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Glaucoma is one of the most common causes of blindness in western industrialized countries. In Europe and the USA, almost 2% of all people over the age of 40 suffer from glaucoma. Around 5 million people in Germany are at risk of glaucoma and around 800,000 people are already manifestly ill.
According to an estimate from the year 2000, around 67 million people worldwide have manifest glaucoma damage and a tenth of these people will go blind because the disease was not diagnosed in time. Approximately 15% of all blindness worldwide can be attributed to glaucoma.
The risk of developing glaucoma increases with age. It occurs, including its preliminary stages, in a good 2.4% of all people from the age of 40. Beyond the age of 75, the frequency is already between 7 and 8%, beyond the age of 80 10-15%.
The common case is primary or chronic open-angle glaucoma, with 2/3 of cases. This occurs when there is an open drainage area where the liquid exits from the eye, but it is not functioning well and the eyeball tension increases. Sometimes drainage hole become narrow and close gradually, it is the chronic type of closure. If the drainage angle is suddenly closed it is the acute type of closure.
Glaucoma with acute closure of the eye`s angle causes severe sudden eyeball pressure rise and is typically painful with the development of redness. Vision is blurred, you can see halos around bright spots of light.
This type of disease may cause a strong sudden pressure increase, as a rule, with the development of painful redness. The vision is blurred, and you can see the halo. Congenital glaucoma can be detected by parents. The children of small age have easily expandable sclera of the eye, so that the eye tension increases with an increase of intraocular pressure. Gaps appear in the corneal endothelium, what leads to edema or swelling of the cornea, which produces a misty, frosted glass view. As corneal stretching, ruptures allow more liquid to fall into corneal stroma and epithelium, which leads to a sharp increase in edema and haze, increased lacrimation and photophobia. The child may become irritable and hide his head in the pillow to avoid the pain caused by bright light.
Glaucoma with narrow eye`s angle - is the anatomical form of the eye, which sometimes leads to high eye tension that can cause glaucoma. When the aqueous solution is discharged with approximately the same rate at which is made, it supports the normal eyeball pressure. If this water solution may not run as fast as it is produced, the pressure in the eye increases. This can occur if the opening is too narrow.
The harmed optic eye´s nerve without increased eye´s pressure is known as "low pressure glaucoma".
The classification of glaucoma is as follows:
The stage is defined by the visual field and optic nerve disk state.
The development of dangerous pathology requires a combination of factors. For a long time it was believed that the causes of the disease were reduced to increased intraocular pressure. The medics then revealed that this factor increases the optic nerve fracture risk, but is not fundamental for the glaucoma development. The progression of the disease requires a sequence of causes that trigger the mechanism of the eye malfunction.
Adult people over 40 are the most vulnerable to the disease. After identifying the pathology, it is necessary to start treatment immediately - pathological changes are irreversible. Causes of glaucoma in adults:
Some babies have congenital abnormalities that occur due to hereditary factors or congenital disorders in the structures of the eye. Due to the obstruction of the liquid outflow in a child, the intraocular pressure rises, the optic nerve receives less nutrition. Causes of primary glaucoma in children:
The whole circulatory system suffers from the lack of insulin produced by the pancreas, the eye retina is also affected. Glaucoma in diabetes has some peculiarities of development. In diabetes, constant changes in the level of sugar occur, which is why the organism forms too many new blood vessels. They cause huge damage to the eyes, growing into the iris and disturbing the outflow of intraocular fluid. As a result of pathological changes, the entire visual system suffers, and the risk of blindness increases.
If you're suffering from glaucoma – causes, symptoms, treatment and prevention of this disease might be interesting for you. At the initial stage the disease is asymptomic, and this poses a danger. The patient doesn't feel anything strange, and the disease can be found on a standard medical examination. In case of the sharp-angled glaucoma, an increase in the amount of liquid can be observed, but the eye looks normal. In some cases, people may complain about reduced vision in the dark, the appearance of rainbow circles, headache. Sometimes they note that one eye can see, and the other is blind.
The symptoms of the closed-angle form of the disease are more pronounced. The ophthalmic examination detects the closed (narrow) angle of the anterior eye. Other characteristic features of closed-angle glaucoma:
Unfortunately, many people diagnosed with this disease miss specific symptoms (if present). Their presence does not necessarily mean intraocular pressure, but is the reason to see an ophthalmologist. The first signs of glaucoma:
The development of glaucoma depends largely on the negative factors (causes) that lead to this pathological process. However, modern ophthalmologists have not yet approved a single, clear opinion on the causes of this disease. The only thing the majority of doctors are sure about is the occurring of the disease due to simultaneous or gradual development of several negative factors in the body, and namely, in the eye.
If you summarize them, you can deduce a single picture - glaucoma develops due to malnutrition of any part of the eye, the function of which is performed by aqueous humour (intraocular fluid).
Intraocular fluid fills the entire cavity of the eye, its anterior and posterior chambers. In addition to feeding all parts of the eyeball, it also performs the function of controlling the intraocular pressure and maintaining the tonus of the whole eye. In case of a violation in its inflow or outflow, a number of pathological processes appear in the eye - an increase in intraocular pressure, obstacles in the blood supply to the eye, the death of retinal cells, etc.
All these factors usually lead to the optic nerve atrophy and in consequence, to blindness.
The onset of glaucoma is marked with the limitation of the visual field - visible objects become fuzzy, then darken. Over the years, the clearly visible part decreases, the restriction increases, the patient sees the surrounding world as though through a dark tunnel. Further development of the disease continues to limit the visual function even more.
The anterior and posterior chambers of the eye are filled with aqueous humour, which is synthesized by the ciliary body. This fluid contains glucose, ascorbic acid, B vitamins, proteins, various minerals, and hyaluronic acid. Its main function is to provide the lens and cornea with nutrition, parts of the eyes deprived of other sources of nutrition (with the exception of the cornea surface layers, which receive the necessary metabolites from the lacrimal fluid).
Aqueous humour is formed in the posterior chamber, from where it moves through the pupil to the anterior chamber. From the eye, it flows through the angle of the anterior chamber, which is located between the root of the iris and the peripheral part of the cornea. Together with intraocular fluid, the lactic acid, carbon dioxide and other metabolic products are also excreted from the eye chambers.
Normally, there is a certain balance between the formation and outflow of aqueous humour. Intraocular pressure may increase either due to excessive production, or due to disruption of the fluid outflow circulating in the chambers of the eye. The first occurs in case hypertrophy of the ciliary body, which develops mainly in individuals with high degrees of myopia.
Violation of the outflow of intraocular fluid is a consequence of closing the angle of the anterior chamber or trabecules blockage through which the filtration of moisture occurs. These phenomena can be caused by a number of provoking factors.
The main problem in the diagnosis of open-angle glaucoma, is the lack of typical symptoms in the early stages. Many people who have this disease are unaware of it. Therefore, it is very important, especially in old age, to undergo regular examination by an ophthalmologist. There are several methods of glaucoma diagnosis:
Medical treatment of glaucoma is carried out in three directions:
The crucial moment in the glaucoma treatment -normalization of the intraocular pressure level, while the methods aimed at improving blood circulation and the impact on the metabolic processes in the eye are auxiliary. In addition, the correct mode of work and life of the patient is required.
Variants of medication impact on intraocular pressure:
In addition, sometimes drugs have a paradoxical effect - the pressure doesn't reduce, but increase instead after the instillation of the drops. Therefore, a diagnostic test is prescribed for each anti-glaucoma drug.
When prescribing the instillation schedule of anti-glaucoma drops, the patient must visit the doctor regularly for at least 2-3 weeks. Subsequently, the control of glaucoma treatment effectiveness is carried out at least once every 3 months.
Regular replacement of drugs after 1-2 years with appropriate re-control is highly recommended to prevent the development of drug resistance.
Medicines used in the treatment of glaucoma are divided into two large groups: drugs that improve the outflow of intraocular fluid from the eye, and drugs that oppress the production of aqueous humour.
The main task of anti-glaucoma drops is the IOP decrease. On the influence mechanism and hypotensive action anti-glaucoma drops are divided into 3 groups:
Laser treatment of glaucoma is used in case of medical therapy low effectiveness and is intended to form additional ways of outflow of intraocular fluid.
The most popular laser treatment methods are:
The operation is performed under local anesthesia. A special lens is installed in front of the patient's eye, through which a laser beam is transmitted. This beam makes small punctures in the trabecular reticulum through which the fluid outflow occurs, and the intraocular pressure decreases.
An alternative method is the so-called cyclodiode laser treatment. It includes the destruction of certain eye areas in which the liquid is formed. As a result, less fluid is formed in the eye and the intraocular pressure is reduced.
Laser treatment is fast and painless. It can be carried out at any age.
Laser iridectomy is a relatively inexpensive, fast and fairly effective method of treating glaucoma. The powerful energy of the laser beam is directed precisely to the selected place in the iris and coagulates it, creating the necessary through hole.
There are laser iridotomy ("burning" the hole in the iris) and laser iridectomy (a part of the iris removal).
Laser open-angle and closed-angle glaucoma treatment can be carried out using the following methods:
Laser iridectomy is performed on an outpatient basis. The patient sits in a special chair, ensuring the immobility of the head. Before the procedure, the eye drops are instilled to narrow the pupil (pilocarpine), then — anesthetic solution. A special gonioliosis is applied to the eye, which allows a good view of the angle of the anterior chamber and focusing the effect of the laser in the desired area.
After the onset of anesthesia, the doctor focuses the laser beam on the selected area of the pigment shell. Usually areas 11 and 1 hour are chosen, with better upper lid coverage. It is recommended to work on several different areas.
The whole procedure lasts about 20 minutes on average.
Within an hour after laser iridectomy, blurred vision is possible, then this sensation disappears.
In an hour after the operation the intraocular pressure is measured, as its increase is possible. If this happens, drops are used to reduce it.
Several days after the procedure it's also necessary to instillate anti-inflammatory drops.
Selective laser trabeculoplasty is the most effective and safe modern method of laser glaucoma treatment. The operation allows to normalize the pressure inside the eye, including in patients insensitive to medical treatment and in case of its contraindication. This procedure prevents severe glaucoma complications, helps to avoid surgery, makes it possible to return the patient to a normal life.
Trabeculoplasty surgery restores fluid outflow in open-angle glaucoma. Laser surgery is not capable to return normal eyesight, but it prevents further progression of the disease quite often.
Varieties of this operation:
It is not advisable to use this procedure for the following types of glaucoma:
It's also prohibited to use this operation on the background of diabetic retinopathy, due to the presence of goniosynechia, neovascularization and pronounced proliferative activity.
As a rule, such procedure is carried out on an outpatient basis. For its implementation a high-energy laser beam is used, the doctor applies about 50 tiny point burns to the surface of the trabecular meshwork. Trabecular meshwork is a part of the drainage system belonging to the anterior chamber of the eye, and the increase of its cellular power improves the outflow of the liquid.
Before the procedure, which is almost painless, the doctor carries out the local drip anesthesia, which allows to install a special reflective surface lens to the eye (goniolens). The patient settles in a comfortable pose before a lamp, the ophthalmologist places a lens in one eye, with the other eye fixed on any object. The treatment takes less than half an hour, during which the patient can see green and red flashes of a laser.
After selective laser trabeculoplasty, the following complications might occur:
Successfully conducted laser trabeculoplasty is quite effective in normalization of intraocular pressure, prevents the glaucoma progression, as well as the development of complications. However, a few years after the procedure, almost 50% of patients observed an increase in intraocular pressure to a dangerous level. In such cases surgical intervention is necessary.
Laser gonioplasty is the procedure for coagulation ("burning") of the iris in its root zone. Through laser exposure, immediate induration, and reducing the tissue volume is achieved, which helps to release the angle of the anterior chamber. Laser gonioplasty is especially affective in narrow-angle glaucoma, in the case of pre-attack disease.
As a rule, this operation is performed as an auxiliary one, since the result obtained is usually temporary. But the access to the corner of the anterior chamber, simplifies the second stage of laser glaucoma treatment - trabeculoplasty.
Laser gonioplasty is performed using a conventional type of "thermal" lasers.
The intervention zone is the root area of the iris along its entire circumference (360 degrees). Manipulation is carried out with a distance of two spot diameters between the coagulums, avoiding visible radial vessels.
Laser gononoplasty as an independent intervention is used extremely rarely, due to the temporary effect of its result. As a rule, this operation becomes the first step to laser iridectomy or laser trabeculoplasty. After opening access to the angle of the anterior chamber, laser goniopuncture - the second step of the treatment, is greatly simplified. Coagulation of the iris during laser gonioplasty promotes rapid hyphema resorption of anterior chamber of the eye.
Laser gonioplasty procedure is prescribed in the following cases:
The main advantages of laser gonioplasty are as follows:
Like any surgery, laser gonioplasty can cause some complications. The most frequent and undesirable consequences of the procedure are: iritis, increased IOP, damage to the corneal endothelium, persistent mydriasis (pupil dilation).
The laser gonioplasty procedure is not performed for persons under the age of 18, as laser intervention during the period of active organism growth can cause an unpredictable result.
Laser surgeries are prohibited during pregnancy and breastfeeding, in case of total one-eye blindness, as well as in case of viral eye infection or general systemic and autoimmune diseases.
Cyclophotocoagulation (synonymous with cyclotherapy or cyclo-dissection) is a popular method that allows to treat glaucoma at the terminal stage. It can also be used in case of permanent pain syndrome. Cyclophotocoagulation is the last measure the ophthalmologist may offer, when other methods are ineffective, when it is not possible to use certain groups of drugs, and when preserving the eyeball is at stake.
The main objective of this procedure is to reduce the amount of fluid in the eye cavity. It's achieved by the operative destruction of a ciliary body part producing moisture. In the relatively recent past, when ophthalmologic clinics didn't have their own lasers, the ciliary body of the eye was attempted to be affected by an electrotherapy method or through cryotherapy sessions.
However, these attempts were found to be ineffective due to weak control over the area of the artificially destroyed tissue. As a result of the destructive impact of these procedures, the eye lost the amount of moisture necessary for normal functioning.
Cyclophotocoagulation is an incomparably more accurate and minimally invasive solution that causes fewer complications, destruction and infection of the operated tissues.
For this reason, this procedure is offered to patients with high IOP level. Patients with abnormal IOP often experience eye pain, to the extent that the optic nerve may be damaged and vision lost.
Today, ophthalmologists widely use a number of methods to establish the production of normal volume of the eye fluid. Among the methods of cyclodestruction are the following:
A kind of cyclodestruction - endoscopic cyclophotocoagulation - is often more preferable then the other methods. The method can be performed independently or be combined with the removal of cataracts. After the probe equipped with a microlaser and a light source, is inserted in the eye, the ophthalmologist observes the state of the ciliary body, moving it around the iris. After laser exposure, the liquid will be produced only by a part of the surviving cells. Diode or neodymium types of lasers can be used for eye surgery.
The indications for cyclophotocoagulation are the terminal stages of neovascular, traumatic, open-angle, primary, and secondary glaucoma, injuries after unsuccessful keratoplasty, a blind aching eye.
Contraindications - pronounced uveitis, malignant neoplasms of the distal segment of the eye, good vision.
Physicians are most concerned about chronic hypotension, occurring in approximately every 10 patients, as well as ophthalmia, which occurs less frequently. There may be subsiding pain after surgery for several days. Usually they are eliminated by the analgesic drugs.
In glaucoma, patients need systematic and long-term treatment, always under the supervision of a physician. As a rule, treatment begins with the medication: eye drops are instilled, reducing intraocular pressure; pills, improving nutrition of the optic nerve and retina are prescribed.
In some rare cases, with such treatment, the intraocular pressure normalizes and the state of the optic nerve does not deteriorate, but such cases are rather rare. In this situation, medical treatment is enough, however, the drugs will have to be applied for life.
Therefore, experts have developed some game-changing new methods of glaucoma treatment: effective, safe and less traumatic. These include laser treatment and surgery.
In the first case, the laser beam, penetrates into the eye freely and affects the drainage system improving the outflow of intraocular fluid. Laser treatment is painless, short on time, and is carried out on an outpatient basis. Its significant advantage is that the eyeball is not exposed to surgery.
Unfortunately, the laser treatment may not help some of the patients suffering from glaucoma. Such treatment can be effective only in the initial stages of the disease, when the intraocular pressure is only slightly increased.
Indications for surgical treatment of the disease don't depend on the type, stage or cause of its occurrence. The decision to perform the operation is made by an ophthalmologist according to the dynamic control data. At high rates eye tissues dying, it's risky to rely on drug treatment due to its being pretty time consuming. The following factors also make surgical intervention necessary:
The main advantage of the surgical method is the possibility to completely eliminate the causes of an increase in IOP. The operation can be performed without dissection, which reduces the risk of infection. Operations don't take much time and are carried out on an outpatient basis.
However, surgery has its drawbacks — the possibility of complications:
In rare cases, the operation may damage the iris or capsule lens vessels.
Options for surgery are divided into non-penetrating and penetrating methods. The latter imply the eyeball dissection to create new ways for the outflow of moisture by artificial means. Non-penetrating method does not require deep opening, affecting the existing ducts.
The type of surgery is chosen taking into consideration the state of the soft eyeball tissues. For example, the secretion of the intraocular fluid is regulated by the ciliary body. When the moisture is increased, the surgery will be directed to its partial destruction. The procedure is based on laser therapy.
If the large lens size prevents the outflow of intraocular fluid, the latter has to be removed. An artificial lens takes its place. Thus, doctors provide protection of optic nerve fibers and maintain visual acuity.
A safe method of open-angle glaucoma surgical treatment is non-penetrating deep sclerectomy. This procedure allows to establish a balance of secretion and excretion of liquid due to intensive moisture exchange with external environment. Since the corneal membrane has a natural water permeability, to stabilize the intraocular pressure, it's only necessary to thin the membrane artificially. This method allows to remove the eye fluid with the help of congenital ducts.
The effect of non-invasive sclerectomy is enhanced in combination with the collagen drains installation or with the use of laser therapy (argon, excimer laser, YAG). Types of drainage structures:
The drainage system helps to avoid the connective tissue formation. The reduction of the effect after surgery creates several advantages of this procedure before other anti-glaucoma operations:
The non-invasive method of surgery reduces the consequences of complications to a minimum. The operation is carried out even in the early stages of glaucoma, when the structure of the optic nerve is not altered and the natural drainage system circulates.
In contrast to non-penetrating deep sclerectomy may offer sinus trabeculectomy with basal iridectomy. The basis is the penetrating method with the implant drainage system installation. The method is less popular, since it is used to deal with a complex clinical situation. During the penetrating treatment a small area of sine and trabecula drainage system is removed. The liquid circulates inside the eye normally, the pressure returns to normal. This method provides efficiency in 60-80% of cases. The operation lasts 20 minutes and requires strict compliance with the ophthalmologist recommendations during the postoperative period. Complications may arise in the form of scar tissue formation. Scars may be removed with subsequent cosmetic surgery.
Although glaucoma is a serious disease which in the worst case, if left untreated, can lead to blindness, a glaucomatous patient can lead a normal life.
As long as there are no severe visual field defects that prevent from driving, the life of these patients is almost the same as that of a person without glaucoma. However, it must be emphasized once again that glaucomatous patients should adhere to the prescribed treatment regimen and regularly have consultations with their ophthalmologist.
Below you will find answers to some questions that patients with glaucoma often have.
A patient with glaucoma, like any other person, may, of course, enjoy life and food, but you should always keep in mind moderation.
During the first hour after ingestion, coffee and tea can cause a moderate increase in intraocular pressure, but this effect is insignificant, so glaucomatous patients do not need to give up drinking these beverages. All glaucomatous patients should not restrict fluid intake, but its use should be evenly distributed throughout the day.
If a glaucomatous patient drinks a large amount of fluid within a very short period of time, let us say, one litre within a few minutes, intraocular pressure will temporarily increase. Therefore, it is recommended to use a sufficient amount of liquid, but it should be distributed evenly throughout the day.
A small amount of alcohol, especially wine, is well tolerated and also has a protective effect on the heart and blood circulation. Patients with glaucoma may consume a small amount of alcohol even every day, without worrying about the consequences for their eyes.
In the case of an acute angle-closure glaucoma attack, a large amount of strong alcoholic drinks can lower intraocular pressure (IOP) for several hours. Of course, drinking alcohol as a “remedy” makes sense only when there is no other way to lower pressure in an emergency situation.
Smoking is a major risk factor that threatens human health and which can be avoided. Smoking causes cancer as well as atherosclerosis. Many eye diseases (retinal vascular occlusion, maculopathy, cataracts, etc.) occur much more frequently and at an earlier age in smokers than in people who do not smoke. Older smokers also have a higher risk of developing elevated intraocular pressure compared with people who do not smoke, but there is no evidence that smoking is an independent (i.e. not associated with IOP) risk factor for glaucomatous lesions.
Despite the fact that marijuana has a lowering effect on intraocular pressure, its medical use has not been studied extensively enough yet so that it can be recommended as a therapeutic agent. There have been too few controlled studies on this issue, so you should carefully weigh all the advantages and disadvantages of long-term use of this substance.
Regular physical activity is just as important for glaucomatous patients as having a proper rest and enough sleep.
Physical exercise tends to cause a reduction rather than an increase in intraocular pressure. However, patients with pigment glaucoma are sometimes the exception to this rule: they may experience an increase in IOP after physical exercise. However, even a patient with this particular form of glaucoma should be able to go in for sports. Prophylactic measures, such as laser iridotomy or pilocarpine instillation before exercise, can prevent IOP elevation. Sport is also recommended for patients with very low systemic arterial pressure to stabilize blood circulation.
Individuals who have already developed visual field defects should be aware of their condition. For example, because of these defects during a game of tennis, at certain moments patients may not see the ball, and during cycling they will not always notice the coming danger.
During swimming or diving in a relatively shallow water body, only minimal changes in intraocular pressure occur. Glaucomatous patients who are going to dive should first consult with an ophthalmologist. Patients with considerable damage to the optic nerve should refrain from underwater swimming.
There are no special observations concerning sauna. In glaucomatous patients IOP responds in the same way as in healthy people: it drops in the sauna and then returns to the initial level in about an hour. However, there is also no evidence that having a sauna is good for patients with glaucoma.
From the viewpoint of physics, intraocular pressure, measured by the doctor, is the difference between absolute intraocular pressure and atmospheric pressure at a certain moment. Thus, a rapid drop in atmospheric pressure causes a relative increase in IOP.
This is usually not a problem for a glaucomatous patient aboard an aircraft, since the artificially created atmospheric pressure inside the aircraft cabin generally compensates for the natural drop in pressure at a considerable height. The eye quickly adapts to the new condition. So, a moderate drop in atmospheric pressure will not cause an increase in IOP.
Another aspect that needs to be taken into account is the air quality in the aircraft cabin with slightly lower oxygen content at a considerable height and, as a result, less availability. But, again, cabin ventilation systems mainly provide passengers with a normal level of oxygen. However, glaucomatous patients with considerable circulatory disorders who fly frequently should discuss this issue with their ophthalmologist.
Playing wind instruments can cause a transient increase in intraocular pressure. Glaucomatous patients playing these instruments should discuss this issue with an ophthalmologist.
Those who wear contact lenses should not worry: these small optical devices do not affect intraocular pressure. In addition, IOP-lowering drugs can be prescribed for glaucomatous patients wearing contact lenses even in smaller doses. This is due to the fact that part of the drug gets into or under the contact lens, which creates a kind of depot from which the drug is constantly released. However, it should be remembered that some antihypertensive drugs can reduce corneal sensitivity. This increases the likelihood that an accidental injury that occurred when inserting the lens may remain unnoticed.
After years of wearing contact lenses, certain changes occur in the conjunctiva of patients. This means that if there is a need for antiglaucoma surgery some day, the risk of a probable closure of the fistula opening is higher.
However, administration of mitomycin C has reduced this risk. Some antiglaucoma medications may exacerbate the symptoms commonly known as dry eyes, making it more difficult to wear contact lenses.
So, patients with glaucoma, of course, can wear contact lenses, but should first consult their ophthalmologist.
As a rule, intraocular pressure drops during pregnancy. This (as well as a moderate increase in IOP after menopause) indicates that sex hormones play an important role in regulating intraocular pressure. Since glaucoma is a chronic disease with very slow progression, the start of treatment can often be postponed until delivery.
If severe glaucomatous lesions are already present, or if intraocular pressure is extremely high, treatment during pregnancy is necessary and possible. The attending physician knows which medications that reduce IOP will be safe for the mother and the fetus, and select the necessary treatment.
Glaucoma prevention includes compliance with the following rules and recommendations:
07.10.2021
There are signs of progress in glaucoma therapy. An implanted chip in the eye, for example, provides precise measurement data of the intraocular pressure at any time of the day or night, which forms the basis of treatment with medicinal eye drops. At the same time, glaucoma surgeons around the world are examining new minimally invasive surgical techniques that could partially replace the tried and tested drop therapy in the foreseeable future.
The most common type of glaucoma is primary open-angle glaucoma. The nerve fibers of the optic nerve slowly die off, in the worst case this leads to blindness. An important factor in this process is the intraocular pressure, which is regulated by the drainage of the aqueous humor in the trabecular system of the eye: If the drainage there is disturbed, the intraocular pressure increases and thus promotes nerve damage. Eye drops are most often used to stop the progression of the eye condition. Around one million people in this country suffer from the disease, and every year 1,000 Germans lose their eyesight due to glaucoma.
If medication does not help, an operation must be carried out. "Trabeculectomy has been available for this for 50 years," explains DOG President Professor Dr. med. Hagen Thieme. With the standard operation, structures on the eye are redesigned in such a way that an artificial drainage for excess aqueous humor is created. "With the trabeculectomy we can achieve a significant reduction in pressure," explains the director of the eye clinic at the Magdeburg University Hospital. "Disadvantages include complications such as bleeding, deterioration of vision, and scarring."
The new minimally invasive methods with mini implants are intended to simplify the procedure. Hair-thin tubes are used for this purpose, which glaucoma surgeons insert through a small incision into the drainage channels of the aqueous humor system with the help of a microscope in order to drain the water out of the eye. "Science is currently evaluating these new processes around the world," reports Thieme. "The length and diameter of the tubes, but also the location of the implantation, are still the subject of discussions." Nevertheless, it is already foreseeable that ophthalmology will offer patient-specific glaucoma surgery with several intervention methods in the future, predicts the Magdeburg ophthalmologist.
New techniques are also developing for measuring intraocular pressure. In a study, for example, a measuring sensor a few millimeters in size was tested, which is incorporated into a silicone ring and which can be implanted with the new artificial lens during cataract surgery. The chip remains permanently in the eye and enables the intraocular pressure to be measured without contact at any time of the day or night. To do this, the patients hold a measuring device in front of their eyes, which calls up the values, saves them and also supplies the chip with power. The values can be transmitted to the treating doctors by telemedicine.
"The chip can be implanted well, is well tolerated and generates a wealth of measurement data that was beyond our imagination," reports study director Thieme. No complications were observed in any of the 22 study participants, and no chip had to be removed. "The study also showed that this intensive intraocular pressure monitoring led to a correction of the medical drop therapy in some cases," said Thieme. The sensor could be an option for patients who have difficulties with measurements and who are about to undergo cataract surgery anyway. "The chip is an example of the development of digital applications in ophthalmology, which will pick up speed in the future," summarizes the DOG President.
20.09.2021
About 75% of all patients with wide-angle glaucoma who receive selective trabeculoplasty as their first treatment can do without eye drops afterwards. In a study at 6 UK eye clinics, the costs of laser treatment were also lower with the same quality of life.
Wide-angle glaucoma is usually treated initially non-invasively with eye drops. A single laser treatment (trabeculoplasty) can improve the drainage of aqueous humor and is considered safe, but it is rarely used as an initial treatment.
In the controlled study "Laser in Glaucoma and Ocular HyperTension" (Light) with blinding for the observers, 718 previously untreated patients with wide-angle glaucoma at 6 British clinics were included and randomized to either laser trabeculoplasty or eye drops according to the severity of the Disease and Recommendations of the European Glaucoma Society. The primary study objective was the quality of life after 3 years, measured with the EQ-5D-5L, which includes a scale from 0 to 1 (ideal).
74.2% of the patients who had received a trabeculoplasty no longer required eye drops after 3 years in order to maintain the target intraocular pressure. Patients achieved the target range in 93.0% of all doctor visits after trabeculoplasty, with eye drops in 91.3%. In the second group, 11 out of 362 patients also required surgery. A cost-benefit analysis showed that the probability of trabeculoplasty being superior as an initial treatment is 97%. The basis for this calculation was the assumption of a value of £ 20,000 per quality-adjusted year of life gained (DALY).
Even if the cost-benefit calculation cannot simply be transferred to German conditions, the study provides good arguments for the early use of trabeculoplasty - a 15-minute procedure that scored better than here in terms of effectiveness and safety the use of eye drops for the rest of life.
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