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Dr. Chelvin Sng: Is surgery always necessary to treat glaucoma?

Glaucoma is a disease that can cause vision loss and blindness by damaging the optic nerve, which is located at the back of the eye. This is usually caused by increased eye pressure. Fluid is continuously produced within the eye and if this fluid is unable to drain adequately, it starts to build up and the pressure within the eye increases, leading to damage to the eye nerve and vision loss1.

Eyes with glaucoma have either open angles or closed angles, and I will be focusing on open angle glaucoma in this article as it is the most common subtype of glaucoma worldwide.

As eye pressure usually increases gradually in eyes with open angle glaucoma, most patients do not experience symptoms in the early stages. By the time they discover that some-thing is wrong, the glaucoma is often already very advanced.

By this stage, many are left with no choice but to undergo surgery to prevent the glaucoma from progressing. However, if detected early, glaucoma can be treated with less invasive options such as topical medications and laser procedures.

Please allow me to explain the non-surgical options for treating open angle glaucoma, how
to ascertain whether surgery is necessary and some simple steps you can take to prevent
your glaucoma from progressing.

Types of glaucoma, close and open angle glaucoma

What are some non-surgical options for treating open angle glaucoma?

For newly diagnosed open angle glaucoma, prescription eye drops are often the first-line treatment. However, recent studies[4] have shown that glaucoma laser procedures are a safe, effective and cost-effective alternative to glaucoma eyedrops as a first-line treatment in newly diagnosed open angle glaucoma patients

Currently, the only modifiable risk factor for glaucoma is eye pressure, hence all glaucoma treatment options aim to reduce the eye pressure. There is no cure for glaucoma and it is not possible to reverse the vision loss or eye nerve damage already sustained.

Hence, it is important to diagnose glaucoma early, initiate treatment as soon as possible, so as to prevent further glaucoma progression.

Type of treatmentHow it worksSide effectsFrequency of treatment
Glaucoma Eye DropsLowers the pressure in the eye by either reducing fluid production in the eye or increasing the drainage of fluid from the eye.These may include:  
- Stinging, itching, burning in your eye
- Blurry vision
- Headaches
- Changes in the eye colour or the colour of the skin around your eye
- Breathing difficulties
Glaucoma eye drops would need to be used everyday as instructed by your eye doctor.
Laser TreatmentSeletive Laser Trabeculoplasty: A laser is used to increase the outflow of fluid from your eye, hence decreasing the eye pressure.Selective laser trabeculoplasty is generally a very safe procedure which requires only 5-10 minutes. Occasionally, it is associated with these complications, which are often transient:
- Increase in eye pressure - Swelling of the cornea, the transparent structure in front of the eye
- Swelling of the retina, the light-sensitive tissue at the back of the eye
- Eye inflammation
A large study has shown that 3 in 4 patients do not require glaucoma medications 3 years after selective laser trabeculoplasty.  

Selective laser trabeculoplasty can be repeated if the eye pressure increases, or other modalities of treatment (eg. glaucoma medications or surgery) may be considered.[1] 

When is surgery necessary and is surgery always the best option?

While eye drops and laser procedures are usually the first-line treatment options for glaucoma, I would recommend surgery in these scenarios:

  • If the medicine causes severe and intolerable side effects
  • If the patient is unable to adhere to the medication regime and often forgets to use the eye drops, and laser treatment is insufficiently effective in lowering the eye pressure
  • The eye pressure is not sufficiently low despite eye drops and/or laser treatment

There are many options for glaucoma surgery, and I would tailor the surgery according to each patient’s needs and requirements. Some surgeries I perform are:

SurgeryHow it works
Tube implant surgeryA tube is inserted into the eye to allow fluid to drain out.
Trabeculectomy surgeryAn incision is made in the eye to allow fluid to drain out.
Minimally Invasive Glaucoma Surgery (MIGS)MIGS uses microscopic instruments to increase fluid drainage out of the eye. MIGS can be broadly divided into two types:  
1. MIGS that increases drainage of fluid via through internal drainage pathways
2. MIGS that drains fluid externally out of the eye area

Please read more about glaucoma surgery here.

Read: Why the Paul Glaucoma Implant is changing the future of glaucoma

Minimal invasive glaucoma surgery

What worsens glaucoma and how do you prevent the condition from progressing?

Using your glaucoma eye drops daily as instructed by your eye doctor is crucial in preventing the progression of glaucoma. It is also very important to schedule regular appointments with your eye doctor so that he/she can monitor your eye pressure and glaucoma tests.

While diet and lifestyle have no direct impact on glaucoma, making diet and lifestyle changes can reduce the risk of conditions like diabetes and hypertension which are risk factors for glaucoma.

As such, I recommend:

  1. Exercise regularly: This may help to lower eye pressure and keep blood flowing to the nerves in your eye.
  2. Eat healthily: Having a nutrient-rich diet can keep your eyes and body healthy.
  3. Avoid smoking: Smoking can increase your blood pressure and lead to eye inflammation.
  4. Reduce caffeine intake: Too much caffeine can raise your eye pressure.

In conclusion, glaucoma can be treated with surgery as well as non-surgical options. If glaucoma medications and laser procedures work well to reduce your eye pressure, surgery may not be required. If you have any questions regarding glaucoma, please feel free to drop me a message.

References

  1. National Eye Institute. (2022, April 21). At a glance: Glaucoma. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/glaucoma
  2. Heijl, A., Bengtsson, B., & Oskarsdottir, S. E. (2013). Prevalence and severity of undetected manifest glaucoma: results from the early manifest glaucoma trial screening. Ophthalmology, 120(8), 1541–1545. https://doi.org/10.1016/j.ophtha.2013.01.043
  3. National Eye Institute. (2021, July 19). Glaucoma Medicines. National Eye Institute. Retrieved May 5, 2022, from https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/glaucoma/glaucoma-medicines
https://www.thelancet.com/article/S0140-6736(18)32213-X/fulltext

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    Dr Chelvin Sng of Chelvin Sng eye center

    Dr Chelvin Sng

    Adjunct Associate Professor
    Senior Consultant Ophthalmologist
    ✓ 4 Gold Medals (Specialist Accreditation Examination)
    ✓ "Top 50 Rising Stars” (2017), “Top 100 Female Ophthalmologists” (2021)
    and "Top 100 Ophthalmologists" (2022)
    ⋆ Global Ophthalmologist Power List (voted by peers worldwide)
    ✓ Cambridge University Graduate with Triple First Class Honours and Distinctions

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    38 Irrawaddy Road Mt Elizabeth Novena Specialist Centre, #06-25, Singapore 329563

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