients, especially those undergoing cataract surgery, can benefit significantly from these techniques. This approach is ideal for individuals looking to reduce their drop burden and achieve lower IOP with a safer profile compared to traditional surgery.
Common MIGS Approaches (examples):
Trabecular outflow (canal-based) methods, such as iStent, Hydrus, OMNI canaloplasty/trabeculotomy, and goniotomy procedures, aim to bypass or open the trabecular meshwork and Schlemm’s canal. Subconjunctival techniques like the XEN Gel Stent create a tiny channel to drain fluid to a bleb (small reservoir) under the conjunctiva. Less commonly used today, suprachoroidal methods enhance uveoscleral outflow.
Benefits:
MIGS procedures offer a lower risk and faster recovery compared to trabeculectomy or tube surgery, often leading to a decrease in the number of drops needed for managing intraocular pressure.
Limitations:
While these approaches can lower pressure, the reduction is typically modest compared to trabeculectomy or tube surgeries. Therefore, they may not suffice for advanced disease or those requiring very low target pressures.
Risks (vary by procedure):
Potential risks include transient bleeding (hyphema), inflammation, pressure fluctuations, device malposition or failure, and the possibility of needing additional procedures. Selective laser trabeculoplasty may also be considered as part of a comprehensive treatment strategy.
TRABECULECTOMY (“TRAB”)
A filtering surgery that creates a bypass for fluid to leave the eye under a protective flap, forming a bleb (a small, blister-like reservoir) on the white of the eye, hidden by the eyelid.
Who it’s for:
Moderate to advanced glaucoma when very low target pressures are required or when minimally invasive glaucoma surgery options like selective laser trabeculoplasty (SLT), drops, or MIGS are insufficient.
What to expect:
Outpatient surgery with stitches and anti-scarring medicines (e.g., mitomycin-C) to help the bleb work long-term. Frequent early post-op visits for pressure checks and adjustments will be necessary to monitor intraocular pressure. Activity restrictions will apply while healing.
Benefits:
This procedure is among the most powerful pressure-lowering options available for managing intraocular pressure effectively.
Risks:
Early: low pressure (hypotony), shallow chamber, bleeding, inflammation. Late: scarring/bleb failure, infection risk at the bleb (endophthalmitis, rare but serious), cataract progression, needling or revision.
Ahmen Valve (Tube Shunt)
A tube shunt implant, such as the Ahmed valve, channels fluid from inside the eye to a plate placed on the eye’s surface (under the tissues), where the fluid is absorbed, effectively helping to manage intraocular pressure. The Ahmed device features a built-in valve designed to minimize the risk of pressure dropping too low immediately after minimally invasive glaucoma surgery.
Who it’s for:
- Patients with moderate to advanced glaucoma
- Individuals with eyes at high risk for trabeculectomy failure, such as those with extensive scarring or certain types of secondary glaucoma
- Cases where prior surgeries or medications have proven inadequate
What to expect:
- Outpatient surgery
- Post-operative drops to prevent inflammation and infection
- Intraocular pressure may fluctuate as the eye heals around the plate
Benefits:
- Strong pressure-lowering effect; particularly useful when other treatment options, like selective laser trabeculoplasty, have failed or aren’t suitable
Risks:
- Potential for double vision (uncommon), tube exposure/erosion (rare but serious), corneal touch/edema if tube position changes, scarring around the plate limiting its effectiveness, and the possibility of needing future revision.
HOW WE CHOOSE THE RIGHT PLAN
At Inland Glaucoma Center, our UCLA Fellowship-Trained Glaucoma Expert will customize an evidence-based plan to protect your eyesight while minimizing risks and side effects. Our goal is to provide a treatment strategy that impacts your life as little as possible, maximizing both your quality of life and vision while safeguarding your precious eyesight.
We consider various factors, including disease stage and target intraocular pressure (how low do we need to go?), your life and preferences (daily drops vs. laser, recovery time, cost considerations), anatomy and prior surgeries (angle structure, scarring risk), and the safety and durability of the treatment (balancing pressure control and risk).
A common path for managing glaucoma includes selective laser trabeculoplasty (SLT) → drops as needed → minimally invasive glaucoma surgery (MIGS), often in conjunction with cataract surgery → trabeculectomy or tube shunt (Ahmed valve vs. Trab) if lower pressures are still necessary.
RECOVERY & FOLLOW-UP SNAPSHOT
SLT, or selective laser trabeculoplasty, typically returns patients to normal intraocular pressure the same day or by the next day, with follow-up appointments scheduled within days to weeks. For ongoing management, drops are prescribed for continuous use, along with periodic pressure checks and side-effect reviews. In the case of minimally invasive glaucoma surgery (MIGS), whether performed with or without cataract surgery, recovery takes days to weeks and comes with fewer restrictions compared to traditional surgery. Conversely, procedures like trabeculectomy or the Ahmed Valve may require weeks to months for recovery, necessitating more visits and activity limits initially, along with long-term monitoring for bleb or tube health, which carries a higher risk of complications.
TAKEAWAY
SLT, or selective laser trabeculoplasty, is a safe and effective first-line option for many patients dealing with elevated intraocular pressure. Eye drops work well when used consistently, and multiple classes of medication exist to tailor therapy to individual needs. Minimally invasive glaucoma surgery (MIGS) can lower pressure and reduce the burden of eye drops, allowing for quicker recovery, especially when performed alongside cataract surgery. For those requiring stronger pressure lowering, trabeculectomy and the Ahmed valve provide the most effective options, although they do involve more intensive aftercare. Your care team will personalize the treatment plan based on your eyes, overall health, and goals—always with the aim of preserving your sight.