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Treatment options for glaucoma

Created: ; Last Update: May 3, 2016; Next update: 2019.

Glaucoma can be treated with medication (eye drops), laser therapy or surgery. The aim of treatment is to lower intraocular pressure, thereby reducing the risk of impaired vision or blindness.

The term "glaucoma" is used to describe a number of different eye conditions, all of which involve damage to the optic nerve. This leads to ever larger gaps in the field of vision. The field of vision is the area you can see without moving your eyes. In advanced stages, your ability to see things sharply (visual acuity) also gets worse. One common cause is too much pressure inside the eye. This pressure is called intraocular pressure.

Lowering high intraocular pressure can help to delay or stop the gradual loss of vision. Glaucoma cannot be cured, though, because existing damage to the optic nerve cannot be reversed.

The following information covers the treatment options for the most common form of glaucoma, primary open-angle glaucoma (POAG).

Which medications are used?

The following medications are used in the form of eye drops:

  • Beta blockers: increase the flow of aqueous humor out of the eye and are often prescribed as first-line therapy.
  • Cholinergic drugs: increase the outflow of aqueous humor. This is also a common, tried and tested treatment for glaucoma.
  • Prostaglandins: increase the flow of aqueous humor out of the eye and, like beta blockers, are often prescribed as first-line therapy.
  • Alpha-adrenergic agonists (sympathomimetics): lower the production of aqueous humor and at the same time increase its outflow.
  • Carbonic anhydrase inhibitors: lower the production of aqueous humor.

The most suitable medication will vary from person to person, depending on a number of factors – including age, amount of optic nerve damage, intraocular pressure and possible side effects. If intraocular pressure cannot be lowered enough by using one medication or there are side effects, it is possible to switch to another medication.

There is an ongoing debate about whether neuroprotective drugs could be used as an alternative treatment. These drugs aim to protect the cells in the retina and in the optic nerve. But not enough research has been done on their benefits for people with glaucoma.

Side effects

Eye drops can have a number of different side effects. All of them can irritate the eyes and, for instance, make them itch and go red. Some, such as the beta blockers, can affect your cardiovascular (heart and circulation) system and your breathing. Closing your eyes for three minutes after using the eye drops is recommended in order to lower the probability of side effects. You can also gently apply pressure to the inside corner of the eye with your fingers. Both of these things are done to make sure that the eye drops act on the eye, and do not flow down into your nose and throat where they can be absorbed into the body through mucous membranes.

What problems can occur when using eye drops?

It can be difficult to use eye drops one or several times a day for many years. And having to find a quiet spot to use the eye drops at work or while out and about is sometimes an inconvenience. Some people regularly forget to use them, or have the feeling that they aren't really working anyway, so they don't use them properly. And the fact that there is no immediate effect if you skip them once doesn't help. The benefits of using eye drops only become apparent much later, so there is no immediate noticeable positive effect. But knowing that the medication will help to preserve your eyesight over the longer term can be a motivating factor.

Keeping regular appointments with your eye doctor might also help you remember to use your eye drops. It is sometimes possible to change the dose so you only need to use the drops three times a day, for example, instead of six. Using the eye drops at set times is also helpful (e.g. before breakfast, at dinner or before going to bed).

Some people mainly have problems when they first start using the eye drops. If you have never used eye drops before, it is not always that easy to do. Older people also often have trouble using eye drops on their own. If you are not sure how to use them properly, you can always ask your doctor what exactly you need to do. Self-help groups can help here too, for instance with practical courses on how to apply eye drops.

Can surgery, laser therapy or acupuncture help?

Glaucoma can also be treated with lasers or surgery. These treatments are mainly only considered if medicine alone doesn't keep the intraocular pressure under control, or if the drops are not well tolerated.

Acupuncture is also sometimes used as a complementary treatment for glaucoma. The acupuncture needles are not inserted directly into the eye, but into the skin between the eyebrows or at other points on the body. This treatment hasn't yet been scientifically proven to help, though.

Surgery: Trabeculectomy

Glaucoma surgery is done to lower intraocular pressure permanently. The most common type of surgical treatment for glaucoma is called trabeculectomy. It involves cutting out a bit of the sclera (the white outer layer of the eye) and the iris in order to allow aqueous humor to flow out of the eye more easily, thereby lowering the pressure inside the eye. Possible adverse effects of this type of surgery include vision problems immediately after surgery, scarring and – over the long term – cataracts.

Laser therapy

Intraocular pressure can also be lowered using lasers, although this is not usually as effective as surgery. In early stages of glaucoma, laser therapy can improve the outflow of aqueous humor. Laser therapy can also be used in addition to eye drops. In later stages, a laser can sometimes be used to destroy part of the tissue that produces the aqueous humor, thereby lowering the intraocular pressure. Laser therapy can cause temporary red or dry eyes and blurry vision immediately after treatment.

How effective is (preventive) treatment for glaucoma?

Medication can be used for prevention if the intraocular pressure is high but the optic nerve and field of vision have not yet been affected. Studies show that people who have high intraocular pressure but who have not yet developed glaucoma are less likely to develop problems with their field of vision if they use eye drops:

  • After about five years, vision was found to be worse in 12 out of 100 people who used eye drops.
  • In contrast, vision was worse in 17 out of 100 people who did not use any eye drops or used a fake treatment (placebo).

Whether it makes sense to have preventive treatment also depends on the possible risk factors. Your odds of benefiting from the treatment increase if your intraocular pressure is very high and you have relatives with glaucoma.

It is also important to use medication to keep intraocular pressure down if glaucoma has already developed, in order to minimize loss of sight as much as possible. But these medications are also used by people who have glaucoma without high intraocular pressure. Sometimes surgery may help to lower intraocular pressure.

A study looked at how newly diagnosed glaucoma develops with and without treatment. To do this, volunteers were randomly assigned to one of two groups. One group had laser therapy and used beta-blocker eye drops. The other group did not have any treatment. After two years, the glaucoma had advanced in

  • 30 out of 100 people in the treatment group,
  • compared to in 49 out of 100 people who did not have treatment.

In other words, treatment stopped glaucoma from becoming worse in 19 out of 100 participants within a time period of two years. Yet even with treatment, your eyesight and field of vision may still worsen.

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