Glaucoma - Medications

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The implant often becomes blocked, and additional surgery may be needed.

Nonpenetrating Surgical Techniques: Deep Sclerectomy and Viscocanalostomy

Deep sclerectomy and viscocanalostomy are less invasive techniques than filtering surgery that leave the anterior chamber (front of the eye) intact and avoid creation of blebs.

In both deep sclerectomy and viscocanalostomy, the surgeon creates a flap in the outer part of the sclera (the white part of the eye) and then removes a deep piece of the sclera underneath.

Many variations are under investigation. In general, the procedures have fewer complications afterward than standard filtering surgery, although they require excellent surgical skill. Nonpenetrating techniques do not lower IOPs as much as conventional surgery does, however.

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Treatment for Patients with both Glaucoma and Cataracts

Cataracts and Glaucoma. For patients with both glaucoma and cataracts, doctors recommend:

• In patients with cataracts and poorly controlled glaucoma, a two-step procedure for both eye conditions is needed. Typically the patient will first have a trabeculectomy for glaucoma, followed by cataract surgery such as phacoemulsification (lens removal through ultrasound). Fluid leakage and the presence of blood in the back chamber of the eye are potential complications of this combined procedure.
• Phacoemulsification is sometimes combined with viscocanalostomy in a procedure called phacoviscocanalostomy.
• In patients who have cataracts plus either closed-angle glaucoma or open-angle glaucoma that is stabilized with medication, the cataract may be able to be extracted and medication continued for the glaucoma.

Some evidence indicates that the combined approach generally offers better control over eye pressure for patients with both cataracts and glaucoma. However, it is still unclear which specific type of surgical procedure works best. [For more information, see In-Depth Report #26: Cataracts.]

Laser Cyclophotocoagulation (Cycloablation) for End-Stage Glaucoma

Diode laser transscleral cyclophotocoagulation (TSCPC), also called laser cycloablation, reduces aqueous production by destroying the muscles that control the lens for near and far vision (the ciliary body). There is a chance of vision loss with this procedure, so it is generally reserved for people with end-stage glaucoma or those who fail to benefit from any other therapies.

Surgery for Acute Closed-Angle Glaucoma

For an acute closed-angle glaucoma attack, emergency microsurgery is usually necessary after reducing pressure with medications.

Iridotomy or Iridectomy. Either laser (iridotomy) or conventional (iridectomy) surgery may be used. With either procedure an ophthalmologist makes a tiny opening in the iris to let the aqueous humor flow out more freely. Because acute glaucoma commonly occurs later in the other eye, surgeons will often recommend surgery in the unaffected eye to prevent a second attack.