Glaucoma

The diagnosis of glaucoma can be difficult and requires several tests. It may not be possible to give a definitive diagnosis at the first consultation.

• Tests for glaucoma include:
  Tonometry: this measures the intraocular pressure of your eyes. It’s performed by Goldman Applanation Tonometry, not the ‘air puff’ that you may have experienced at the opticians.
• Slit lamp examination: a slit lamp allows us to examine the eye in detail, especially the optic nerve.
• Gonioscopy: this test enables us to examine the drainage angle. It’s performed using a special contact lens on the eye.
• Pachymetry: pachymetry is a test that allows us to measure the thickness of your cornea. This is important, as a thicker-than-average cornea could lead to an overestimated intraocular pressure, while a thinner-than-average cornea could result in an underestimated pressure reading so it’s important to get a very accurate measurement.
• Visual field perimetry: this test measures the specific area of sight loss, especially in the peripheral vision.
• Optic nerve imaging: this test measures the thickness of the nerve fibre layer of the optic nerve and can detect areas of nerve fibre loss. It can also be used to monitor any further loss.

Selective laser trabeculoplasty (also called SLT) is a treatment aimed at lowering the pressure in the eyes if you have ocular hypertension or open angle glaucoma (see ‘Types of glaucoma’). The laser treatment helps fluid drain from the eye, which in turn lowers the pressure.

Some people respond better to the treatment than others. While the initial treatment may be successful, the pressure can rise again in time. If this happens, the treatment can be repeated, although the results may not be quite effective as after the first treatment. You may also need to continue eye drop treatment. In some cases, we may also recommend further treatment, including surgery, if the pressure does not return to a satisfactory level.

Complications of SLT: complications are rare but may include inflammation, a temporary increase in eye pressure, blurred vision, headaches and corneal oedema (clouding of the clear window at the front of the eye).

How SLT works: During treatment, patients are normally given drops to make the pupil smaller, which can often cause a slight headache above the eye. Once you sit in front of the laser machine, further drops are given to numb the surface of the eye.

The consultant doctor will place a special contact lens onto the eye and aim the laser at the part of the eye where the fluid drains (known as the ‘trabecular meshwork’, in the angle between the iris and the cornea). Many patients don’t feel any discomfort from the treatment, but those that do usually describe the pain as mild. It takes about five minutes to treat one eye.

After laser treatment, the eyes will be temporarily dazzled, but vision should improve over the following few hours. It may help to wear sunglasses when you go home.

There is a chance that you may experience a headache during the first few hours following the procedure. If this happens, you should take your usual painkiller. You may also need to take extra drops for a week or so after the treatment. You will probably also be advised to continue with your usual glaucoma drops until your next appointment.

Glaucoma can get worse if the pressure inside the eye is too high. If this happens and eye drops are not sufficiently lowering the pressure, and if there is a significant risk that glaucoma is going to cause further damage to your sight, we may recommend trabeculectomy surgery.

A trabeculectomy is an operation to lower the pressure inside the eye. It involves making a new channel in the white wall of the eye (the sclera), through which fluid flows out into a space underneath the outer layer of the eye (the conjunctiva). A successful trabeculectomy creates what we call a ‘bleb’ (a small elevation), which is usually covered by the upper eyelid.

Trabeculectomies are usually done as day cases, under local anaesthetic. The local anaesthetic involves an injection beside the eye a few minutes before the start of the operation. This makes the eye numb, and usually blurred as well.

It’s common for the eye that has had the surgery to be quite blurred for a few weeks, and sometimes longer. There’s no need to change your glasses straight away, but some patients benefit from getting new glasses sooner than they normally would (though it’s best to wait for three months while things settle). You can resume driving if your vision is sufficient for you to meet the legal requirements. Bear in mind, however, that trabeculectomy doesn’t improve vision. Its purpose is to prevent sight loss in the future.

You can use your eyes for reading, television and computers etc as soon as you wish; this won’t harm your eye. Gentle exercise such as walking is fine, but you should avoid strenuous exercise (such as running, ball sports and fitness workouts), or lifting heavy objects, for at least a month after the operation. You should avoid swimming or immersing the eye in water for at least one month. Please ask at your check-up if you’re planning to resume swimming.

The treatment helps to lower the pressure in the eye in about 80% of cases, and most patients will not need glaucoma drops in the eye that has had the operation. A lower pressure is beneficial to nearly all patients with glaucoma, but glaucoma can still progress – in some cases even after a ‘successful’ trabeculectomy.

Glaucoma surgery aims to reduce intraocular pressure, which is essential in slowing the progression of glaucoma and preventing vision loss. By creating new pathways for fluid drainage or reducing fluid production in the eye, these surgeries can stabilise or even improve your current level of vision.

The treatment is performed with you lying on your back. A paper drape is placed over your face, with fresh air piped beneath it. A clip is used to keep the eye open. You may see light and shadow, but you will not see the surgery itself. It usually takes between 40 and 80 minutes to complete the operation. At the end of the procedure, a patch is taped over the eye. You will leave this on until the next day.

In many cases we will treat the area of the trabeculectomy with additional medication during the surgery, to prevent scar tissue from closing the new channel we have created. The medications we use for this include mitomycin-C and 5-fluorouracil (5-FU).

Frequent follow-up is required in the first few weeks after this operation. You will need to be reviewed the day after surgery. If all is well, you will be reviewed a week later, and again one to three weeks after that. The exact timing of these and future reviews depends on how your eye is settling down; more frequent visits are quite often required. The first few weeks after the operation is a very important time for checking the eye and carrying out adjustments. Most of these adjustments are minor and will be done as part of an outpatient visit. To be on the safe side, it’s best to avoid planning any holidays within two months of the treatment.

You will be given new drops (an antibiotic and steroid) to use in your eye for several weeks after the operation. You won’t need to use your previous glaucoma drops in the eye that has had the operation (although, in the longer run, some patients do need to restart these to lower the pressure sufficiently). In your other eye, you should continue with any glaucoma drops as you did before.

It’s important to weigh up the risks as well as the potential benefits before undergoing any form of surgery. The surgeon who has recommended this operation will have judged that the risk to your sight from glaucoma without the operation is greater than the risks of the operation itself. For most patients, trabeculectomy achieves a lower pressure without any significant problems. But as with all operations, there are some risks. These include:

Reduced vision: this is very common in the first two weeks after the operation due to swings in the eye pressure, minor bleeding inside the eye and inflammation. These typically settle within the first few weeks. A small minority of patients (around five to eight percent) may have some degree of permanently reduced vision after the operation. As with all intraocular surgery, loss of all vision in the eye due to the surgery itself is possible, but it’s very unusual.

Discomfort: any discomfort from the procedure usually settles within a few weeks, but some patients do experience long-term discomfort. However, the symptoms are usually mild and can be controlled with artificial tears.

Increased likelihood of cataracts: This is quite common within five years of the operation. If cataracts do occur, they can be treated in the normal way. In some patients, a trabeculectomy works less well if a cataract operation is performed subsequently.

Infection and loss of vision in the eye: There is a small risk of infection after any form of eye surgery, including trabeculectomy. With trabeculectomy there is also a permanently increased risk of infection getting inside the eye. But the risk is small: roughly one in every 100 operations.

Further surgery may be required to ensure that the operation is successful, or to correct low pressure. It’s not unusual for an additional procedure of some sort to be required, but this is usually a much shorter procedure than the trabeculectomy itself.

Minimally invasive glaucoma surgery (also known as micro invasive glaucoma surgery, or MIGS) is the latest advance in surgical treatment for glaucoma. It aims to reduce intraocular pressure by either increasing outflow of aqueous humour, or reducing its production.

MIGS comprises a group of surgical procedures which share common features. They focus on a minimally invasive approach, often with small cuts or micro-incisions through the cornea that cause the least amount of trauma to surrounding scleral and conjunctival tissues. The techniques minimise tissue scarring, allowing for the possibility of traditional glaucoma procedures such as trabeculectomy or glaucoma valve implantation (also known as a glaucoma drainage device) to be performed in the future if needed.

MIGS procedures reach their surgical target from an internal route, typically through a self-sealing corneal incision. This contrasts with traditional surgery, where external techniques are used. By using an internal approach, MIGS procedures often reduce discomfort and lead to more rapid recovery periods.

While MIGS procedures offer fewer side effects, they don’t tend to lower intraocular pressure to the same extent as trabeculectomy or glaucoma tube shunt implantation.

Post-surgery, patients may experience mild discomfort and temporary visual disturbances. Recovery time varies depending on the type of procedure, but most activities can typically be resumed within a few weeks. We provide detailed aftercare instructions and close monitoring to ensure the best possible outcome.

Most people are able to return to office-based work two weeks after the treatment, although some patients need longer. It’s usually wise to wait at least a month before resuming physically strenuous work, or work in a dusty or dirty environment.

We provide a range of surgeries, including laser treatments like Selective Laser Trabeculoplasty (SLT), conventional surgeries like trabeculectomy, and shunt procedures. The choice of surgery depends on the type and severity of glaucoma, as well as the individual’s specific health profile.