Early Glaucoma: Finding the Right Treatment for You

Learn about the treatment options for those diagnosed with early-stage primary open-angle glaucoma.

Finding the right glaucoma treatment starts with identifying an ophthalmologist you trust, since you are potentially embarking on a lifelong relationship with him or her. Furthermore, deciding on the right treatment options should be a shared decision.

The treatment options for early glaucoma have expanded in recent years and fall into three categories: medications, laser, and incisional surgery.

Medications or laser are both considered first-line treatments. It is not imperative that you start with medications and then proceed to laser treatment. In deciding between medications and laser, it is important to understand the positives and negatives associated with them.

Medications

For eye drop medications, the positives include the following:

• They are an effective treatment option.
• When one of the first-line medications are used, eye pressure can be lowered by 20-35 percent.
• The drugs are safe and well tolerated in a large proportion of patients.

Negative factors to consider include:

• Eye drops have side effects.
• It is important to use them in a consistent fashion (usually 1-3 times a day).
• Some people have difficulty with instilling the drops.
• The drugs can be costly.

Laser Treatment

For laser treatment, the positives include:

• There is a potential for the elimination of eye drop use altogether (and avoidance of drop-related problems such as compliance).
• The procedure is relatively low risk and safe.
• Most insurance companies cover the procedure when medically necessary.

Negative factors to consider include:

• While laser treatment is generally safe, there are of course risks associated with any surgical intervention, and laser treatment is no different.
• The laser procedure is not a “cure,” and the effect does wear off over time.
• There are potential side effects from the procedure, including an eye pressure spike around the time of the procedure. Your ophthalmologist will ask you to wait after the procedure so that you can be checked for this potential complication. If the eye pressure does increase, usually this is short-lived and can be treated with eye drops.

In making the decision about medications versus laser, it helps to have a sense of your attitudes about medications and procedures. Do you have difficulty remembering to take other medications in general? Do you have arthritis in your hands or dislike having to put eye drops in your eyes? Or are you risk averse, and do not like the idea of a laser procedure being performed on your eyes? If you decide to start with medications, but find that you are missing doses or have intolerable side effects, you can opt for the laser at a later date. Moreover, while the laser is not reversible, if it turns out to be ineffective you can always start eye drops later.

Incisional Surgery

Finally, there are many new surgical options on the horizon for primary open-angle glaucoma patients with early- to moderate-disease. This new class of procedures is known as “MIGS,” or minimally invasive glaucoma surgeries. They were developed because of the need for a safer, effective glaucoma surgery that has fewer risks. There are many types of MIGS procedures, and they are typically combined with cataract surgery. Indeed, in some patients, cataract surgery alone may even lower eye pressure. However, by combining cataract surgery with MIGS, the eye pressure typically lowers to approximately 15 mmHg (millimeters of mercury) with the need for fewer eye drops. In other words, you can expect that your eye pressure will be in the mid-teen range and you will be taking one or two drops fewer than before the surgery.

MIGS procedures include (but are not limited to):

• iStent, one of the earliest FDA approved MIGS procedures
• Trabeculotomy-like procedures such as Trab360, Kahook Dual Blade, Trabectome, and Gonioscopy-Assisted Transluminal Trabeculotomy (GATT)
• Supraciliary space procedures such as Cypass*

New procedures are coming out frequently, so it is important to recognize that these surgical options are rapidly evolving. It is possible that the “latest and greatest” MIGS procedure may not be performed in 5-10 years.

Even though these surgeries are termed “minimally invasive,” there are still risks, so you will need to weigh the pros and cons of each type of treatment option (medications, lasers, or surgery), in making your decision. In addition to MIGS, there are additional glaucoma surgeries outside the scope of this article, since many would be used in more moderate- to advanced-glaucoma situations.

Summary

In conclusion, with such a rapidly changing environment, how do you find the right glaucoma treatment for you? It comes to having an ophthalmologist you trust with whom you can have a frank discussion about the risks and benefits of particular treatment options. My favorite question to ask my own doctor is: “What would you do if you were in my shoes?”

In a future article we will discuss treatment options for those with moderate- to advanced-glaucoma.