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Medications lower pressure by either decreasing the production of fluid within the eye or by opening the drainage system to allow more fluid out. There are numerous classes of medications available, each with its own set of side effects. Your doctor will suggest medications for you based upon their safety and efficacy, taking your general health and use of other medications into account.

This is a Micro-Invasive Glaucoma Surgery, or MIGS procedure, attempting to reestablish good flow through the eye’s normal drainage system. Currently, there are two types of stents available for implantation in the United States, the Glaukos® iStent®, which is now in its third generation is known as the iStent Inject®, and the Ivantis® Hydrus® microstent.

Initially approved by the FDA in 2012 and 2018, respectively, these stents are inserted through the trabecular meshwork and into Schlemm’s canal in order to drain aqueous humor more effectively. On average, however, these stents lead to pressure reduction of one to two millimeters of mercury beyond that produced by cataract surgery alone and decrease the need for medications by one to two drugs. There is minimal additional risk to the implantation of these stents, and no impact on the normal healing period for cataract surgery. In general, blood thinners do not need to be stopped. The decision regarding which stent to implant is best made based upon the anatomy of the individual eye, conditions found at the time of surgery, and the surgeon’s familiarity with each device.

This MIGS procedure dilates and cleans out Schlemm’s canal. A tiny catheter, or hollow tube, is inserted into the canal through the trabecular meshwork and passed 360 degrees around the entire eye, breaking adhesions and scar tissue that have formed over time.

As the catheter is withdrawn, a thick liquid is injected into the canal, further dilating it and forcing out debris. This procedure is effective and reimbursed by insurances either combined with cataract surgery or when performed by itself. Several reasonably sized studies have shown pressure reductions of as much as 30%, or four to six millimeters of mercury, though actual reduction may be more or less than this. Complication rates are relatively low and generally mild, though bleeding is more likely than with stent implantation and therefore discontinuation of blood thinners is recommended for this procedure. Recovery to clear vision may be slightly delayed by a few days due to bleeding.

This MIGS procedure involves either cutting into or removing a variably sized section of the trabecular meshwork, allowing aqueous humor a more direct pathway into Schlemm’s canal. Overall, efficacy is similar to that of AbIC, though depends upon the extent of meshwork treated.

This procedure bridges the gap between MIGS procedures and traditional filtering surgery. Like filtering surgeries, aqueous humor is diverted from inside to outside the eye via a bypass through the sclera, forming what is known as a “filtering bleb.” However, much less cutting and manipulation of tissues is required when implanting these devices, with considerably shorter operative and recovery times.

Some of the risks of traditional filtering surgery are reduced, though certainly not eliminated. Therefore, unlike other MIGS procedures that can be performed by nearly any eye surgeon trained appropriately, trans-scleral stents are generally implanted by surgeons experienced with glaucoma filtering surgeries and their post-operative management. There is only one such device approved for use in the US by the FDA: the XEN45 glaucoma implant. Another such implant, known as the PreserFlo shunt, is expected to be approved in 2021.

This laser treatment relieves intraocular pressure by stimulating the internal drainage system allowing adequate outflow of fluid from the eye. There are two types of laser trabeculoplasty procedures: argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT)

The original procedure, described in 1979, was performed using an argon laser, though currently a solid-state diode laser is often employed. These lasers produce light in the visible spectrum with a blue-green color. This type of treatment is often called “argon laser trabeculoplasty,” or ALT. ALT is a time-tested procedure which has been performed for over 40 years. The greatest drawback to ALT is that it can only be performed two to three times on an eye, as further treatments can actually cause injury. A newer version of the procedure, known as “selective laser trabeculoplasty,” or SLT, achieves the same goal using a frequency-doubled neodymium:YAG laser, also producing light in the blue-green spectrum. Because the amount of energy delivered by this laser is less than that in ALT, the procedure can theoretically be repeated as many times as desired without risk of injury to the eye. Multiply repeated treatments performed years apart are often successful. Presently, we perform primarily the SLT procedure, based upon its better safety profile and ability to be repeated multiple times, as needed. Trabeculoplasty will not cure glaucoma. Damage to the optic nerve cannot be reversed. The goal of trabeculoplasty, as with all treatments for glaucoma, is to lower intraocular pressure and prevent the further loss of vision. In some cases, glaucoma medications may be eliminated, however many patients will need to continue all pre-treatment eye drops to maintain adequately low IOP. Trabeculoplasty is not 100% effective at lowering intraocular pressure. Results often vary depending upon the type of glaucoma, number and type of eye drops being taken, and other conditions affecting the eye. Your surgeon will discuss your specific situation and will provide appropriate guidance.

This laser treatment makes a small opening in the peripheral iris (the colored part of the eye). This changes the fluid dynamics in the eye and “opens” the angle. If a patient already has acute angle closure glaucoma, the small opening that is made in the peripheral iris allows fluid to drain more normally and also lowers the eye pressure.

The Iridotomy acts as a low-resistance”bypass,” giving aqueous a clear pathway into the drainage system. In most cases the iris will actually move slightly backwards after iridotomy, as there is less pressure built up behind it. This deepens the anterior chamber, opening the angle wider, further facilitating the outflow of aqueous humor from the eye. Laser iridotomy is therefore the initial treatment of choice for patients with chronic angle closure. It is also the best means of prophylactically reducing the risk of acute angle closure in patients predisposed to the condition.