Glaucoma Southern California
Glaucoma Treatments Long Beach

What is glaucoma?
What different types of glaucoma exist?

Glaucoma is a name given to a group of diseases that are potentially blinding and have a characteristic pattern of serious damage to the optic nerve and visual field loss. An estimated 3 million Americans have glaucoma and it is the most common cause of irreversible blindness in African- Americans.

There are several ways to classify the different types of glaucoma. Traditionally, they have been classified as open angle glaucoma and closed angle glaucoma. This terminology describes the way the drainage system of the eye appears; to understand this, one needs to understand a little bit of anatomy. Inside the eye there is a constant flow of fluid that nourishes the front part of the eye. The area through which the fluid leaves the eye joins the iris at an angle and it is called the trabecular meshwork. In open angle glaucoma, the iris is not blocking the trabecular meshwork. Open angle glaucoma is more common and will often go undetected because the rise in pressure tends to be slow and mild and as a result there are usually no initial symptoms. The vision worsens slowly over time which is hardly noticeable but without treatment, blindness can ensue. The American Academy of Ophthalmology estimates that 50% of people affected by glaucoma may not even know they have the disease.

Closed angle glaucoma is far less common than open angle glaucoma, but the damage to the optic nerve can be faster and more severe. With closed angle glaucoma, the iris blocks the drainage canals when the pupil enlarges. in dim illumination or as a result of stress or medications. When the drainage gets blocked, the pressure can rise quickly and the patient may notice symptoms such as headaches, eye pain, rainbows around lights at night, blurred vision, and nausea. As a note of importance,there is a subacute (slower) form of closed angle glaucoma where the symptoms are not as intense and may go unchecked; patients sometimes mistake their symptoms for those of migraines. Closed angles or narrow angles can easily be diagnosed with a simple in office test and could save your vision. If you have narrow angle glaucoma you must consult your doctor before taking over the counter cold medicines, allergy medications, antidepressants, and of course always read all package inserts for warnings regarding glaucoma.

There are many other classifications of glaucoma. Normal tension glaucoma occurs when the typical optic nerve damage happens at normal intraocular pressures (IOP, the pressure inside the eye). In patients with normal tension glaucoma, the optic nerve appears more sensitive to pressure and undergoes damage at what are normal pressures for others. Most people think glaucoma means increased intraocular pressure, but while we know intraocular pressure is a risk factor, glaucoma could also happen with normal pressures and some patients with elevated pressures will never develop the disease.

Other classifications depend on whether or not there is a cause for the elevation in pressure. Primary glaucoma occurs when open angle glaucoma pressure is elevated without an identifiable cause. Secondary glaucoma occurs when there is an abnormality causing an obstruction and a rise in pressures.

Regardless of the type of glaucoma, the results are damage to the optic nerve. The optic nerve is the cable that sends all the images from the eye to the brain. When one looks at the optic nerve through the pupil, it resembles a doughnut composed of very fine strands (nerve fibers). Each of these strands transmits impulses back to the brain. As the disease progresses, the optic nerve fibers are damaged, causing the nerve to look increasingly "cupped" which means some of the doughnut tissue has been lost and the central empty space becomes bigger. As the loss of tissue progresses, it becomes more visible to the doctor while examining the eye and is easier to diagnose. The loss of tissue in the optic nerve causes the vision to deteriorate over time. First, peripheral vision is affected, followed by progressive loss of central vision which could ultimately progress to blindness. However, glaucoma usually responds to medication if it is detected and treated early.

What causes of glaucoma?

The front of the eye is nourished, in part by fluid that circulates through it, called the aqueous humor. This fluid is constantly being produced and evacuated from the eye. When the rate of production equals the amount evacuated, a stable pressure without wide fluctuations is achieved. The main area through which the fluid is evacuated is known as the trabecular meshwork. In open angle glaucoma, the trabecular meshwork appears normal upon examination, but there is an increased resistance to fluid outflow that is microscopic; this resistance leads to an increase in pressure. In angle closure glaucoma, the trabecular meshwork may become blocked by the iris, abnormal blood vessels or scar tissue, which can also cause an increase in eye pressure. Higher intraocular pressures lead to a higher risk of glaucoma.

Intraocular pressures are a complicated risk factor in the development of glaucoma. Higher pressures lead to a higher likelihood of developing glaucoma at a faster rate however, some patients with elevated pressures will not develop glaucoma. Furthermore, some patients with normal pressures will develop glaucoma.

What are the symptoms of glaucoma?

Patients suffering from early open angle glaucoma, usually have no symptoms but as the disease worsens, increased loss of peripheral vision becomes apparent. In the late stages of the disease, a person may experience a marked reduction in peripheral vision. In most cases, the central vision remains strong but this too will deteriorate over time. Regular eye exams are encouraged so patients can be screened for glaucoma for early diagnosis.

Patients with angle closure glaucoma tend to have more recognizable symptoms such as nausea or periods of pain, ranging from minimal discomfort to an extreme aching pain in the eye and head. With each episode of pain, the vision may become very blurry or colored halos may be seen around lights at night. For this reason, patients with closed angle glaucoma often seek medical help sooner and are diagnosed with the disease before those with open angle glaucoma. Sometimes, if the angle closes slowly, symptoms can be very mild and can go undetected by the patient.

How do you diagnose glaucoma?

To determine if you have glaucoma, your ophthalmologist will perform a series of tests during your initial examination of your eye. At Eye Physicians of Long Beach, our doctors will perform a thorough evaluation in including measuring your visual acuity, checking your refraction, or best vision with glasses, and measuring your eye pressure. The thickness of your corneas may also be checked, as thinner corneas are a risk factor for glaucoma and variations in corneal thickness can lead to false reading of pressures. Thinner central corneal thickness (CCT) may lead to an underestimation of pressure, while thicker CCT may lead to an overestimation of pressures. A dilated exam will be performed to test your pupils, which helps the doctor determine if one optic nerve works better versus the other. Our doctors will use a microscope to examine the eye, the lens, the optic nerve, and other important structures of the eye. The trabecular drainage system of your eye will also be examined with a special contact lens called a gonioscopy lens. In addition, you may also have an automated visual field examination which is a computerized examination of your peripheral vision. As glaucoma develops into the moderate or advanced stages of the disease, optic nerve fibers are destroyed, causing the optic nerve to appear hollowed out. Your doctor will also be able to see the loss of small sections of retinal nerves around the optic nerve, or small areas of bleeding on the optic nerve. Additionally, if angle closure is present, your doctor will be able to see iris or scar tissue physically blocking the trabecular drain. An examination of your retina may also be performed during the dilated examination. Photographs of your optic nerves may be taken in order to view the appearance of your optic nerves.

Computerized optic nerve imaging may also be done At Eye Physicians of Long Beach, we have both an HRT (Heidelberg Retina Tomograph) and an OCT (Ocular Coherence Tomograph). The HRT can give detailed information about the 3-dimensional structure of the optic nerve cup by using a laser to create 3-D photographs of the optic nerve and the surrounding retina. The laser is able to take pictures of 32 layers of the optic nerve by simply changing the focus of the laser each time so that it can image/photograph deeper areas of the nerve and creates a three-dimensional image of the optic nerve. The optic nerve when seen as it enters the eye looks like a doughnut. The HRT is useful in calculating things like the size of the optic nerves, the area of the rim, and the volume of the cup (the hole in the doughnut). These measurements are useful in differentiating an optic nerve that has glaucoma from a normal nerve or follow the optic nerve for changes.

The Ocular Coherence Tomograph (OCT) instrument utilizes a technique called optical coherence tomography which creates images by use of special beams of light in a similar fashion to the HRT. The OCT machine can create a contour map of the optic nerve, optic cup and measure the retinal nerve fiber thickness before it enters the optic nerve. The OCT is a better tool for monitoring and detecting early glaucoma and the HRT for moderate changes.

How is glaucoma treated?

Initial options in the treatment of glaucoma typically include pressure lowering drops and/or laser treatment. For open angle glaucoma and even normal tension glaucoma, drops are usually the initial treatment of choice. Pressure lowering agents commonly work by decreasing the amount of fluid produced by the eye, which usually results in lower pressures. Other medications work by increasing the outflow of fluid out of the eye. While drops cannot cure the disease, in most cases, the use of these medicated eye drops can slow or halt the worsening of glaucoma. There are 256 combinations of drops that can be used and if effective, surgery is not frequently needed.

If drops do not provide sufficient treatment, laser therapy in the form of an argon laser trabeculoplasty or selective laser trabeculoplasty, may be recommended. Our doctors will speak with you and help you understand your glaucoma and which options will be best for your situation.

In the case of angle closure, the physician will need to remove the blockage to reduce the pressure. In this case, the suggested laser procedures are a peripheral iridotomy or a peripheral iridoplasty. In both cases, the purpose of the laser is to pull the iris away from the angle. In a peripheral iridotomy, the surgeon will create a small opening in the peripheral iris and stabilize the pressure behind and in front of the iris, pushing the iris back. This works when the mechanism of angle closure is pupillary block which is that the pupil gets too close to the lens, preventing the fluid from behind the iris to come around, causing a buildup behind the iris. The laser creates a new path for fluid and releases the increased pressure behind the eye. In a peripheral iridoplasty, the laser is used to shrink the mid peripheral iris, pulling it away from the angle.

The next level of therapy if laser and eyedrops fail, consists of incisional surgery, or surgery that involves cutting. Dr. Martinez or Dr. Donovan may recommend one of a variety of surgical procedures for the treatment of your glaucoma, and a trabeculectomy is one of the available options. A small incision will be made into the drainage system of the eye and a new channel for the fluid created, which then flows under or oozes through the conjunctiva. This allows for increased ouflow of fluid and a reduction in pressure. A small bubble will appear on the conjunctiva at the point of intersection of the cornea and the sclera.

A trabeculotomy is useful for cases of congenital glaucoma. A goniotomy is a procedure performed on small children or infants, when a special lens is used for viewing the inner structures of the eye to create a system of drainage throughout the trabecular meshwork.

Other options include shunts are small artificial devices that are surgically attached to the eye's surface for treatment of glaucoma. The devices have a tiny tube that is inserted in the eye and creates a passageway for the fluid to escape. The shunts and implants allow fluid to escape the eye without having to pass through the damaged trabecular meshwork. Shunts are made of materials such as polypropylene and silicone and depending on the type of glaucoma, the shunts may either be hollow to improve drainage or have valves to control the drainage. The main shunts used are Baerveldt shunts (no valve) or an Ahmed shunts which have a valve.

Shunts may create complications for the eye by creating a pressure that is too low for the eye to function. When they are implanted too close to the front of the eye's surface and could cause a breakdown of the cornea; erosion of the tubes where they have been surgically implanted is also a concern. Dr. Martinez and Dr. Donovan will discuss the risks and complications of any glaucoma treatments with you during your appointment.

Prevention of visual loss in glaucoma:

The best way to avoid loosing vision from glaucoma is to have regular eye examinations with your ophthalmologist. Early detection of glaucoma, is important so that it can be treated, which may be able to slow or halt the progression of the disease. Once the vision is lost, it cannot be restored. Having a regular eye exam can help prevent the possibility of glaucoma and other diseases from harming your vision. The main risks factors for glaucoma include, advanced age, decreased corneal thickness, racial background, decreased corneal thickness, and a positive family history of glaucoma.

People of Asian descent and Caucasians have a higher risk of closed angle glaucoma. Asians represent a large portion of those diagnosed with this type of glaucoma. African- American patients have 3-8 times the risk of developing glaucoma and 15 times the risk of going blind from this disease when compared to the rest of the population.

If you have a family history of glaucoma or any other eye diseases it is vital that you seek the attention of an ophthalmologist. Patients who have a parent with glaucoma have a 5-15% risk of developing glaucoma; this is 2.5 to 15 times the general risk, and siblings of patients with glaucoma have a 10% risk of developing the disease.

If you have never been examined and think you may have glaucoma, or have a family history of the disease and would like to schedule an appointment, please call our office at 562.421.2757.

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