FAQ's: Glaucoma

What is glaucoma?
Glaucoma is the name given to a group of eye diseases that lead to damage of the optic nerve (the bundle of nerve fibers that carries information from the eye to the brain), which can then lead to vision loss and possibly blindness. Optic nerve damage usually occurs in the presence of high eye pressure (also called intraocular pressure, IOP); however, it can occur with normal or even less than normal eye pressure. The only treatment for glaucoma is to lower the IOP.
If you think about the inside of the eye like a drain and a faucet, and using this analogy, high IOP is related to an imbalance between the amount of fluid made inside the eye and the amount of fluid the eye can drain. This fluid is called the aqueous and when we consider various treatment options to lower IOP, we can either decrease the amount of aqueous the eye makes or increase the drainage of aqueous from inside the eye.

Are there different forms of glaucoma?
There are two main forms of glaucoma: (1) open-angle glaucoma- the most common form, affecting approximately 70-90% of individuals; and (2) angle-closure glaucoma. There are also several other subsets of glaucoma, including: normal-tension, congenital, juvenile, and secondary glaucoma.
 
Who is at risk for developing glaucoma?
The exact cause of Glaucoma still eludes scientists. Because most forms of glaucoma develop slowly and silently, everyone, especially those at high risk, should be sure to have their eyes examined on a regular basis, preferably every one to two years or as directed by a doctor.
 
·   People over the age of 40.
    While glaucoma can develop in younger patients, it occurs more frequently as we get older.
·   People who have a family history of glaucoma.
    Glaucoma appears to run in families. The tendency for developing glaucoma may be inherited. 
​    However, just because someone in your family has glaucoma does not mean that you will necessarily 
    develop the disease. And likewise, just because you have no family history also doesn’t mean that you
    aren’t at risk for developing the disease.
·   People with abnormally high intraocular pressure (IOP).
    High IOP is the most important risk factor for glaucoma damage.
·   People of African, Latino, and Asian descent.
    People with African and Latino ancestry have a greater tendency for developing primary open-angle   
    glaucoma than do people of other races. People of Asian descent are more prone to develop angle-
    closure glaucoma and normal-tension glaucoma.
·   People who have:
           o    Diabetes
           o    Myopia (nearsightedness)
           o    Regular, long-term steroid/cortisone use
           o    A previous eye injury
           o    A family history of glaucoma
           o    Extremely high or low blood pressure
 
How do I know if I have glaucoma?
Your doctor will review your medical history and conduct a comprehensive eye examination. He or she may perform several tests, including:
Measuring intraocular pressure (tonometry) Testing for optic nerve damage with a dilated eye examination and imaging tests Checking for areas of vision loss (visual field test) Measuring corneal thickness (pachymetry) Inspecting the drainage angle (gonioscopy)  
I was told I have “pre-glaucoma”– what does that mean?
This is another way of saying that you are a glaucoma suspect. A glaucoma suspect is someone who might have glaucoma but it's too early to tell. This term includes patients with ocular hypertension (persons with elevated intraocular pressure but no detectable disc or visual field damage), and patients with large cup/disc ratios and normal visual fields who may or may not have early normal-tension glaucoma. If you have been diagnosed as a glaucoma suspect, it is important that you see your eye care specialist regularly to monitor your condition so that you do not experience any unexpected loss of vision.
 
What is normal eye pressure?
Unfortunately, the answer is not any single number. While the average eye pressure is approximately 15, the range of normal eye pressure is much larger. About 90 percent of people will fall between a pressure of 10 and 21. Even so, this does not mean that if you have a pressure of 22 or higher it is abnormal. Every individual and every eye is different. There are many patients with pressures in the mid-20s who do not have glaucoma, and they can be followed with routine eye examinations by their eye care specialist. There are also patients who have been diagnosed with glaucoma and yet, even though their pressure may be within the “normal range,” they still experience worsening of their glaucoma. It is important that you see an eye care specialist to receive a thorough examination and determine if your eye pressure is problematic.
 
Is there a cure for glaucoma?
Unfortunately, glaucoma cannot be cured or prevented. But you can take preventive measures to stop further damage to your eye sight. The sooner you get it diagnosed, the better. While vision loss due to glaucoma cannot be recovered, further vision loss can hopefully be prevented with appropriate treatment. Early detection, ongoing treatment and monitoring are key factors to limiting damage from the disease, which lasts a lifetime.
 
What are the most common treatments for glaucoma?
Although glaucoma cannot be cured, it can be controlled. Prescription eyedrops, oral medications, laser treatment, surgery or a combination of any of these are used to prevent or slow further damage from occurring. With any type of glaucoma, regular eye examinations are very important to detect progression and alter treatments to prevent vision loss.

Eyedrops: Glaucoma treatment often starts with prescription eyedrops. These can help decrease eye pressure by improving how fluid drains from your eye or by decreasing the amount of fluid your eye makes. Depending on how low your eye pressure needs to be, more than one eyedrop may need to be prescribed until your doctor finds the combination that works best for you. It is important to take your medications regularly and exactly as prescribed. Patients who are not compliant with taking eyedrops will not be successful controlling glaucoma and eye pressure with eyedrops.

Oral medications: If eyedrops alone don't bring your eye pressure down to the desired level, your doctor may also prescribe an oral medication, usually a carbonic anhydrase inhibitor. These pills, which have more systemic side effects than eyedrops, also serve to lessen the production of fluid inside the eye. These medications are usually taken from two to four times daily.

Laser Treatment: If eyedrops and medications are not working effectively, most patients are a candidate for laser treatments.
Laser surgery has become increasingly popular as an intermediate step between drugs and other more invasive glaucoma surgeries. The following techniques are intended to improve the drainage of fluid within the eye, thereby lowering the risk of glaucoma progression.
                     SLT: The most common type performed for open-angle glaucoma is called “Selective Laser Trabeculoplasty.” The laser beam (a high energy light beam) is focused upon the eye's
                    drain. Contrary to what many people think, the laser does not burn a hole through the eye. Instead, the eye's drainage system is changed in very subtle ways so that aqueous fluid 
                    is able to pass more easily out of the drain, thus lowering eye pressure. This procedure takes between 10 and 15 minutes, is painless, and can be performed in the doctor's office.
                   Your doctor will likely check your eye pressure 1-2 hours following laser surgery, but then you may go home and resume your normal activities following surgery. After this
                    procedure, many patients respond well enough to be able to avoid or delay surgery. While it may take a few weeks to see the full pressure-lowering effect of this procedure, during
                   which time you may have to continue taking your medications, many patients are eventually able to discontinue some of their medications. This, however, is not true in all cases.
               Your doctor is the best judge of determining whether or not you will still need medication. Complications from laser are minimal, which is why this procedure has become increasingly popular and many doctors are recommending the use of laser much sooner for patients.  

LPI: You may need a procedure called a “Laser Peripheral Iridotomy” in which the doctor creates a small opening in your iris using a laser. This allows fluid (aqueous humor) to flow from behind the iris directly to the anterior chamber of the eye, relieving eye pressure. This is most common for patients with “Anatomically Narrow Angles” or “Acute angle-closure glaucoma.” This procedure takes between 10 and 15 minutes, is painless, and is performed in an outpatient surgery center. Your doctor will likely check your eye pressure 1-2 hours following laser surgery, but then you may go home and resume your normal activities immediately following surgery.  
 
Minimally invasive glaucoma surgery (MIGS). Your doctor may suggest a MIGS procedure to lower your eye pressure. MIGS can be thought of in a few broad categories, either enhancing fluid outflow using the eye’s inherent drainage system (GATT, Kahook Dual Blade Goniotomy, Trabectome, iStent, OMNI), shunting fluid to the outside of the eye (XEN Gel Stent) or decreasing production of fluid within the eye (ECP).  
These procedures generally require less immediate postoperative care and have less risk than some of the traditional more invasive glaucoma surgeries.  The traditional glaucoma surgeries (trabeculectomy and glaucoma drainage devices), while very effective, are associated with risks such as double vision, devastating eye infections, exposure of a drainage implant, swelling of the cornea, and excessively low IOP. Although these risks are relatively infrequent, they make most surgeons delay glaucoma surgery until all other less invasive treatment options are maximized (medications and laser treatment) and the patient has definitive glaucoma worsening.
 
The procedures have been developed in recent years to reduce some of the complications of most standard glaucoma surgeries, and work by using microscopic-sized equipment and tiny incisions. Fortunately, the revolution has allowed us to change our approach to surgical glaucoma for many patients. The main theme and priority of is patient safety. While no surgery is without risk, provide improved safety while usually providing mild-to-moderate lowering. In addition, MIGS procedures are often combined with cataract surgery requiring no different post op care for the patient.
 
 
Does insurance cover glaucoma evaluations or treatments?
Because glaucoma is an eye disease, evaluation and treatment for the condition is usually covered by medical health insurance plans, but not vision health insurance plans. Under the Affordable Care Act (ACA, also known as Obamacare), all qualified health plans must cover eye diseases such as glaucoma.