SURGICAL TREATMENT OF GLAUCOMA

when medical therapy is ineffective in the treatment of glaucoma

What are the options?

If medical therapy for glaucoma is ineffective at halting the ongoing damage to the optic nerve and loss of vision, your eye doctor may recommend glaucoma surgery. There are many different types of surgery for glaucoma. Each one of them is performed in order to lower intraocular pressure. By lowering intraocular pressure, it is hoped that optic nerve damage and loss of vision can be halted. Often, incisional surgery is recommended after attempts with medications or lasers are unsuccessful.

Listed in the left column are some of the surgical options available via the doctors at Glaucoma Associates. Always feel free to call our office at 214-360-0000 with any questions.

LASER IRIDOTOMY

treatment of closed angle glaucoma

What is a Laser Iridotomy?

Closed-angle (of pupillary-block) glaucoma is one of many types of glaucoma. Often it can be cured through a procedure called an iridotomy. To better understand closed-angle glaucoma and its treatment, iridotomy (Figure 1), it is important to understand the different factors which determine eye pressure.

Figure 1: In laser iridotomy, a small hole is placed in the iris (the colored portion of the eye). In most patients, the iridotomy is placed in the upper portion of the iris and cannot be seen under the upper eyelid.

What is eye pressure?

Aqueous humor (the nourishing fluid within the front of the eye) leaves the eye through a tiny drain called the trabecular meshwork (Figure 2 below).

Figure 2: Aqueous humor leaves the eye through a tiny drain called the trabecular meshwork, which is located just in front of the iris.

The trabecular meshwork is located on the side of the eye, just in front of the iris (the part which gives an eye color). Since the fluid is made just behind the iris, it must pass between the iris and lens before leaving through the trabecular meshwork (Figure 3a).

Figure 3a: (Normal Fluid Outflow) In the normal eye, fluid passes between the iris and lens before leaving through the trabecular meshwork in the front of the eye.

Figure 3b: (Pupillary-Block Glaucoma) In pupillary-block glaucoma, a type of closed-angle glaucoma, the flow of fluid between the iris and lens is blocked and the pressure builds in the eye. As it rises, the iris is pushed forward.

The balance between how much fluid is made, and how much leaves the eye, determines the pressure within the eye. All eyes have measurable pressure. However, when the amount of aqueous humor draining from the eye is reduced, the pressure within the eye can increase. This high pressure often leads to glaucoma.

Although many people think of glaucoma as just one single disease, in fact there are many different forms of glaucoma. Differences depend upon where in the eye the blockage to the drainage occurs. Both the border between the iris and lens as well as the trabecular meshwork are areas where the flow of aqueous can be limited, leading to increased eye pressure. One type of glaucoma, pupillary-block glaucoma, occurs with the former. In this type of closed-angle glaucoma, the flow of fluid between the iris and lens is blocked (Figure 3b). It is called pupillary-block glaucoma because the fluid is trapped behind the pupil.

Pupillary-Block Glaucoma

As many as 10% of all glaucoma patients in the United States may have pupillary-block glaucoma. The blockage of fluid flow between the iris and lens can cause the pressure behind the iris to rise. As it rises, the iris is pushed forward. If it moves forward enough, the iris can cover trabecular meshwork like a rubber stopper in a drain.

Sometimes a patient is unaware of the pupillary-block. However, the eye may become red. A patient also may experience headache or pain, blurred vision, and halos around lights. Rarely, there is nausea.

If there is sudden pupillary-block and if the eye is left untreated, permanent damage can occur which can lead to blindness.

The sooner the blockade of fluid flow between the border of the iris and lens is treated, the less damage occurs. Therefore, it is desirable to treat this disease as early as possible.

The best treatment for pupillary-block glaucoma is to create a hole in the iris (known as an iridotomy) (Figure 4A). The iridotomy allows the flow of fluid to the front of the eye to be restored, bypassing the pupil, the location of the blockade (Figure 4B).

Figure 4a: (Laser iridotomy) The hole in the iris is known as an iridotomy. The iridotomy allows the flow of fluid to the front of the eye to be restored.

Figure 4b: Final hole in iris to release pressure in eye. With fluid passing through the iridotomy, the iris is no longer pushed forward. Fluid can leave the eye through the trabecular meshwork again.

How do lasers work to treat glaucoma?

Lasers deliver a type of light energy. This type of light energy is similar to using a magnifying glass to harness the energy of the sun to burn a hole in a piece of paper on a sunny day. The magnifying glass needs to properly focus the light to create a hole in the paper. Likewise, if the laser is not aimed properly at the iris, there is no effect. In order to focus the laser, your eye doctor uses an instrument called a slit-lamp.

This is the same instrument which is used to routinely examine your eyes. Since this is actually a type of microscope, the laser energy can be focused with extreme accuracy.

Several types of lasers can be used to treat pupillary-block glaucoma. The use of the argon laser to create an iridotomy was accepted widely by 1980. Since then, another type of laser, the neodymium: YAG laser, also has proven to be safe and effective. Although there are some differences between these two types of lasers, the use of one or another is best left to your ophthalmologist.

How is laser iridotomy performed?

Before having an iridotomy, your ophthalmologist may place some different types of drops on your eye. The first drop, pilocarpine, will make your pupil smaller. This stretches and thins your iris, similar to stretching out the top surface of a drum. By doing this, it is easier for the laser to penetrate and make a hole in your iris. You may be asked to continue using this eye drop for a few days following the laser treatment. This medication may temporarily cause blurred vision (especially at night) and also may give you a brow-ache.

Another type of eye drop may be used within a few hours of your laser treatment to prevent eye pressure from increasing following laser treatment, or to treat and eye pressure that already has increased. Still other eye drops may be used to reduce inflammation.

The only kind of anesthesia required to perform a laser iridotomy is an eye drop (Figure 5). This is the same type of drop which your doctor places in your eye when the eye pressure is measured. With the eye drop, the laser surgery should be painless. You may see a bright light, like a photographer's flash from a close distance. Also, you may feel a pinch-like sensation.

Figure 5: The only anesthesia required to perform a laser iridotomy is an eye drop.

Your doctor will next place a special contact lens on your eye to focus the laser light upon the iris (Figure 6). This lens keeps your eyelids separated so that you do not blink during the treatment. This also reduces small eye movements so that you do not have to worry about your eye moving during the treatment. To protect the eye from being scratched by the contact lens, special jelly is placed on its surface. This jelly may remain on your eye for about 30 minutes, leading to blurred vision or a feeling of heaviness.

Figure 6: A special contact is placed on your eye to focus the laser upon the iris.

What to expect after an iridotomy.

After treatment, your doctor may ask you to stay for a few hours to check your eye pressure and insure that it has not increased.

When it is safe, you will be sent home and may be asked to use eye drops. Your ophthalmologist will explain their use and when you need to be examined again.

In general, there are no restrictions in activity following the laser treatment. You can return to your normal daily chores immediately. It is advisable to have someone drive you home from your doctor's office. You can expect some redness of the eye, a sensitivity to light, and a scratchy sensation. All of these might last for a period of days. You also might expect a small headache later that day or night.

The chance of losing vision following a laser procedure is extremely small. The main risks of a laser iridotomy are that your iris might be difficult to penetrate, requiring more than one treatment session. The other risk is that the hole in your iris will close. This happens less than one-third of the time. Once the hole stays open for six weeks, it is unlikely that it will close in the future. In addition, you may still require medications, or other treatments to keep your eye pressure sufficiently low. This further treatment is necessary if there is damage to the trabecular meshwork prior to the iridotomy or if you also have one of the other types of glaucoma, in addition to the pupillary-block type.

Do not worry about the size of the hole in your iris. Neither you nor your friends will notice it. It is usually placed in a portion of the iris which is covered by your upper eyelid. The size of the iridotomy is only that of a pin head.

Remember that the creation of a laser iridotomy is both safe and effective. There are a few risks. The purpose of an iridotomy is to preserve your vision, not to improve it.

GLAUCOMA LASER SURGERY

used in the treatment of narrow and open angle glaucoma

Common glaucoma laser surgeries

Laser surgery is used in the treatment of both, narrow angle as well as in open angle glaucoma.Laser Iridotomy and laser iridoplasty are used for the treatment of narrow or closed angle glaucoma. In open angle glaucoma, Selective Laser Trabeculoplasty (SLT) is performed to help with intraocular pressure control. All laser procedures are out-patient procedures performed in the glaucoma clinic. These are usually associated with minimal pain and have no need for restricted activity after the laser. Your doctor or technician will check the eye pressure approx 30 minutes to an hour after the procedure before you go home. You will be sent home with some anti-inflammatory eye drops and a post-operative appointment.

Cyclophotocoagulation is a procedure where the intraocular pressure is controlled by reducing the amount of intraocular fluid made within the eye. Aqueous humor is actively secreted by the ciliary processes. A diode laser is used to coagulate the ciliary processes with laser light. This procedure is usually performed in an operating room facility under anesthesia to make the procedure comfortable and safe. The laser is applied using a special probe inside your eye either with cataract surgery or by itself (ECP). Another way to treat the ciliary processes is to deliver the laser light through the wall of the eye using a special probe placed over the surface of the eye (CPC). This last procedure is usually recommended when the prognosis for vision is poor or if all other surgical options have been exhausted.

INCISIONAL GLAUCOMA SURGERY

day surgery performed in an ambulatory surgery center

Two goals of Incisional Surgery

This usually involves surgery in an operating room facility. All glaucoma surgeries are day surgeries performed in an ambulatory surgery center. During the surgery, your ophthalmologist makes tiny cuts, also known as incisions, into the outer or inner layers of the eye with a tiny knife while looking through a microscope. It involves plenty of tiny sutures to keep the tissues of your eye together. It is not uncommon to feel these sutures in the early post-operative period.

You will meet with a pre-operative scheduling nurse prior to your surgery, who will provide you with detailed instructions on how to prepare yourself for your upcoming eye surgery. You will need to report at your allocated time to the surgery center. You are not to eat or drink anything after midnight prior to the day of your surgery. You can take your regular pills with a limited amount of water (not juice or milk) the morning of surgery.

The goal of incisional glaucoma surgery is to improve drainage of intraocular fluid (aqueous humor). This can be accomplished in two ways:

1. Improving the drainage of aqueous into its natural physiological pathway. This involves finding and working in Schlemm's canal (Canaloplasty, Trabectome®)
2. Creating a bypass channel, for fluid to flow from within the eye to pass unimpeded into the outer layers of the eye, Aqueous bypasses trabecular meshwork( the tiny drain within the eye) which is impaired in glaucoma. The new bypass channel can be created using natural tissues of the eye (Trabeculectomy,Express® glaucoma mini shunt) or by using a silicone tube implant Glaucoma Drainage Implants

Sometimes your doctor may suggest combining these surgeries with Cataract Surgery to help improve your vision. Occasionally cataract surgery alone may be recommended for treatment of your glaucoma. Whenever cataract surgery is performed, a replacement intraocular lens implant (IOL) is always placed within your eye at the time of surgery. Currently there is a choice of intraocular lens implants available and your doctor will help pick the right IOL for you based upon the measurements of your eye, your visual needs and your stage of glaucoma. The intraocular lens implants available are Multifocal lens implants, Toric lens implants and Monofocal lens implants. Feel free to discuss these lens options with your doctor or technicians during your appointment or after to see if you are a candidate for one of these implants.

Your doctor will discuss your surgical options with you and recommend the appropriate procedure at the time of your appointment. When successful, these procedures lower intraocular pressure and preserve vision.

SELECTIVE LASER TRABECULOPLASTY

a new procedure to lower pressure

Selective Laser Trabeculoplasty

Selective Laser Trabeculoplasty (SLT) is a new procedure performed to lower intraocular pressure (IOP). SLT is an outpatient laser used to selectively target the pigmented trabecular meshwork cells in the angle of the eye. The outflow of aqueous humor is then enhanced and the IOP is lowered.

The procedure takes about 15 minutes to perform. Prior to the procedure, a topical anesthetic drop is placed on the eye and a contact lens is placed on the eye. The laser applications are made through a microscope that looks similar to the one your doctor examines your eye with in the office. Once the laser is completed, you will have to wait for a period of time to have your eye pressure checked. Allow 2 hours for the entire procedure. You will need to use an anti-inflammatory drop in the eye for several days following the procedure.

Several postoperative visits will be scheduled to monitor your eye pressure. Expect several weeks before your doctor sees a lower pressure in the eye treated. Early results show that the laser may be repeated if necessary.

Benefits of the laser include no adverse events from added medications and the delay of a surgical procedure. Please feel free to discuss this laser or other procedures with your physician.

GLAUCOMA DRAINAGE IMPLANTS

a trabulectomy alternative

What are Glaucoma Drainage Implants?

In some patients, particularly those with certain types of glaucoma, such as aphakic glaucoma, neovascular glaucoma and uveitic glaucoma the standard trabeculectomy is known to be less successful in reducing intraocular pressure due to an aggressive healing response. Also in patients who have failed a previous trabeculectomy surgery or have had other eye surgeries a glaucoma drainage device works better than a standard trabeculectomy procedure in control of intraocular pressure. It should be noted that the glaucoma implant is not used to improve vision, but to lower intraocular pressure. In this respect, it is completely different from the type of implant which is used during cataract surgery.

Occasionally, a glaucoma implant will be recommended as an initial surgical procedure. In these patients, the implant is necessary because there is expected to be extensive scarring in the outer layers of the eye. Compared to the channel made with trabeculectomy, the tube of the glaucoma implant is less likely to become blocked by this scar tissue.

Glaucoma drainage implants come in different shapes and sizes (Figure 1). They are generally two types of implants: Valved and Non-valved implants. All these implants have a tube and plate design. With each of them, a silicone tube is inserted into the front of the eye behind, but not touching, the cornea. The plate of the implant is usually placed in the area underneath the upper eyelid (Figure 2). Unless the lid is pulled back, neither you nor your family will notice it. With the upper lid retracted, a white patch may be noted. This is a patch that covers the tube and prevents irritation. The tube is like an artificial drain, and fluid passes through it to a reservoir over a plate which has been placed over the surface of your eye. The fluid then slowly percolates through this reservoir and is absorbed into the body fluids. Regardless of the type of drainage implant it can take up to 3 months after surgery for the intraocular pressure to stabilize, as the capsule surrounding the plate of the implant needs this time to mature in the eye.

Figure 1: Glaucoma implants come in many shapes and sizes. A clear thin tube is placed into the front part of the eye, and is connected to a reservoir (white) outside the eye.

Figure 2: The clear tube is seen through the cornea. The reservoir cannot be seen because it is covered by the eyelid and outer portions of the eye.

Types of Implants

Valved Implants:

The Ahmed glaucoma implants are currently the only valved implants used in our practice. These valved implants can potentially avoid low intraocular pressure in the early postoperative period. These are available both with silicone (FP7, FP8) as well as polypropylene plates (S2, S3).

Non Valved Implants

1. Baerveldt implants available in two sizes (350mm2 and 250 mm2)
2. olteno implants (Single plate Molteno and Molteno 3 implants)

Since these tubes do not have a restrictive device within them they have the potential to decompress the eye completely when implanted. Hence these tube implants are tied off when first implanted into the eye. The ligature used to tie off the tube spontaneously dissolves at around 6 weeks or if your doctor has placed a stent to block the tube, this can be removed in the office to make your tube implant completely functional. Usually by six weeks a thick capsule has formed around the plate that has been placed over the surface of your eye. When fluid passes from within the eye through the tube to over the plate the capsule provides some resistance and helps prevent the eye from collapsing.

What is my chance of success with a Glaucoma Drainage Implant?

Since glaucoma implants are used in patients with more complicated problems, the success rate is slightly lower than a standard trabeculectomy. However, in many patients, these implants may be the best remaining available option. In about 10% of cases a second tube implant is necessary to adequately control intraocular pressure. When a second tube is necessary it is usually place in the lower part of the eye under the lower eye lid.

Remember that the goal of glaucoma implant surgery is to lower intraocular pressure and preserve vision. It will not restore vision that already has been lost. The goal of trabeculectomy is to lower eye pressure. By lowering eye pressure, it is hoped that the operated eye will be spared further glaucoma damage and can maintain its vision. Occasionally, there can be loss of vision. Sometimes your doctor will combine the drainage tube surgery with cataract surgery. In these cases there may be some visual improvement from clearing of the cataract and replacing it with a clear intraocular lens implant.

What is involved with a Glaucoma tube procedure?

When you and your doctor make a decision to proceed with implantation of a Glaucoma drainage tube you will meet with our preoperative scheduling nurse who will give you detailed instructions on how to prepare yourself for your upcoming surgery and what is involved in getting to the operative room for the procedure. See Preoperative instructions for more information. Your doctor after discussing the pros and cons, will decide on the appropriate type and of tube implant to be placed in your eye.

The surgery is an outpatient procedure performed in an ambulatory surgery center. The surgery itself takes about one hour in most cases. The surgery is usually done under local anesthesia with intravenous sedation. An injection of local anesthetic through the eyelid numbs the eye completely so that it will not move during surgery, and there is no discomfort. Sometimes a general anesthetic is used, in which the patient is put to sleep for the operation. Local anesthesia offers several advantages. There may be less pain after surgery, and there is no sore throat from the airway tube used in general anesthesia.

Patients quickly return to normal alertness without the nausea often felt after general anesthesia. With local anesthesia, there is less risk than with a general anesthetic, especially in the elderly or those with health problems.

After surgery, the eye generally is covered by an eye patch and protected by a plastic shield overnight. On the morning following the surgery, it is removed and the eye is examined by your ophthalmologist. Eye drops are then prescribed to relax the muscles in the eye, prevent infection, and reduce inflammation. Occasionally, a pill may be prescribed, as well, to further reduce inflammation. It is important to take these as directed by your ophthalmologist since they can make a great deal of difference in the success of the procedure. See Postoperative instructions.

Immediately after the surgery, intraocular pressure may not be lower. Depending on how surgery is performed, glaucoma medications may be continued during this period. For several weeks following the surgery, your ophthalmologist will observe your eye closely and examine you frequently. When a non-valved implant such as a Baerveldt or a Molteno implant is used the tube usually opens and begins to drain at about 6 weeks after surgery. When this happens the eye pressure can drop suddenly in some cases. The pressure then builds up back again and most patients experience a 'hypertensive phase' for the next few months needing continued use of glaucoma medications. It may take up to 12 weeks after your surgery for the healing to be complete and for the implant to mature in your eye. During this time it is not unusual for your intraocular pressure, as well as your vision to fluctuate. You will be ready to change your glasses prescription at around two months after surgery.

TRABECULECTOMY

ophthalmic surgery when medication is not enough

What is a Trabeculectomy?

When treatment with eye drops, pills, or laser surgery does not lower intraocular pressure to a safe level, your ophthalmologist may determine that glaucoma surgery should be performed. One way to reduce pressure in an eye with glaucoma is to make a new drain in the eye. This type of surgery is called a trabeculectomy.

During this operation, a tiny piece of the wall of the eye, which may include the trabecular meshwork (the natural drain), is removed by the surgeon. This opens a new drain which creates a bypass for the trabecular meshwork to reduce eye pressure. The eye pressure is reduced because fluid can now drain with relative ease through the new opening into a reservoir (bleb) underneath the conjunctiva (which comprises the surface of the eye). The fluid is then absorbed by the body.

The natural response of the body is to heal this newly made drain as it does with every other wound or injury the body sustains. However trabeculectomy surgery is unique in that we need the drain to remain open so that the eye pressure remains controlled. At the same time we need the surface tissues (conjunctiva) to heal back down so that the internal fluid of the eye does not leak into the tear film (bleb leak), as that could be a risk for infection. The risk of scarring down the drain and failure of the procedure is higher in younger individuals (less than 40 yrs), patients of African-American ancestry, history of previous eye surgery, previous ocular inflammation (uveitis) and in patients with neovascular glaucoma. When your doctor performs a trabeculectomy procedure, they will often apply an anti-scarring medicine called Mitomycin (MMC) or 5-Flurouracil (5FU) to the surface tissues of your eye to reduce the chance of surgical failure. Adjuvant use of these drugs with trabeculectomy surgery has vastly improved the success rate of the procedure. Sometimes even with use of these drugs in surgery your eye might exhibit an exuberant healing response. In these cases your doctor might elect to inject 5-Flurouracil during your postoperative visits to help slow down the healing response.

What is my chance of success with a trabeculectomy?

Although the results of the trabeculectomy depend on numerous factors and can vary greatly, as a general rule approximately 70% of operated eyes will have satisfactory eye pressure and no need for medication one year after surgery. If eye drops are added, over 90% of eyes will have a satisfactory lowering of eye pressure.

The goal of a trabeculectomy is to lower eye pressure. By lowering eye pressure, it is hoped that the operated eye will be spared further glaucoma damage and can maintain its vision. Although vision sometimes can improve following trabeculectomy, in most eyes it remains unchanged. Occasionally, there can be loss of vision. Sometimes your doctor will combine the trabeculectomy surgery with cataract surgery. In these cases there may be some visual improvement from clearing of the cataract and replacing it with a clear intraocular lens implant.

What is involved with a trabeculectomy procedure?

When you and your doctor make a decision to proceed with the trabeculectomy surgery you will meet with our preoperative scheduling nurse who will give you detailed instructions on how to prepare yourself for your upcoming surgery and what is involved in getting to the operative room for the procedure. See Preoperative instructions for more information.

Trabeculectomy is an outpatient procedure performed in an ambulatory surgery center. The surgery itself takes less than one hour in most cases. The surgery is usually done under local anesthesia with intravenous sedation. An injection of local anesthetic through the eyelid numbs the eye completely so that it will not move during surgery, and there is no discomfort. Sometimes a general anesthetic is used, in which the patient is put to sleep for the operation. Local anesthesia offers several advantages. There may be less pain after surgery, and there is no sore throat from the airway tube used in general anesthesia. Patients quickly return to normal alertness without the nausea often felt after general anesthesia. With local anesthesia, there is less risk than with a general anesthetic, especially in the elderly or those with health problems.

After a trabeculectomy, the eye generally is covered by an eye patch and protected by a plastic shield overnight. On the morning following the surgery, it is removed and the eye is examined by your ophthalmologist. Eye drops are then prescribed to relax the muscles in the eye, prevent infection, and reduce inflammation. Occasionally, a pill may be prescribed, as well, to further reduce inflammation. It is important to take these as directed by your ophthalmologist since they can make a great deal of difference in the success of the procedure. See Postoperative instructions.

For several weeks following the surgery, your ophthalmologist will observe your eye closely and examine you frequently. Because it is not possible to know the precise size of the opening to make in the eye to drain fluid, sometimes too much fluid may drain after surgery. Also it is not possible to predict your individual healing response to the surgery. If your eye pressure is running higher than intended, your doctor may use a laser during your postoperative visits to cut the sutures laying the trap door down to promote further flow of fluid from within the eye. It may take up to 12 weeks after your surgery for the healing to be complete. During this time it is not unusual for your intraocular pressure, as well as vision to fluctuate. You will be ready to change your glasses prescription at around 6-8 weeks after surgery.

ExPRESS® Glaucoma Mini Shunt

In a traditional trabeculectomy procedure a new drain is created by punching a sclerostomy under a partial thickness scleral flap. The size of this sclerostomy can be variable leading to an unpredictable intraocular pressure response in the early postoperative period.

The ExPRESS® Glaucoma mini shunt is a less than 3 mm long stainless steel implant that is inserted under a scleral flap, through a 27G needle track, to create a new drain. It diverts aqueous humor into the subconjunctival space through a standardized channel reducing intraocular pressure. The shunt has an inbuilt resistor that creates a standardized opening of 50 microns or 200 microns depending on the model implanted (P50, R50, P200). The entire procedure is a safer closed system reducing the risk of anterior chamber collapse and vitreous shifting. The implant is completely MRI safe and has been tested in magnetic fields of up to 3 tessa forces.

When a decision is made for glaucoma surgery, your doctor will discuss your options with you and if appropriate will discuss implantation of the ExPRESS® glaucoma mini shunt. The procedure for implantation of this shunt device is very similar to a trabeculectomy procedure. Most often anti-scarring medications such as Mitomycin C or 5-Flurouracil will be used during surgery to reduce the chance of postoperative scarring. Please refer to the trabeculectomy page for more details on what to expect if you are scheduled for this procedure.

CANALOPLASTY

Canaloplasty reduces IOP by restoring the trabeculocanalicular outflow pathway

What is Canaloplasty?

Canaloplasty is circumferential dilation and stenting of Schlemm's canal with a viscoelastic agent and a Prolene suture. Schlemm's canal is the drainage channel into which intraocular fluid drains after passing through the pores of the trabecular meshwork. It is a circular microscopic canal that lies within the tissues at the junction of the cornea and the sclera.

Recent advances in technology have enabled the development of a 250 micron flexible microcatheter with an illuminated tip (iTrack™, iScience Interventional, Menlo Park, CA) that passes through Schlemm's canal (Fig. 1). The availability of this microcatheter along with advances in ocular ultrasound and viscoelastics have lead to the development of Canaloplasty, as a promising non-penetrating surgical technique for lowering intraocular pressure in patients with open angle glaucoma.

Who is a good candidate for Canaloplasty?

Canaloplasty is indicated for the surgical treatment of open angle glaucomas. It is contraindicated in patients with angle recession, neovascular glaucoma, chronic angle closure, narrow angle glaucoma, narrow inlets with plateau iris and in patients with previous surgery which would prevent 360 degree cathetereization of Schlemm's canal.

How does it work?

Canaloplasty reduces IOP by restoring the trabeculocanalicular outflow pathway. It increases the flow of aqueous humor from the anterior chamber, through the trabecular meshwork and Descemet's window, into and around Schlemm's canal, and out through the collector channels (Fig.3). The hypothesis is the suture tensioning acts similar to pilocarpine increasing trabecular meshwork permeability. This procedure does not create a 'bleb' on the surface of the eye as fluid is routed through normal physiological pathways.

For more details visit www.canaloplasty.com

What is involved with a Canaloplasty procedure?

When you and your doctor make a decision to proceed with Canaloplasty you will meet with our preoperative scheduling nurse who will give you detailed instructions on how to prepare yourself for your up coming surgery and what is involved in getting to the operative room for the procedure. See Preoperative instructions for more information.

This is an outpatient procedure performed in an ambulatory surgery center. The surgery itself takes less than one hour in most cases. The surgery is usually done under local anesthesia with intravenous sedation. After surgery, the eye generally is covered by an eye patch and protected by a plastic shield overnight. On the morning following the surgery, it is removed and the eye is examined by your ophthalmologist. Eye drops are then prescribed to prevent infection, and reduce inflammation. For more details click on Postoperative instructions.

For several weeks following the surgery, your ophthalmologist will observe your eye closely and examine you frequently. During your postoperative visits your doctor may perform a high resolution ultrasound examination of your eye to visualize Schlemm's canal and to assess the extent of its dilation. It may take up to 12 weeks after your surgery for the healing to be complete. During this time it is not unusual for your intraocular pressure, as well as vision to fluctuate. You will be ready to change your glasses prescription at around 8 weeks after surgery.

TRABECTOME®

minimally invasive surgical treatment for the management of open angle glaucomas

What is the Trabectome® procedure?

The Trabectome® procedure is a minimally invasive surgical treatment for the management of open angle glaucomas. A tiny 1.7mm incision is made in the periphery of your cornea through which the surgery is performed. The surgical procedure involves unroofing Schlemm's canal using a specially designed handpiece that delivers an electrosurgical pulse. The trabecular meshwork tissues are electro-cauterized and all tissue debris is removed by washing out through an automated irrigation-aspiration system. Usually, 90-120 degrees of tissue is removed from the nasal angle. At the present time, it is unknown as to whether removing more of the trabecular tissue will be helpful in lowering the IOP further.

This procedure does not involve opening up the conjunctival tissues to access Schlemm's canal. This is a major advantage of this procedure as it makes future glaucoma surgery (if needed) a lot simpler with less risk of failure.

Who is a good candidate for Trabectome®?

Trabectome® is indicated for the surgical treatment of open angle glaucomas. It is contraindicated in patients with neovascular glaucoma, chronic angle closure, narrow angle glaucoma and narrow inlets with plateau iris.

How does it work?

Trabectome® reduces IOP by restoring the trabeculocanalicular outflow pathway. It increases the flow of aqueous humor from the anterior chamber, directly into and around Schlemm's canal, and out through the collector channels (Fig.3). This procedure does not create a 'bleb' on the surface of the eye as fluid is routed through normal physiological pathways.

For more details visit www.trabectome.com

What is involved with a Trabectome® procedure?

When you and your doctor make a decision to proceed with Trabectome® you will meet with our preoperative scheduling nurse who will give you detailed instructions on how to prepare yourself for your up coming surgery and what is involved in getting to the operative room for the procedure. See Preoperative instructions for more information.

This is an outpatient procedure performed in an ambulatory surgery center. The surgery itself takes less than one hour in most cases. The surgery is usually done under local anesthesia with intravenous sedation. After surgery, the eye generally is covered by an eye patch and protected by a plastic shield overnight. On the morning following the surgery, it is removed and the eye is examined by your ophthalmologist. Eye drops are then prescribed to prevent infection, and reduce inflammation. For more details click on Postoperative instructions.

For several weeks following the surgery, your ophthalmologist will observe your eye closely and examine you frequently. It may take up to 12 weeks after your surgery for the healing to be complete. During this time it is not unusual for your intraocular pressure, as well as vision to fluctuate. You will be ready to change your glasses prescription at around 6-8 weeks after surgery.

CATARACT

your doctor might recommend cataract surgery for treatment of your glaucoma

What is a Cataract?

A cataract is hardening and clouding of the natural crystalline lens within your eye ball. It is a normal process of aging. However this process can occur sooner in glaucoma patients secondary to chronic use of glaucoma drops or from previous glaucoma surgery. In an eye with a narrow angle, a cataract further narrows the angle recess. In such eyes removal of the cataract alone will widen the anterior chamber angle and help prevent an acute angle closure attack.

Your doctor might recommend cataract surgery for treatment of your glaucoma and improvement of your vision. Often this may be combined with a glaucoma procedure such as a trabeculectomy, glaucoma drainage implant, Canaloplasty or Trabectome.

What is Cataract Surgery?

Removal of the cataract is a surgical procedure. Modern day cataract surgery is small incision and virtually sutureless. A tiny incision is made in the clear part of your eye called the cornea. A circular opening is made in the bag (capsule) of the cataract. A probe is inserted into your eye through this incision. The cataract is broken up into several tiny pieces with the help of an ultrasound probe. The cataract debris is removed using an automated irrigation aspiration system. Once all the lens material is cleaned out, the bag of the cataract is filled with a viscoelastic agent and an intraocular lens implant (IOL) is injected into the bag. The artificial lens implant is placed in the natural anatomic position and it stays there for life. If the capsular bag is unstable your doctor may chose to implant the IOL just in front of the capsular bag or rarely the IOL may need to be sutured to the eye wall to hold it in position. On completion of the procedure your doctor may or may not take a stitch through your corneal wound based on the wound integrity.

What are my lens implant choices?

Trabectome® reduces IOP by restoring the trabeculocanalicular outflow pathway. It increases the flow of aqueous humor from the anterior chamber, directly into and around Schlemm's canal, and out through the collector channels (Fig.3). This procedure does not create a 'bleb' on the surface of the eye as fluid is routed through normal physiological pathways.

In preparation for cataract surgery certain measurements are taken of your eye to determine the correct power of the IOL to be placed in your eye at the time of cataract surgery. The axial length of the eye ball along with the corneal curvature is measured. Based on the measurements your IOL choices would be a standard monofocal lens implant, Toric lens implant or a Multifocal lens implant. Your doctor will discuss these options with you prior to the surgery.

What is involved with Cataract Surgery?

When you and your doctor make a decision to proceed with Cataract surgery alone or in combination with a glaucoma procedure you will meet with our preoperative scheduling nurse who will give you detailed instructions on how to prepare yourself for your upcoming surgery and what is involved in getting to the operative room for the procedure. See Preoperative instructions for more information. If you have not has your eye measurements you will be set up to have these done to help choose the appropriate replacement IOL. You and your doctor after discussing the pros and cons, will decide on the appropriate type of IOL to be placed in your eye at the time of cataract surgery.

The surgery is an outpatient procedure performed in an ambulatory surgery center. The surgery itself takes about 30 minutes in most cases. The surgery can be done with drops or under local anesthesia with intravenous sedation. An injection of local anesthetic through the eyelid numbs the eye completely so that it will not move during surgery, and there is no discomfort. Rarely a general anesthetic is used, in which the patient is put to sleep for the operation. Local anesthesia offers several advantages. There may be less pain after surgery, and there is no sore throat from the airway tube used in general anesthesia. Patients quickly return to normal alertness without the nausea often felt after general anesthesia. With local anesthesia, there is less risk than with a general anesthetic, especially in the elderly or those with health problems.

After surgery, the eye generally is covered by an eye patch and protected by a plastic shield overnight. When you have ha surgery under topical anesthesia (drops and anesthetic gel) your doctor may only place a plastic shield over your eye and instruct you to start eye drops right away. On the morning following the surgery, the eye patch is removed and the eye is examined by your ophthalmologist. Eye drops are then prescribed prevent infection, and reduce inflammation. It is important to take these as directed by your ophthalmologist since they can make a great deal of difference in the success of the procedure. See Postoperative instructions.

It takes about 4 to 6 weeks after cataract surgery for the vision to stabilize. You will be ready to change your glasses prescription (if needed) then.

SELECTIVE LASER TRABECULOPLASTY

a new procedure performed to lower intraocular pressure

What is Selective Laser Trabeculoplasty?

Selective Laser Trabeculoplasty (SLT) is a new procedure performed to lower intraocular pressure (IOP). SLT is an outpatient laser used to selectively target the pigmented trabecular meshwork cells in the angle of the eye. The outflow of aqueous humor is then enhanced and the IOP is lowered.

The procedure takes about 15 minutes to perform. Prior to the procedure, a topical anesthetic drop is placed on the eye and a contact lens is placed on the eye. The laser applications are made through a microscope that looks similar to the one your doctor examines your eye with in the office. Once the laser is completed, you will have to wait for a period of time to have your eye pressure checked. Allow 2 hours for the entire procedure. You will need to use an anti-inflammatory drop in the eye for several days following the procedure.

Several postoperative visits will be scheduled to monitor your eye pressure. Expect several weeks before your doctor sees a lower pressure in the eye treated. Early results show that the laser may be repeated if necessary.

Benefits of the laser include no adverse events from added medications and the delay of a surgical procedure. Please feel free to discuss this laser or other procedures with your physician.

ENDOCYCLOPHOTOCOAGULATION (ECP)

combined with cataract surgery to help reduce intraocular pressure

What is Endocyclophotocoagulation (ECP)?

ECP is often combined with cataract surgery to help reduce intraocular pressure. The procedure involves coagulation of the ciliary processes under direct visualization so as to cause inflammation and scarring with subsequent decrease in the amount of intraocular fluid produced within your eye. Since glaucoma usually involves a drainage problem, reducing the amount of fluid being made helps with the intraocular pressure.

After cataract surgery is completed a 20G special probe is introduced into the eye through the same cataract incision. This probe has both a special camera as well as fiberoptic cables that will help deliver the laser energy. Your surgeon will observe the internal structures of your eye on a TV monitor and will direct the laser energy to the ciliary processes under direct visualization. The amount of energy delivered is titrated to achieve a blanching of the processes. An attempt is made to treat about 270 to 360 degrees around the eye to achieve maximal effect.

After the procedure an eye patch will be placed over your eye for the first 24 hours. Your doctor will want to examine you in the office the following morning when the patch will be removed and your eye pressure checked. You will be prescribed a regimen of postoperative drops for the next four to six weeks.

If the procedure is successful you can expect a decrease in the intraocular pressure and you possibly may come off some of your glaucoma medications. It takes about 6 to 8 weeks before the outcome of the laser procedure is known.

The procedure takes about 15 minutes to perform. Prior to the procedure, a topical anesthetic drop is placed on the eye and a contact lens is placed on the eye. The laser applications are made through a microscope that looks similar to the one your doctor examines your eye with in the office. Once the laser is completed, you will have to wait for a period of time to have your eye pressure checked. Allow 2 hours for the entire procedure. You will need to use an anti-inflammatory drop in the eye for several days following the procedure.

Several postoperative visits will be scheduled to monitor your eye pressure. Expect several weeks before your doctor sees a lower pressure in the eye treated. Early results show that the laser may be repeated if necessary.

Benefits of the laser include no adverse events from added medications and the delay of a surgical procedure. Please feel free to discuss this laser or other procedures with your physician.

DIODE CYCLOPHOTOCOAGULATION (CPC)

recommended for patients with refractory glaucoma

Why would Cyclophotocoagulation be recommended for me?

Cyclophotocoagulation is recommended for patients with refractory glaucoma who have persistent elevated eye pressure. Patients usually have failed tube shunt procedures or trabeculectomies. Some patients have minimal useful vision. The procedure may be used on patients with no visual potential and a need for pain relief.

Diode cyclophotocoagulation is an outpatient procedure. The patient receives a peribulbar block (anesthesia around the eye) prior to the laser. The laser, performed by your ophthalmic surgeon, takes 20 to 30 minutes and will require use of postoperative drops to decrease inflammation in the eye. Most patients have minimal postoperative pain. The procedure is often combined with injection of a pain killer (Chlorpromazine) behind the eye ball.

Since there are no incisions made into the eyeball there are usually no postoperative restrictions associated with the procedure. You will have a patch on the eye for the first 24 hours after the procedure and your doctor will want to see you the day following the procedure in the office to check your eye pressure.

CPC may be repeated if the desired eye pressure is not achieved.

Forms for Surgery

Click here or click the link below to download the necessary forms for surgery

All Three Forms in One File

The forms include the Request for Pre-Surgery Evaluation. This form must be completed by your doctor and be sent back to us. We must receive it at least three days prior to surgery.

The PDF form also includes a list of things to do and NOT do the week prior to your ophthalmic procedure or surgery.

The last page of instructions is a guide for your post ophthalmic surgery (post-surgery) recovery period.

Click here for the forms

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