Treatment of Open Angle Glaucoma
The goal of Open Angle Glaucoma Treatment is to lower the pressure in the eye to a level where damage will not occur. It is not possible at this time to recover any vision that has been lost. There are three main ways of lowering pressure in an eye. In most people the first treatment is with medication, usually in the form of eye drops. If eye drops are inadequate or ineffective then laser treatment may be tried. Finally, if medications and laser are inadequate surgical treatment can be used.
Open Angle Glaucoma is not a curable disease. It is controllable. This means that people with glaucoma must be treated for the rest of their lives, and that they must be monitored for evidence that the treatment may not be adequate. Regardless of the treatment used to lower the pressure, people with glaucoma are re-examined periodically for signs of further damage to the optic nerves. This means that they have their pressures measured to make sure they are staying below the Target Pressure, but they also undergo periodic examination of the optic nerves through dilated pupils. Visual Fields are repeated periodically for signs of progression. Photographs must be repeated periodically. If techniques such as Scanning Laser Polarimetry or Ocular Coherence Tomography are being used they will be repeated as well.
With adequate treatment most people with Open Angle Glaucoma can look forward to life of good vision, but it is now a problem that can be ignored.
Medical Treatment:
For most people medications are used as first treatment for glaucoma. The medications that are used can be divided into five main classes.
Miotics: These medications include pilocarpine, carbochol and phospholine iodide. They are the original glaucoma medicines and have been in use for more than a hundred years. They are relatively inexpensive, but most must be given frequently, sometimes as often as four times a day. They also make the pupil of the eye small, which can cause blurring, and dimming of the vision. They also can cause headaches, at least when they are first started. Finally, because they make the pupil small, they may make it difficult to detect changes in the optic nerve or other problems in the back of the eye.
Adrenergics: These include epinephrine, divephrin (Propine), apraclonidine (Iopidine), and brimonidine (Alphagan). There are subtle differences among them. Generics are relatively inexpensive, but there are no generics for the newer, more powerful medications (Iopidine and Alphagan.) All must be given at least twice a day, and some three times a day. Epinephrine is rarely used these days because it causes elevation of blood pressure and irregular heart beats in some people. Dipivefrin works poorly in many people, but works quite well in others. All of the adrenergics have a strong tendency to cause allergic reactions after a time, which may be mistaken for conjunctivitis or “pink eye.”
Carbonic Anhydrase Inhibitors: These medications come as both pills and drops. The pills are acetazolamide (Diamox) and methazolamide (Neptazane.) As generics they are relatively inexpensive. They are given one to four times a day and a very effective for lowering pressure. However, they have significant side effects and many patients are not able to take them long because of them. They include nausea, diarrhea, loss of appetite, weight loss, depression, kidney stones, tingling of fingers and toes and rarely anemia. They are diuretics, or fluid pills, and must be used cautiously in patients taking other diuretics. The drops are dorzolamide (Trusopt) and brinzolamide (Azopt). The drops are expensive, and less effective than the pills, but cause fewer side effects. The most common side effects with the drops are a bad taste, and stinging. They are usually used three times a day. All carbonic anhydrase inhibitors are related to sulfa drugs and must be used cautiously in people who are allergic to sulfa.
Beta-adrenergic Antagonists: These drops include timolol (Timoptic, Betimol), levobunolol (Betagan), betaxolol (Betoptic), metopranolol (Optipranolol) and carteolol (Ocupress.) They are given once or twice a day and the generics are inexpensive. They are very reliable medications but may lose some effectiveness with time. Side effects include asthma, slowed heartbeat, lowered blood pressure, depression, erectile dysfunction, worsening of diabetes and myasthenia gravis. Many patients are already taking similar medications for blood pressure or heart problems and in those patients these eye drops may not be very effective.
Prostaglandins: These drops include latanoprost (Xalatan), bimatoprost (Lumigan), travoprost (Travatan) and uroprostone (Rescula). All but uroprostone are given once a day. They are very effective for most people. They are also very expensive. They frequently cause some redness of the eyes. They cause eyelashes to grow longer and thicker. They may cause hazel eyes to turn browner. Rarely they can cause headaches and other aches and pains.
While the side effects listed above are the most common ones, any person may have a unique reaction to a medicine. If you feel that a medication that you are taking may be causing a problem don’t hesitate to discuss it with your doctor. Usually it is safe to stop a medication for a short period of time to see if a side effect gets better.
Laser Treatment for Open Angle Glaucoma –
Laser Trabeculoplasty
Laser treatment has been available for Open Angle Glaucoma for nearly 20 years. It is called Laser Trabeculoplasty. Several different types of lasers are used for trabeculoplasty and the procedure goes by several different names. These include “Argon Laser Trabeculoplasty” (ALT), “Selective Laser Trabeculoplasty” (SLT) and “Micropulse Laser Trabeculoplasty” (MLT). None has been shown to be superior to any other.
Laser Trabeculoplasty is usually used in patients where medications have been inadequate to lower pressure to a safe level, but there is some evidence that using laser therapy before trying medications may be reasonable in some people.
Laser Trabeculoplasty involves shining a small spot of laser light repeatedly on the drainage channels of the eye. Each application is short – about 1/10 of a second - and small – about 50 microns. The treatment is done as an outpatient procedure. At the Taustine Eye Center we perform it in our office. It is nearly painless and takes only a few minutes.
How laser trabeculoplasty lowers pressure is not known. It is effective in about 80% to 90% of people. The effect is always temporary but it may last for several years. It can be repeated when the pressure rises again, but after two treatments in an eye, further treatment is usually ineffective.
The procedure is usually very safe. Occasionally after the treatment the pressure will rise for a time, and additional medications will be required to protect the vision. At the Taustine Eye Center, we use eye drops at the time of the procedure that reduce the chances of this pressure rise. We also ask you to stay at the office for a while after the procedure so that we can monitor the pressure and insure that it is not rising.
The eye that is treated is often sore and light sensitive for a few days. Anti-inflammatory drops are prescribed to keep this discomfort to a minimum.
It normally takes 4 to 6 weeks to know if the procedure has been effective. It is rare for laser trabeculoplasty to be so effective that medications can be reduced, but it does happen occasionally.
BACK TO TOP 
