Glaucoma laser surgery and treatments
There isn't just one type of glaucoma, but several. Glaucoma surgeries are also varied and aim to lower intraocular pressure. These include laser treatments performed in the office or operating room, as well as more complex surgeries: minimally invasive procedures (MIGS), filtering procedures (trabeculectomy and sclerectomy), and the placement of drainage tubes. In cases of narrow-angle glaucoma, or glaucoma that is progressing despite medication (eye drops), your ophthalmologist will likely recommend surgery. It's important to understand that glaucoma surgery does not cure glaucoma! These procedures lower intraocular pressure to slow the progression of your glaucoma.
Glaucoma surgeries
There are several types of glaucoma treatment. A distinction must be made between laser treatments performed in the office, which are generally benign and often recommended early upon diagnosis of glaucoma, and true surgical procedures performed in an operating room. The main interventions are:
Peripheral laser iridotomy (IP)
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The procedure is performed in cases of narrow-angle glaucoma or risk of angle-closure glaucoma.
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An OCT or UBM examination is frequently performed beforehand to objectively assess the obstruction of the trabecular meshwork (aqueous humor drainage system) by your iris.
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The procedure involves making a small hole in the iris to normalize the flow of aqueous humor in your eye and release the trabecular meshwork. Follow-up care will be necessary afterwards!
Laser trabeculoplasty (SLT)
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Laser trabeculoplasty, also called SLT or Selective Laser Trabeculoplasty, increases the permeability of the trabecular meshwork, the membrane responsible for the drainage of aqueous humor.
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Widely used in Anglo-Saxon countries and underused in France, the SLT laser allows for the effect of a hypotonic drop.
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It can be performed as a first-line treatment upon discovery of glaucoma if you have difficulty putting in your eye drops, or as a second-line treatment if you do not tolerate your treatments well or have too many eye drops to instill.
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The laser treatment lasts for 2 to 5 years on average and can be renewed.
Filtering surgery – Trabeculectomy and sclerectomy
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Filtering surgery was the first glaucoma surgery developed. Trabeculectomy is the most frequently performed procedure worldwide, and sclerectomy is a variation of it.
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During a trabeculectomy, the surgeon creates a small bypass between the inside of your eye and under your conjunctiva. This is done by making a hole in your trabecular meshwork during a trabeculectomy, or by thinning it during a sclerectomy.
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The diverted aqueous humor settles under the conjunctiva, where it is naturally absorbed by your periocular tissues.
Diode laser – Cyclo attenuation
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The diode laser reduces the secretion of aqueous humor in your eye by cauterizing the ciliary body, the organ that secretes it behind the iris.
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The laser treatment is performed in the operating room because it requires careful anesthesia. Several laser impacts are made on your ciliary bodies, which have been previously located through your pupil.
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This treatment is intended for advanced glaucoma that cannot be treated with filtering surgery. The laser can be used in its full-dose version (thermal diode) or its micro-dose version (sub-cyclo).
MIGS – Minimally Invasive Glaucoma Surgery
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Innovation in glaucoma treatment is ongoing in the quest for the perfect cure. However, such a cure does not (yet) exist!
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For the past few years, MIGS, a new minimally invasive surgical technique, has been making headlines. However, many devices have already been abandoned!
There's no need to get lost in the various innovations about which we have little or no experience; here are the MIGS used in practice in France:
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The iStent – This is a small drain placed in the trabecular meshwork to increase its drainage flow. It acts like a drop and, for the moment, can only be inserted during cataract surgery.
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XenGel – This is a small tube made of porcine gelatin that allows aqueous humor to drain from the trabecular meshwork to the area under the conjunctiva. Its effectiveness is comparable to that of a deep, non-penetrating sclerectomy.
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The PreserFlo – This is a drain made from an inert material (SIBS) designed to limit conjunctival fibrosis, which is responsible for ocular pressure surges. The drain is said to have the effect of an improved trabeculectomy; however, long-term follow-up studies may lead to a reassessment of this position and a reduction in its use.
When is glaucoma treated with surgery?
Be careful not to take the easy way out; glaucoma surgery isn't performed to avoid using eye drops or to cure it. The indication for glaucoma surgery must be carefully considered! Here are a few examples:
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Peripheral iridotomy helps prevent acute glaucoma in cases of pupillary blockage mechanism.
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Trabeculoplasty allows the effect of a drop to last for 2 to 5 years and thus limits the discomfort of daily instillations.
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Cataract surgery helps prevent acute glaucoma in cases of excessively thick lenses (lens arrow mechanism).
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Trabeculectomy is the procedure of choice in cases of open-angle or narrow-angle glaucoma.
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Non-penetrating deep sclerectomy is a French and Soviet specificity that can be offered in cases of open-angle glaucoma.
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Diode laser surgery is an operation for advanced glaucoma, when the visual field is severely impaired.
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Drains and tubes are indicated in cases of failure of filtering surgery with a still partially preserved visual field.
Warning! Glaucoma should not be operated on because it is serious, but because it is worsening. If your glaucoma is diagnosed late, a daily eye drop or laser treatment performed during a consultation is sometimes enough to stabilize it!
What happens after the operation?
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Your surgeon will prescribe antibiotic and anti-inflammatory eye drops to control inflammation and reduce the risk of infection. Depending on the technique used, you will need to continue or stop your eye pressure medication.
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Your eye pressure and the progression of optic nerve damage will be monitored regularly.
What is the success rate for glaucoma surgery?
Glaucoma surgery using filtering techniques is dependent on your healing process! In case of excessive scarring, touch-ups will be necessary, such as scraping, injections of anti-scarring agents, or laser treatment. The key figures to remember are:
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70% of patients will experience immediate success.
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30% of procedures require a touch-up to adjust the drainage rate of aqueous humor.
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10% of interventions will result in partial failure with the need to resume hypotonic treatment with eye drops.
Glaucoma is a master of deception. Intraocular pressure can fluctuate throughout life, and treatments or interventions are regularly adjusted. Only regular monitoring by your ophthalmologist will allow you to win this game of bluff.
Will I need another surgical procedure?
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For some patients, the benefits of surgery last a lifetime. For others, intraocular pressure rises slowly or suddenly. In these cases, they will need to use eye drops again or undergo surgery.
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These therapeutic adjustments help to slow down the degeneration of the optic nerve.
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Many patients are dissatisfied with their surgeon's work because the pressure returns. However, this is a natural healing process within their eye, not a result of a failed operation.
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As with cancer, glaucoma surgery will bring about remission in some patients, others will need several treatments, and some will not win this battle.
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It is essential to avoid medical uncertainty once you are being treated by a glaucoma specialist.
Second opinion glaucoma
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If you would like a second opinion for your glaucoma, do not come to the consultation empty-handed, but with detailed records: consultation reports, treatments, pressure readings, visual field tests, etc.
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A fresh perspective on your condition is one that factually considers your entire medical history. Patients' perceptions of their illness are often biased by a desire to contradict previous decisions. This attitude is unfortunately counterproductive to your eye health.
What are the side effects of glaucoma surgery?
Glaucoma surgery can have side effects, like any operation. After the operation, vision will be blurred, and the eye will be swollen and painful. These are normal after-effects.
The following are the side effects and complications:
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Postoperative rise in intraocular pressure or peak.
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Excessive drop in intraocular pressure and hypotonia.
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Corneal damage: keratitis or ulcer.
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Postoperative leakage.
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Loss of vision.
Glaucoma surgery is never benign and should not be prescribed to discontinue well-tolerated eye drops or to hope for a cure and improved vision. Apart from consultation laser procedures (iridotomy and trabeculoplasty), a measured and sometimes pessimistic approach from the surgeon is expected.
Frequently Asked Questions
Can glaucoma be treated surgically?
Yes and no! It's important to understand that glaucoma is a degeneration of the optic nerve linked to abnormalities in intraocular pressure. In practice, glaucoma surgery is therefore an operation to correct intraocular pressure in order to stop the degeneration of the optic nerve. However, it is impossible to regenerate the optic nerve. In short, with glaucoma, any lost visual field is permanent.
Can cataracts and glaucoma be operated on at the same time?
Yes! It is possible to remove the cataract at the same time as a procedure on eye pressure is performed: stent placement or filtering surgery.
What are the side effects of glaucoma surgery?
What is the success rate of glaucoma surgery?
The success rate of glaucoma surgery depends on the technique used. A rough estimate would be:
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95% for stent placement (iStent) – But the operation is reserved for low-aggressive glaucomas.
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90% for filtering surgery, with 30% touch-ups to adjust the tension (laser or scraping "needling").
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80% for a diode laser – Reserved for refractory glaucoma.
What kind of recovery period should be expected after glaucoma surgery?
A minimum recovery period of 15 days is required after glaucoma surgery. Vision will be blurry and the surgical site generally fragile at first. Therefore, it is important to rest.