Glaucoma Diagnosis, Monitoring and Treatment

What glaucoma is

The eye makes a clear fluid that drains through a meshwork at the angle where the iris meets the cornea. When drainage is impaired, pressure rises, and sustained pressure damages the fibers of the optic nerve where they leave the eye. Damaged fibers do not regrow. Loss begins in the periphery and progresses inward, so central reading vision is preserved until late, which is why patients rarely notice. Some patients develop glaucoma at normal pressures, and some have high pressure without damage, which is why diagnosis rests on the nerve rather than on the pressure alone.

Who is at risk

• Age over 60, and over 40 in Black and Hispanic patients, who are at higher risk and affected earlier
• A family history of glaucoma, which raises risk several fold
• High eye pressure, thin corneas, or a suspicious optic nerve at an exam
• High nearsightedness or farsightedness, diabetes, and long-term steroid use
• Previous eye injury or inflammation

Everyone over 40 should have a glaucoma check as part of a comprehensive eye exam, and those with risk factors should be checked regularly.

How we diagnose and monitor it

A glaucoma evaluation measures eye pressure and corneal thickness, examines the drainage angle, and looks at the optic nerve directly. Optical coherence tomography measures the thickness of the nerve fiber layer to the micron, detecting loss before any vision is affected, and visual field testing maps the peripheral vision. These are repeated at intervals to detect change, which is how treatment is judged.

How we treat it

Treatment lowers eye pressure, the one modifiable factor. Prescription drops, used once or twice daily, are the traditional first step. Selective laser trabeculoplasty, a painless office laser that improves drainage, is now an equally accepted first treatment and frees many patients from drops. iDose TR, a tiny implant placed inside the eye that releases a pressure-lowering medication continuously, is now offered at our practice for patients who need ongoing treatment and want less dependence on daily drops. Laser peripheral iridotomy opens a narrow angle to prevent angle closure. When drops and laser are not enough, surgery is the next step: minimally invasive stents can be placed during cataract surgery, and filtration surgery is performed by a glaucoma subspecialist. SLT is performed in the office at our Woodland Hills location, and our surgeon performs MIGS at an outpatient surgery center. Iridotomy and filtration surgery are arranged through our care or by referral to a glaucoma subspecialist, with whom we co-manage your care.

Glaucoma and cataract surgery

Cataract surgery itself lowers eye pressure modestly and is often timed with glaucoma in mind. In suitable patients a minimally invasive glaucoma stent can be placed during cataract surgery, reducing the need for drops afterward. Your cataract evaluation considers this if you have glaucoma.