What is Glaucoma?
Glaucoma is a disease of the optic nerve which, if untreated, can result in permanent damage to the field of vision.
Detection and Treatment
In most cases, glaucoma is treated by lowering the intraocular pressure (pressure inside of the eye). Because glaucoma may not affect the central vision until late in the disease process, it has been called the sneak thief of vision. Those at risk for glaucoma include anyone with a family history of glaucoma, those with myopia (near-sightedness), the elderly, and African Americans. The only way to be sure that you are unaffected by glaucoma is to undergo a comprehensive eye examination. The physicians of Weill Cornell Eye Associates are available for comprehensive ophthalmic care (including glaucoma screening) and can additionally provide expert medical and surgical glaucoma care. Contact our offices at 646-962-2020 to arrange an evaluation.
Types of Glaucoma
There are many different types of glaucoma. They are broadly grouped into two categories based on whether or not the eye's natural fluid drainage system has been physically blocked by the iris. In open angle glaucoma there is no physical blockage. In angle closure glaucoma, the iris is in contact with the eye's natural drain and prevents fluid from leaving the eye.
Primary Open Angle Glaucoma
Primary Open Angle Glaucoma (POAG) is the most common form of glaucoma and is present in approximately 1% of all Americans. Unfortunately, up to one half of all people with this disease do not yet know that they have it and are therefore untreated. Ophthalmologists diagnose glaucoma by evaluation of the optic nerve and the visual field. In glaucoma, there is a specific pattern of optic nerve damage called "cupping". This term describes the hollowed out appearance of the optic nerve that occurs as a result of the death of optic nerve fibers. Since nerve fibers carry visual information back to the brain, death of these fibers results in damage to the field of vision. As glaucoma progresses, the cupping of the optic nerve progresses and the visual field becomes more damaged. Reduction of intraocular pressure is the only proven way to prevent or slow the progression of glaucoma.
Often, patients with POAG will have elevated intraocular pressure. The drain that lets fluid out of the eye is considered "open" however it is not draining quickly enough and the pressure builds within the eye. However, up to 1/3 of patients with POAG have normal intraocular pressures (Normal or Low Pressure Glaucoma). While this form of glaucoma is similar to POAG, it has some unique clinical characteristics (such as an association with migraine headache and cold hands or feet) and is managed somewhat differently. Regardless of the initial intraocular pressure, the mainstay of glaucoma therapy is to lower the intraocular pressure to slow or stop the progression of the disease. Intraocular pressure reduction can be achieved through medications (usually eye drops), lasers (argon laser trabeculoplasty or selective laser trabeculoplasty), or by surgery (trabeculectomy, tube placement, or others). Ophthalmologists treat glaucoma by reducing the intraocular pressure and by monitoring the visual field and the health of the optic nerve.
Closed angle glaucomas
Closed angle glaucomas are often preventable. In chronic angle closure glaucoma, the iris becomes scarred to the eye's drain after a long period of contact, often years. In acute angle closure glaucoma, the iris closes of the drain very suddenly and the intraocular pressure rises very quickly, often resulting in an "attack" of pain, eye redness, and blurry vision. Before the angle becomes closed, it is often very narrow. If diagnosed at this stage, a laser iridotomy can prevent both the acute angle closure glaucoma attack as well as the insidious chronic angle closure glaucoma. Laser iridotomy is a procedure in which a small hole is created in the iris to allow fluid to escape from the eye without pushing the iris against the eye's drain. Not all patients with narrow angles require laser, so careful evaluation and monitoring is required. The doctors at Weill Cornell Eye Associates are experienced in the management of narrow angles and angle closure glaucoma. If required, highly specialized diagnostic imaging equipment such as the Artemis very high frequency (VHF) ultrasound eye scanner or the non-contact slit lamp Optical Coherence Tomography unit are available.
Ocular Hypertension (elevated intraocular pressure). Occasionally, a person will develop elevated intraocular pressure without any signs of damage to the optic nerve. This condition, termed Ocular Hypertension, can lead to glaucoma in some individuals. A large clinical trial, the Ocular Hypertension Treatment Trial, recently provided very useful information to ophthalmologists to guide them on which patients require treatment. At Weill Cornell Eye Associates, patients with Ocular Hypertension undergo a comprehensive risk assessment based on demographic information, data from the ophthalmic examination (such as optic nerve appearance, intraocular pressure, and central corneal thickness), and visual field data. This risk calculation allows us to treat patients who are likely to go on to develop glaucoma (damage to the optic nerve), and to avoid unnecessarily treating patients who are unlikely to develop glaucoma. Each patient receives the results of his or her risk assessment and discusses treatment options with the doctor.
The term glaucoma suspect refers to a patient who is at high risk for glaucoma, or who may even have glaucoma at its earliest stage when it is difficult to detect. Examples of glaucoma suspects would include patients with a strong family history of glaucoma, patients with ocular hypertension (see above) or patients with "suspicious" appearing optic nerves. In glaucoma, the optic nerve changes over time, developing an appearance commonly referred to as "cupping," where the healthy nerve tissue has died, leaving behind a hollowed out appearance. However, some individuals are simply born with optic nerves that appear damaged or "cupped" but are in fact healthy. It is sometimes difficult to determine whether a person with a "cupped" appearing optic nerve has early glaucoma or is just born with a suspicious appearing optic nerve. In this case, the doctors at Weill Cornell Eye Associates use high-resolution optic nerve imaging technology as well as standard photography to monitor the optic nerve for any changes. Eyes with glaucoma will show change over time, whereas healthy optic nerves will remain unchanged. In addition, specialized visual field testing can be performed to assess for early glaucomatous changes. If the optic nerve shows evidence of change or if the visual field deteriorates, treatment is usually required to arrest the disease in the earliest possible stage.
Minimally Invasive Glaucoma Surgery (MIGS)
Minimally invasive glaucoma surgery is now being offered at Weill-Cornell/New York Presbyterian Hospital and Weill Cornell Eye Associates.
For patients with glaucoma, elevated intraocular pressure can, over time, result in vision loss. Fortunately, for many patients with glaucoma, the daily use of eyedrops will slow or stop the disease. Traditional glaucoma surgeries including trabeculectomy and tube shunt procedures are typically reserved for patients who are at risk of severe vision loss from glaucoma.
However, the daily administration of eye drops can lead to side effects in some patients, and many glaucoma patients would prefer not to take eye drops.
Recently a new type of glaucoma surgery called minimally invasive glaucoma surgery (MIGS) has become available for glaucoma patients. These MIGS procedures are typically performed at the time of cataract surgery and increase the length of the cataract surgery by just a small amount. Importantly, MIGS procedures do not significantly change the overall (favorable) safety profile of cataract surgery, but can result in additional benefits to patients with glaucoma, including lower intraocular pressure and the need for fewer (or no) glaucoma medications.
While MIGS are not indicated or appropriate for every glaucoma patient, these safer surgeries are a welcomed new treatment option for our glaucoma patients. The glaucoma specialists at Weill Cornell Eye Associates currently perform MIGS procedures, including the recently FDA-approved iStent.
Why Choose Weill Cornell Eye Associates?
The physicians of Weill Cornell Eye Associates are trained in the most state of the art evaluation and treatment methods for patients with glaucoma. Through the use of advanced imaging technology in the hands of experienced professionals, our goal is to diagnose glaucoma as early as possible and to arrest the disease in its earliest stage. Although glaucoma surgery is avoided whenever possible, the doctors at Weill Cornell Eye Associates are experienced in the most sophisticated surgical techniques for the treatment of glaucoma.
Weill Cornell Eye Associates is a comprehensive, university-based academic practice group, and has superb physicians, staff, and facilities to evaluate and treat any visual disorder or eye disease. If your interests or concerns involve a condition not highlighted on this website, please contact our offices at 646-962-2020 to discuss an appointment suited to your needs.
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