Glaucoma Treatment in India

Glaucoma is a disease where the pressure of eye becomes high damaging the nerve fibers forming the optic nerve. This nerve carries the visual information from eye to brain and therefore any damage to the nerve fibers causes defects in the visual area we see around and decreased vision which may even progress to blindness if not treated in time. Normally eye has a certain pressure — 11 to 21 mm Hg (like a balloon filled with water) which is required for the eye to function in a healthy way. This pressure is created by a fluid called aqueous humor that is being continuously formed and drained out from the eye through out life. Any disturbance in maintaining this delicate balance leads to high pressure, which in turn damages the nerve fibers.

Glaucoma is a common cause of blindness across the world. In our country alone the prevalence of glaucoma is estimated to be 4% in population of above 30 years of age. The main problem in picking up this SILENT disease is that mostly it does not have symptoms in early stages and by the time patients report with visual complaints, the damages which have occurred in the eye are irreversible. Most of the cases are picked up on a routine eye examination by an eye surgeon. Though the disease is blinding it is treatable if detected early enough. The cure of glaucoma means to keep the eye pressure within normal range and stop further deterioration by means of eye drops, laser or surgery. To avoid fears & misconceptions about the disease this manual helps you in understanding the disease better. Following are frequently asked questions by patients but do not hesitate to ask your Eye Surgeon about any of your problem or doubt.

What are the symptoms of glaucoma?

The presentation of glaucoma varies depending on the type of glaucoma. These broadly depend on the exit channels for fluid inside the eye, situated at the angle of anterior chamber of the eye.

·        OPEN ANGLE GLAUCOMA is the silent chronic variety. It does not have any symptom in early stages and is most often picked up during a routine eye examination by the eye surgeon. Later there can be a feeling of heaviness in & around eyes, headache, and frequent change in spectacle number or even inability to see certain areas in the field of vision around us.

·        NARROW ANGLE GLAUCOMA can cause acute pain, redness, headache or seeing colored rings around bulb light. These symptoms are more in evenings or dim-light because the pupil dilates leading to compromised exit channels for fluid to drain out and results in high pressure inside the eye.

·        SECONDARY GLAUCOMA can occur due to various causes like injury, inflammation, tumors of eye, hemorrhage, drugs like steroids etc. They can present with any of above symptoms.

·        CONGENITAL GLAUCOMA is a condition where the exit channels are poorly formed since birth. Due to high pressure the cornea becomes opaque and eye may gradually enlarge. Child presents with decreased vision, glare, watering or enlarged eye, and requires immediate treatment.

How does high pressure affect vision?

High pressure leads to poor blood circulation damaging nerve fibers forming the optic nerve that carries visual impulses from eye to brain. Initially there are corresponding areas of loss in visual field and gradually progress to marked decrease in vision.

Rarely even apparently normal pressure level may adversely affect the eyes in some people who have susceptibility to optic nerve damage even with pressure in normal range due to abnormal blood flow. This is called normal tension glaucoma. Here it is the nerve-head -disc and visual field changes which decide the course of treatment and what pressure is normal for you.

What is the difference between cataract (safed motia) and glaucoma (kala motia)?

Cataract is due to opacity in the lens of eye, which does not allow image to be properly focussed on the retina while glaucoma is due to rise in pressure of eye, which damages the optic nerve fibers. Loss of vision is recovered in cataract by surgery (Phacoemulsification with intra-ocular lens implantation) while visual loss in glaucoma is permanent. Sometimes a patient can have both cataract & glaucoma.

Who are the people more at risk of glaucoma?

What tests are done to diagnose glaucoma?

It is not enough to record only eye pressure to diagnose glaucoma. Once a patient has suspicion of having glaucoma, we study the angles of eye, optic nerve and visual fields.   All these are looked into together by the eye surgeon to establish a complete picture of the type and nature of glaucoma. The basic work up of a patient includes:

·         Applanation tonometry - most accurate method to measure intraocular pressure.

·         Ophthalmoscopy - to assess the changes in the anterior visible portion of optic nerve, seen through the pupil.

·         Gonioscopy - to study the details of exit channels for eye fluid situated at the angle of anterior chamber.

·         Computerized Perimetry or Visual Fields Charting - to detect loss in visual field corresponding to the nerve fiber damage. This is a very sophisticated test, which shows the changes in both qualitative & quantitative manner and is very crucial for further treatment course and to study the progression of disease.

·         Disc or Fundus Photographs may be taken to assess the changes in optic nerve head and retinal nerve fiber layer for detailed objective analysis and further comparisons.

Above tests need careful analytical assessment for baseline treatment and future management. Because glaucoma is a progressive disease, a long-term careful follow up is required where these tests are repeated and compared to the previous reports. If any progression in the damage is noted, then the treatment is modified

Is glaucoma curable?

Mode of treatment includes eye drops, medicines, laser or surgery. These do not cure the disease but treat the condition by preventing further damage. Hence the importance of early detection. It is a condition that needs long term follow-up, mostly life long. The treatment is modified based on time to time evaluation of the disease status.

What is the treatment for glaucoma?

The treatment is aimed to keep eye pressure in normal range. For any individual the normal or “target pressure” is different, which is decided by the eye surgeon after studying the reports of all above mentioned tests. The lowering of eye pressure is achieved by eye drops or medicines alone or in combination with laser procedure. If the eye pressure is not controlled by above, surgery is required. The modality of treatment is decided by factors like type & stage of glaucoma, damage already done at the time of presentation, response to prior treatment, patients ability to put medication regularly etc.

How do eye drops/medicines treat glaucoma?

The first attempt to control glaucoma is made with eye drops alone or combination with oral pills. These medicines act by lowering the eye pressure either by decreasing the production of aqueous fluid within the eye or by improving the flow through drainage channels. Various combinations of eye drops may be given to control the eye pressure depending on the type of glaucoma and systemic condition. To be effective these medicines have to be put at regular intervals as advised by the doctor and never be stopped without consulting him. A time to time evaluation of eye pressure and other tests are crucial to monitor the glaucoma status.

What is the role of laser in glaucoma?

Laser surgery may be effective for some types of glaucoma. In open angle variety, trabeculoplasty is done where the drainage angles are treated by laser to increase the outflow of aquous fluid and lower eye pressure. In narrow angle glaucoma, a hole is made in the iris –peripheral iridotomy, to restore the flow of aquous fluid to drainage angles.

What is the surgery done for glaucoma?

It is a microscopic filtering surgery-trabeculectomy where a small drainage channel is created for the fluid to leave the eye and thus lower the eye pressure. It is done under local anesthesia and you need to be in our hospital for couple of hours only. Usually the surgery is done when eye pressures are not controlled by medicines and laser. In few situations, surgery can be the primary mode of treatment for eg. Inability to put the eyedrops regularly, advanced glaucoma, combined cataract  & glaucoma etc

Whatever may be the approach, the objective of the treatment is to lower eye pressure at a level at which optic nerve damage and loss in vision & visual field does not develop or worsen. Maintaining normal eye pressure means that present treatment is adequate but does not mean glaucoma is cured. The success of your treatment depends on early diagnosis, timely intervention and regular follow ups. People over forty years of age should get their eye pressures checked once every two years. We advice all our patients to maintain the glaucoma file comprising of periodic checkups as the future treatment depends on closely monitoring the changes occurring in your eye. The key to preventing blindness from glaucoma is regular treatment and follow-up.

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