GLAUCOMA MODERN TREATMENT METHODS ORALOV BEKHRUZ Glaucoma is

GLAUCOMA MODERN TREATMENT METHODS ORALOV BEKHRUZ

ü Glaucoma is sometimes labeled the “silent thief of sight” because it results in peripheral vision loss without any warning symptoms. ü However, with early detection and modern treatment methods, about 90% of people can avoid vision loss due to glaucoma. What Is Glaucoma? ü The eye has an internal fluid system that is constantly producing liquid that starts inside the eye, then drains out onto the surface where it becomes the tear fluid that keeps your eyes from drying out. ü In most types of glaucoma, the drainage ducts of the eye become clogged or blocked, preventing fluid from draining out of the eye. ü This leads to an increase in pressure in the eye (called the intraocular pressure) and this pressure damages the optic nerve.

TYPES OF GLAUCOMA Open angle glaucoma is the most common type of glaucoma. It occurs when an accumulation of sediment gradually clogs the drainage ducts of the eye: 1. african-americans 2. hispanics 3. persons over age 60 4. steroid users 5. persons with high blood pressure. 6. if you have a family history of glaucoma, you are at elevated risk. Angle closure glaucoma occurs when the iris blocks the drainage ducts. Because this can suddenly cut off fluid drainage, causing a dramatic increase in intraocular pressure and rapid damage to the optic nerve, it is sometimes called acute glaucoma. It requires emergency attention. It is more common in people who are farsighted, Asian-Americans, and women. Risk also increases with age. If you experience: • eye pain • halos • nausea • vomiting • vision loss • you may be having an attack of acute glaucoma and should get emergency care.

ü Secondary glaucoma is when clogging of the drainage angle is caused by something else, such as injury to the eye, eye cancer, cornea overgrowth, infection, or other causes. It can have effects similar to either open angle or angle closure glaucoma. Risk factors are related to the primary causes. ü Pediatric glaucoma is when children suffer glaucoma. Most commonly, a child is born with elevated intraocular pressure. This affects about 1 in 10, 000 infants, and seems to be genetic. ü Normal tension glaucoma occurs when the optic nerve suffers damage without elevated intraocular pressure. This is more likely in people with a family history of glaucoma, cardiovascular disease, or Japanese ancestry.

SIGNS AND SYMPTOMS ü Open angle and chronic angle-closure. A visit to an optometrist or ophthalmologist might show that an individual who has either of the two common types will have abnormalities in their optic nerve endings and visual field loss. ü Acute angle-closure. Although it is not as common as the other two types, it has a characteristic sign of the impairment. Most patients reported the occurrence of severe and chronic eye pain, visual blurring, nausea and vomiting, and headache. The eyes can also appear reddish and the pupils might be dilated but shows no reaction to light. In the naked eye, a person with acute-angle closure might look cloudy. Optometrists and Ophthalmologists often note a decrease in visual clarity, closed drainage angle, and swelling of the corneal tissue. ü Elevated intraocular pressure (IOP). In cases of glaucoma, the most detected condition is when there is an increase in the pressure of the fluid of the eyes. This is due to the build-up of aqueous humor, a natural clear fluid that is secreted in between the cornea and the eye lens. During the development stages of the disease, a person’s aqueous humor will not be filtered or drained properly in the trabecular meshwork, thus a buildup can occur. ü Although there is still no known cure for glaucoma, medical researchers have definitely made a progress that can help in providing modern treatment methods for this kind of eye disease. In most cases it can be stopped from progressing or slowed downed.

ü Discovery of myocillin. The discovery of this natural fluid has led researchers into creating a model-type module that helps in simulating the occurrence of glaucoma. Through these methods, they are able to study the molecular mechanisms that take place in the onset of the disease, leading them to produce oral medicines, topical eye drops, as well as laser therapies which can delay or prevent the damages of elevated intraocular pressure among patients. ü Prescription medicines. For several years, a topical treatment method has also been introduced, namely latanoprost and dorzolamide, as well as the development of non-invasive treatment method that facilitates the application of topical medicine to the patients’ eyes. ü OPA-6566. This is another drug that is still being developed by Acucela and Otsuka Pharmaceutical which aims to lower IOP, and at the same time, decrease the probability of any unwanted side effects to the system.

Glaucoma treatment has greatly evolved for the past 30 years. From eye drops to eye surgery, a myriad of treatment options are now available for glaucoma patients. Though it has been previously a practice of glaucoma specialist since the 60’s to begin treatment with a wide array of eye medications like : • Miotics • Beta-blockers • Prostaglandin analogs ( pilocarpine, timolol and latanoprost) As examples respectively, they are now slowly being replaced by sophisticated procedures like: • Canaloplasty • Viscocanalostomy • Sclerotomy. The advantage of these modern glaucoma cures is that they are far safer than and just as good in terms of lowering intraocular pressure as traditional eye surgery called trabeculectomy. Clinical trials have proven this, with early surgery saving the patient the inconvenience of applying eye drops each day and from suffering from their many side effects. Since majority of glaucoma patients are in their advanced years, it is expected for them to have medical comorbidities like diabetes, hypertension and heart disease. Thus, eye medications in these cases can do more harm than good

Therapeutic trends show a growing number of glaucoma specialist foregoing medicines altogether and proceeding to glaucoma treatment surgery. The catch with traditional eye filtering surgery like trabeculectomy however, is its high rate of post-operative complications like infection, eye trauma and scarring. Trabeculectomy is often reserved only for those who have frank angle closure glaucoma- a severe form of glaucoma wherein patients are at the brink of blindness, and those whose remain to have uncontrolled eye pressures despite years of medication and laser. BUT WITH THE ADVENT OF NON-PENETRATING SURGERY USING : • Artificial drainage devices (ADD) • Collagen implants ( deep sclerotomy) • Micro catheter technologies(viscocanalostomy & canaloplasty) The treatment middle ground may not be far behind. One of the amazing and most promising among these is canaloplasty, which uses a flexible tube as thin as a human strand of hair to create an alternate bypass and enlarge the normal fluid channels without interfering with the rest of the structures of the eye.

Glaucoma Surgery involves either laser treatment or making a cut in the eye to reduce the intraocular pressure (IOP). The type of surgery your doctor recommends will depend on the type and severity of your glaucoma and the general health of your eye. Surgery can help lower pressure when medication is not sufficient, however it cannot reverse vision loss. Glaucoma surgery is indicated when intraoculare pressure is very high or the optic nerve is badly damaged and unresponsive to topical medication. Laser surgery is usually performed in the initial stages of glaucoma and is used to reduce the number of topical medications needed to control intraocular pressure. There are several types of glaucoma microsurgery. They can be divided in penetrating and non-penetrating glaucoma surgery. LASER PERIPHERAL IRIDOTOMY (LPI) ü Narrow-angle glaucoma occurs when the angle between the iris and the cornea in the eye is too small. ü This causes the iris to block fluid drainage, increasing inner eye pressure. ü LPI makes a small hole in the iris, allowing it to fall back from the fluid channel and helping the fluid drain.

ARGON LASER TRABECULOPLASTY (ALT) v The laser beam opens the fluid channels of the eye, helping the drainage system work better. v In many cases, medication will still be needed. Usually, half the fluid channels are treated first. v If necessary, the other fluid channels can be treated in a separate session another time. v This method prevents over-correction and lowers the risk of increased pressure following surgery. v Argon laser trabeculoplasty has successfully lowered eye pressure in up to 75% of patients treated. SELECTIVE LASER TRABECULOPLASTY (SLT) v SLT uses a combination of frequencies that allow the laser to work at very low levels. v It treats specific cells "selectively, " leaving untreated portions of the trabecular meshwork intact. v For this reason, it is believed that SLT, unlike other types of laser surgery, may be safely repeated many times.

FILTERING MICROSURGERY When medicines and laser surgeries do not lower eye pressure adequately, doctors may recommend a procedure called filtering microsurgery. THERE ARE TWO TYPES OF FILTERING SURGERY: 1. penetrating - the most common type of penetrating surgery is: TRABECULECTOMY 1. non-penetrating - the most common type of non-penetrating surgery is: DEEP SCLERECTOMY Ø In trabeculectomy, a tiny drainage hole is made in the sclera (the white part of the eye). The new drainage hole allows fluid to flow out of the eye and helps lower eye pressure. This prevents or reduces damage to the optic nerve. Ø In non-penetrating deep sclerectomy (NPDS), a deep scleral flap is removed, leading to the formation of an empty scleral space called an 'aqueous decompression space', wherein the aqueous humor will be collected before its drainage. In order to keep the aqueous decompression space open, different implant devices have been proposed such as collagen Aquaflow implants, reticulated hyaluronic acid implants, and the T Flux implant.

FILTRATION DEVICE SURGERY A glaucoma implant consists of a very small plate with a unique valve system that regulates your eye pressure. Attached to the plate is a tube that drains the fluid out of the eye, thus reducing the eye pressure. The implant is outside the eye but it is covered by the skin of the eye so it cant be seen or felt. Implant surgery immediately reduces the pressure in the eye by giving the fluid a means to drain out more efficiently. Because the glaucoma implant is a valve, it adjusts itself according to the fluid pressure in the eye. There is a precise control on the amount of fluid that is allowed to flow through it. This ensures that there is no excessive drainage from the eye, which can be a serious problem. Implant surgery is done on an outpatient basis under local anesthesia. The total procedure takes about one hour. Postoperatively, you will need to take some medications until your eye is completely healed, and any pain medication for any discomfort you feel. Regular follow-up exams will track the pressure changes in your eye and ensure that the glaucoma implant is working successfully. This type of surgery in performed in patients with previous glaucoma surgeries and / or poor conjunctival tissue where filtering microsurgery may not be as successful.

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