There are various methods to treat glaucoma (glaucoma):
Damage to the optic nerve and visual field can be stopped as it progresses but cannot be reversed.
Which treatment is right for each patient depends decisively on the type of glaucoma and its stage.
There are basically three types of glaucoma, each of which has different treatment approaches:
In narrow-angle glaucoma, the outflow of aqueous humor through the iris is narrowed, resulting in a backflow of chamber water which can lead to a massive increase in intraocular pressure in a short period of time. This rapid increase in pressure usually results in pronounced dull pain that radiates to the head; more rarely, nausea and vomiting can also occur. Emergency treatment is absolutely necessary for this so-called glaucoma attack to prevent permanent damage to the optic nerve. There are also intermittent, i.e. recurring, narrow-angle situations that cause eye pressure to rise less sharply and return to normal on their own. Over a longer period of time, this situation also leads to tissue damage to the optic nerve and should therefore be treated.
With the YAG laser, a small opening can be created in the iris (YAG iridotomy). This allows the accumulated chamber water to flow out from the front chamber into the back chamber. As a result of this relief, the iris flattens out again and the outflow at the angle of the chamber is exposed again.
Since the narrow-angle situation usually also occurs in the partner eye, there is also a significantly increased risk of suffering a glaucoma attack there. As a result, a so-called iridotomy should also be performed there promptly.
If the natural lens is thickened due to the gray starling and this creates a narrow-angle situation, this is known as a phacomorphic narrow angle and only cataract surgery can sustainably improve the anatomy.
Primary open-angle glaucoma is the most common type of glaucoma and usually affects both eyes. The only treatment is to lower eye pressure.
In the form of eye drops, active substances can reach the interior of the eye via the conjunctiva and cornea, where they reduce the production of aqueous humor or improve its outflow.
There are four different groups of drugs that lower eye pressure in different ways, so they can also be combined if necessary.
In the past, an argon laser (argon laser tarabeculoplasty, ALK) was used to obliterate the so-called trabecular tissue near the root of the iris and thus improve the flow of aqueous humor. This laser was later replaced by a more tissue-friendly YAG laser (Selective Laser Tqrabeculoplasty, SLT), which only treats certain cells in the trabecular area. Both methods result in a pressure reduction of 20-30%, and the SLT method can be repeated several times.
To prepare, eye drops are administered, which narrow the pupil, prophylactically reduce eye pressure and expose the trabecular system. After administration of anesthetic eye drops, a contact glass is placed on the eye. In a sitting position, the YAG laser is now used to treat the trabecular meshwork all around the iris, either just half or the entire circumference. The existing therapy with pressure-lowering eye drops is continued until the effect occurs after six weeks at the latest. Only then are the drops settled. To prevent inflammation as a result of the treatment, eye drops containing cortisone are prescribed for one week.
If these conservative therapeutic strategies do not lead to the desired reduction in eye pressure, surgical procedures are necessary.
Here is an overview:
In minimally invasive glaucoma surgery, small tubes or tubes are inserted into the chamber angle to achieve improved chamber water drainage. These methods were developed to minimize surgical trauma to the eye and speed up post-operative recovery. The experience is promising, but the microtubes can sometimes close again over time. The extent of eye pressure reduction is significantly lower than with more invasive methods.
In December 2023, the BAG decided that this method should no longer be a compulsory benefit of basic health insurance from 2024.
Trabeculectomy is the oldest established glaucoma operation. This involves cutting a small window with a lid into the sclera (leather skin), the so-called seepage cushion. This serves as a type of valve through which the aqueous humor can flow out of the eye under the conjunctiva. The first 4 to 6 weeks after surgery are decisive for the success of the new drainage path, as the natural wound healing reaction can lead to a blockage of the outflow path. Eye drops containing cortisone and regular eyeball massage prevent the seepage pillow from closing.
Deep sclerectomy differs from trabeculectomy in the fact that no direct connection is created between the anterior chamber and conjunctiva. Only a wafer-thin layer of tissue with easier flow for eye water is left behind during deep sclerectomy. The outflow is supported by a small implant made from the body's own tissue. The post-treatment is similar to trabeculectomy, but without massages. The risk of too much pressure reduction after the procedure is significantly lower than with trabeculectomy.
After filtering glaucoma operations (MIGS, trabeculectomy or deep sclerectomy), a newly created artificial drainage path of the aqueous humor under the conjunctiva is created. This path can dry up again, which requires a further shorter procedure.
Canaloplasty is a recent surgical technique in which the natural outflow path (in this case the Schlemm canal inside the eye) is stretched using a microcatheter and a gel or thread. This improves the flow of chamber water. Canaloplasty usually does not produce a filter pad. However, there may be fluctuations in intraocular pressure in the first few weeks, so that regular checks are also necessary here in the first 4 weeks.
Drainage implants have been used in glaucoma surgery for over 50 years. They consist of one or more plastic tubes with a downstream reservoir. Because of the greater risks of complications than filtering methods, these are therefore generally only performed on patients for whom conventional glaucoma surgery (see above) had not led to the desired effect.
During cyclophotocoagulation, parts of the eyewater-producing cells of the ciliary body are destroyed using a laser. Compared to all other procedures, this procedure aims to reduce eye water production. Repeated treatments are usually necessary to stabilize intraocular pressure in the medium and long term. This method is mainly used in advanced stages of the disease.
Secondary open-angle glaucoma is due to other eye diseases. The most common causes are eye infections (uveitis), new vascular formations (e.g. after occlusion of retinal vessels or diabetes), pseudo-exfoliation syndrome, pigment dispersion or trauma. In addition to lowering eye pressure, it is also important to find and treat the cause.
