Glaucoma, a group of eye conditions in which the pressure in one or both of your eyes increases and damages your optic nerve, is a sneaky disease with no symptoms in its early stages.
If it’s left untreated, you can lose your sight. Although there is no cure, if it’s detected and treated early, treatment can usually stop or significantly slow down vision loss. Because glaucoma is progressive, the best treatment for you will depend on what stage of the disease you’re in, but the choices are pretty straightforward: eye drops, laser therapy and surgery.
Eye drops are typically the most common treatment and the one your doctor will likely start with. There are several different types of eye drops that each help decrease the pressure in your eye in different ways. They also have different side effects, though most people don’t notice these.
1. Prostaglandin analogs: “Prostaglandins are the No. 1 prescribed medication, the gold standard,” says Steven Anderson, MD, an ophthalmologist and glaucoma specialist at Sanford Eye and Optical in Fargo, ND. “The beauty of a prostaglandin analog is that it has fewer systemic side effects, it’s a once-a-day drug that lasts for 24 hours, and it’s very effective.” Prostaglandin analogs such as Xalatan (latanoprost) and Travatan (travoprost) lower eye pressure by increasing the outward flow of the fluid in your eye. Possible side effects include eye irritation, dry eye, blurry or cloudy vision and headache.
2. Beta blockers: Once the gold standard before the advent of prostaglandins, these drops lower eye pressure by reducing the amount of fluid your eye produces, slowing down the flow. Examples include Alphagan (brimonidine) and Timoptic (timolol). Possible side effects include eye irritation, fatigue, double vision, headache and dizziness. Barbara Roman, 65, had to switch from Alphagan and Timoptic because both made her extremely tired and drowsy. She’s now on Azopt (brinzolamide), a carbonic anhydrase inhibitor (see #5), and Xalatan (Prostaglandin, #1), and doesn’t notice any side effects at all.
3. Alpha adrenergic agonists: Lopidine (apraclonidine) and Propine (dipivefrin) are 2 types. These drops lower eye pressure by reducing the amount of fluid your eye produces and increasing the outward flow of fluid. Potential side effects include eye irritation, swelling or pain, blurry vision, fatigue and dry mouth. These drops often cause an allergic reaction.
4. Miotic or cholinergic agents: These eye drops force your pupil to become smaller and help fluid drainage. Examples include Isopto Carpine (pilocarpine) and Phospholine Iodide (echothiophate). They can cause nearsightedness and blurry or dim vision.
5. Carbonic anhydrase inhibitors: Trusopt (dorzolamide) and Azopt (brinzolamide) are eye drops that reduce your eye’s fluid production, though they aren’t used often. This type can also be given as an oral medication like Diamox (acetazolamide) or Neptazane (methazolamide). “I usually use oral medication as a bridge for getting to surgery or when I’m really limited for medication options,” says Dr. Anderson. “The problem is that they can cause a lot of side effects like rashes, lethargy, loss of appetite, a metallic taste in your mouth, electrolyte imbalances and tingling in your hands and feet.”
6. Combination eye drops: These drops use 2 drug types in one drop to get even better results. Examples include Cosopt (dorzolamide [#5] and timolol [#2]), Xalacom (latanoprost [#1] and timolol [#2]), Simbrinza (brinzolamide [#5] and brimonidine [#2]) and Combigan (brimonidine [#2] and timolol [#2]).
Laser therapy is the most commonly used procedure for glaucoma and its effect is equivalent to using a single glaucoma medication, says Dr. Anderson.
“It’s an option for a patient who doesn’t want to do drops or who may have a hard time using them,” he says. “You may do it as a first-line agent, or you may use it as an adjunct [supplemental] agent.”
Laser therapy can also be used for people whose medication is creating significant side effects or who are already on 2 or 3 eye drops and still aren’t achieving lower pressure. While the procedure alone may effectively control your eye pressure, you may need one or more glaucoma medications as well.
Laser procedures are performed on an outpatient basis in your ophthalmologist’s office with numbing drops, a contact lens and specific laser targets. Though the procedure usually results in decreased eye pressure, how long the effects last depends on your age, other medical conditions and the type of glaucoma you have. Additional procedures may be necessary later.
Trabeculoplasty: “The most popular [laser therapy] now is the selective laser trabeculoplasty [SLT], which is a newer version of the old argon laser trabeculoplasty. It treats the area within the eye where the fluid filters out,” says Dr. Anderson. “The SLT laser cleans up any pigment and debris that’s clogging up the filter and stimulates the body’s own immune system to come in there and clean up the filter to get better flow in a more natural way.”
One big difference between the SLT laser and the argon laser is that the latter tends to cause scar tissue, reducing its ability to be repeated, and over time becoming less effective. “The SLT laser is a different frequency and so it doesn’t really scar the filtering mechanism, meaning that you can repeat [the procedure] more effectively,” Dr. Anderson says.
Other types: Other types of laser treatments include laser peripheral iridotomy, cyclophotocoagulation and scatter panretinal photocoagulation. The side effects of laser therapy are minimal. Inflammation and discomfort do occur, but they’re generally mild and easily treated with drops. Eye pressure spikes are a risk, but rare. This did happen to Roman after one of many laser treatments, and she had to have an emergency needle procedure to get the pressure down.
Mary Gordon, 70, was diagnosed with acute angle-closure glaucoma 15 years ago and has had multiple trabeculoplasties, as well as many laser peripheral iridotomies, in which one or more holes are made in your iris with a laser. “The procedures were easy, done at the office, and there was no pain and no recovery time,” she says.
Roman was diagnosed with early-onset open-angle glaucoma when her kids were still young. “It was a shock to get this diagnosis at such a young age and I hadn’t noticed any symptoms,” she says. “Understandably, I now crusade friends and family to get checked.”
Her glaucoma is thought to be one outcome from the chemotherapy, radiation and prednisone she had for stage 4 lymphoma in 1983. She has also had multiple laser treatments “hoping to arrest progression, but unfortunately, glaucoma continues to progress,” she says. “It was surprising to me that laser treatments have been quick, easy and painless.”
Glaucoma surgery is usually reserved for patients for whom medications and laser treatments haven’t worked. “When you’re judging a patient with glaucoma, you think, ‘What is the ideal pressure for this patient?’ If they’re above that ideal pressure either on drops or after having laser therapy, then surgery is considered because we’re trying to prevent irreversible vision loss,” says Dr. Anderson. Most of these surgeries will involve a hospital or surgery center and recovery may take a few weeks.
Minimally invasive glaucoma surgery (MIGS): This surgery uses “microscopic metal or synthetic tubes in the eye to provide another pathway for the fluid to get out to lower the pressure,” Dr. Anderson says. It’s being researched and developed as a safer way to treat glaucoma than traditional surgery, while also potentially lessening your need for eye drops. One type of MIGS involves a device called a trabectome, which uses heat to cut away tiny amounts of tissue from the mesh inside of your eye, lowering the buildup of fluid and eye pressure.
Last year, Gordon had a procedure in her left eye called endocyclophotocoagulation (ECP) along with her cataract surgery.
ECP is a type of minimally invasive surgery and uses a laser to cause inflammation and scarring, which in turn decreases your eye pressure. About 2 months after ECP and using dorzolamide HCL and timolol maleate, a combination eye drop, twice a day in both eyes, Gordon’s eye pressure is within normal limits. She recently had ECP in her right eye as well with similar results. After having pressure in the 30s for years, she’s thrilled with the improvement.
Filtering surgery: This may be a trabeculectomy or a trabeculectomy with an EX-PRESS shunt. In a trabeculectomy, small amounts of tissue from the mesh inside of your eye are removed, but it’s more invasive than the trabectome procedure and may have more side effects.
The EX-PRESS shunt is “a stainless steel tube that’s placed in the eye that provides a pathway for the fluid to get out,” says Dr. Anderson. “In my practice, it’s my go-to surgery in many cases. I find it very effective in getting pressures where I want. It gives me a lot of control and good results.” Because trabeculectomy can result in scarring, an anti-scarring medication like mitomycin-C is used to prevent this from happening.
Aqueous shunt surgery: This is typically done with a Baerveldt, Molteno or Ahmed shunt, which are “implants that are designed to provide better outflow and reduce the risk of scarring,” Dr. Anderson says. “The shunts are for more severe glaucoma and for people who’ve failed other surgeries.” Roman is in the process of getting a consult to have an Ahmed shunt placed in her right eye “in an attempt to keep it from deteriorating to the same condition as my left eye,” which is in the severe stage, she says.
The Marijuana Controversy
You may have heard that marijuana helps glaucoma. However, the American Academy of Ophthalmology does not recommend using marijuana as a glaucoma treatment. Marijuana can lower your blood pressure, causing decreased blood flow to your optic nerve, which increases your risk of vision loss. Although marijuana does lower the pressure in your eye, this effect only lasts for a few hours, whereas eye drops last a lot longer.
For the effects to be long-lasting, you would need to use marijuana every few hours, day and night, which is harmful to your body and limits your daily activities, such as driving. “I don’t think you want to live a lifestyle where you’re inhibited by the drug all day,” notes Dr. Anderson. “I don’t prescribe it.”
New and Upcoming Treatments
In 2017, two new eye drops were approved for glaucoma. Vyzulta (latanoprostene bunod) is the first medication for glaucoma to contain nitric oxide, a chemical that may affect blood flow to the optic nerve. It also contains a prostaglandin analog, so the potential side effects are similar to that of prostaglandins. Rhopressa (netarsudil) is in a new class of eye drops called rho-associated protein kinase inhibitors. It improves fluid drainage and decreases fluid production.
A hydrogel eye drop that forms a lens when you put it in and treats glaucoma while you sleep is currently being studied. A wearable medicated silicone ring that disperses a prostaglandin analog on a daily basis is in clinical trials, as is an eye drop that combines netarsudil and latanaoprost called Roclatan. This would be the only combination eye drop that only needs to be used once a day.
Dr. Anderson recommends implementing lifestyle changes that may help control your eye pressure or increase your eye health.
- Quit smoking. Dr. Anderson notes that some of the worst cases of glaucoma he sees are in smokers. Smoking increases your risk of developing other eye diseases as well.
- Eat healthy foods. Getting all your vitamins and nutrients won’t prevent or stop your glaucoma, but it helps your health in general. Fish high in omega-3 fatty acids and dark, leafy greens all promote good eye health too.
- Loosen up your tie. “Wearing your tie too tight can restrict blood flow up to the head and can affect glaucoma,” says Dr. Anderson.
- Exercise, but avoid strenuous activities. “Standing on your head has been shown to increase eye pressure,” Dr. Anderson says. “Strenuous activities like power lifting where you’re putting a lot of force and strain on your head isn’t good either.” Talk to your doctor about what activities are safe for you.
- Don’t drink fluids too quickly. Try to keep your fluid intake regular throughout the day. Drinking too much at once can raise your eye pressure temporarily.
- Take your medications as prescribed. It may be tempting to skip your eye drops because you don’t feel any symptoms from your glaucoma anyway, but this is a dangerous practice. When you aren’t taking your medication, you’re not controlling your eye pressure, which means your optic nerve is becoming more damaged. Any vision loss that results from glaucoma is irreversible, so it’s important that you’re compliant in taking your medications as directed. If you’re having difficulty, talk to your doctor about other options.
- Be aware. If you’re in your 40s, it’s time to get your eye pressure checked, says Dr. Anderson. Early detection and understanding your family history are key since a strong family history can play a role in developing glaucoma.