Glaucoma is a leading cause of blindness both in the United States and worldwide. The disease is largely asymptomatic until the final stages, and many patients unfortunately do not know they have glaucoma until it is too late. Fortunately for most patients, early diagnosis and treatment can significantly help slow down the disease.

The risk for developing glaucoma is higher if one or more of the following apply:

1. 40 years old or older
2. Family history of glaucoma
3. Hispanic, African-American, Caribbean, Asian, or Indian-American ancestry
4. History of eye or head trauma, diabetes, chronic steroid use, near-sightedness, or farsightedness

If you have any of these risk factors, a routine annual glaucoma screening by a fellowship trained glaucoma specialist is particularly important.

Medical Treatment

The goal of glaucoma treatment is to reduce the pressure in the eye, and there are several medications to help achieve this goal. The various eye drops and pills available in glaucoma treatment generally work by two different mechanisms:

1. Increasing the fluid outflow from the eye, or
2. Decreasing the fluid inflow into the eye

Many factors determine which medications (or combination of medications) is best for a patient. A fellowship trained glaucoma specialist is uniquely trained to find the optimal treatment strategy for each individual patient and to maximize a patient’s chances of maintaining good vision.

The use of laser-based therapeutics has revolutionized glaucoma management. Laser treatment is considered to be both safe and effective in helping control the disease. Many types of laser treatments exist:

1. Selective Laser Trabeculoplasty (SLT) – SLT treatment is an in-office, cold laser that is carefully and precisely applied in the eye for the treatment of certain types of open angle glaucoma. When performed by a fellowship trained glaucoma surgeon, the treatment can be effective, painless, and extremely safe. Kruti Dajee, MD is an expert with the SLT laser and is the only glaucoma specialist in North Texas to be directly trained by the inventor and developer of the laser, Dr. Mark Latina.
2. Laser Peripheral Iridotomy (LPI) – LPI treatment is usually performed in-office for closed angle glaucoma or to prevent closed angle glaucoma from developing. The “angle” in the eye contains drainage channels that are important in allowing normal fluid egress from the eye. When the angle becomes closed or starts to show signs of closing, the drainage channels are not able to function properly, which can lead to intermittent high eye pressure, progressing glaucoma, and sometimes permanent vision damage. Successful LPI treatment provides the eye with an alternate drainage channel so that the eye pressure remains stable and normal at all times
3. Endocyclophotocoagulation (ECP) – ECP is a surgical laser that can be used in all stages of glaucoma. During the procedure, the eye is anesthetized and then a small incision is made to allow a laser probe into the eye. The laser is then gently applied directly to the ciliary body, the part of the eye responsible for making aqueous humor. By shrinking the ciliary body, the goal is to reduce the amount of fluid produced, thus lowering eye pressure and protecting the eye from worsening glaucoma. ECP treatment can be performed by itself, but it is often combined with other procedures such as cataract surgery or other glaucoma surgeries.
4. Trans-scleral Cyclophotocoagulation (CPC) – Trans-scleral CPC is another surgical laser that is an effective tool for moderate to severe stages of glaucoma. Similar to ECP, the purpose of the laser is to shrink the ciliary body, which is the fluid producing part of the eye. Unlike ECP, the laser does not require a surgical incision into eye, and the application of the laser is based on anatomic landmarks and not direct visualization of the ciliary body.

Minimally Invasive Glaucoma Surgery (MIGS) refers to glaucoma surgeries that are less invasive, safer, and faster healing that traditional glaucoma surgery. Broadly speaking, these procedures aim to lower eye pressure and help control glaucoma by restoring the eye’s natural drains and physiology.

1. Kahook Dual Blade (KDB) – The KDB is a safe and quick surgery designed to remove the trabecular meshwork, which is the part of the eye that blocks normal fluid outflow in certain glaucoma patients. During the procedure, a small incision is made into the eye and then a specially designed blade is used to painlessly remove parts of the trabecular meshwork in an atraumatic fashion. Postoperatively, patients are started on prescription eye drops to help heal the eye. Recovery is generally fast, painless, and uneventful.
2. Istent Inject
3. Goniosynechialysis – Patients with angle closure glaucoma can develop scar tissue inside the eye that may block drainage channels and cause the eye pressure to increase. During goniosynechialysis, a small incision is made and microforceps are used to gently peel away this scar tissue and restore the eye’s normal outflow mechanism. Most patients recover quickly and without complications.
4. Xen Gel Stent – The Xen stent is a breakthrough procedure to help control glaucoma in which an implant is surgically placed inside the eye. The implant is a microshunt that drains fluid from inside the eye to the outer subconjunctival space, thus lowering intraocular pressure. The device is about the size of an eyelash and is designed to remain permanently in the eye.

Major glaucoma surgery is typically reserved for cases of dangerously high eye pressure, severe and refractory glaucoma, or when the eye’s natural drains are unsalvageable. There are two types of major glaucoma surgery: trabeculectomy/express shunt and glaucoma drainage implant. Essentially, both of these involve making a new “drain” for the eye, and the outcome is largely dependent on how a patient’s body responds to the surgery.

Even in the best of hands, these surgeries have a higher rate of complication compared to most other eye surgeries, and the decision to proceed with major glaucoma surgery should not be taken lightly. Kruti Dajee, MD will attempt to exhaust any and all options to avoid major glaucoma surgery, but if you end up needing the surgery, he will discuss the operation with you in detail, will skillfully perform the surgery, and will be with you every step of the way postoperatively.

1. Trabeculectomy/Express Shunt – During a trabeculectomy or Express shunt surgery, a small piece of the sclera (outer wall of the eye) is removed to create a small opening for fluid from inside the eye to drain better. Occasionally, a small metal device called the Express shunt is used to help regulate the flow through this opening. The conjunctiva is then meticulously closed with sutures to prevent any leakage of fluid (leaking fluid can lead to aggressive infections and/or dangerously low eye pressures). The end result of the surgery is the creation of a small reservoir called a bleb, which provides the eye a space to drain excess intraocular fluid. The postoperative course is variable, and patients are typically seen numerous times in the weeks following the operation.
2. Glaucoma Drainage Implant – Glaucoma drainage implants are devices that consist of a tube that is inserted into the eye and a plate that is sutured to the outside part of the eye. Once the implant is placed, excess fluid in the eye is able to drain through the tube and to the outside of the eye, thus lowering eye pressure and improving glaucoma control. Like with trabeculectomies, the postoperative course is variable, and surgical success is highly dependent on the healing response of each individual patient.