When to treat
Laser can be the first treatment, instead of eye drops, or be added to them. Surgery is used when eye drops and laser are not enough to control intraocular pressure. Both aim to protect the optic nerve from irreversible damage.
- When laser is used
- As a first treatment instead of eye drops, or when eye drops are not enough or are poorly tolerated — outpatient, quick, repeatable.
- When surgery is used
- When laser and medicines are not enough — operating theatre, more complex cases.
- Common goal
- Creating new drainage routes for aqueous humour and lowering IOP.
- Follow-up
- Always needed — glaucoma remains a chronic disease.
Laser procedures
Laser treatments are outpatient procedures, quick and non-invasive. The technique chosen depends on the type of glaucoma — angle-closure and open-angle glaucoma need different approaches.
The choice depends on the type of glaucoma: for angle-closure glaucoma, YAG laser iridotomy is used; for chronic open-angle glaucoma, trabeculoplasty, today mostly in its selective form (SLT). The LiGHT study (2019) showed that SLT can be used as first choice, instead of eye drops: after three years, three out of four patients did not need eye drops. It is also used when eye drops are not enough or are not tolerated.
The procedure
The treatment is carried out by placing a contact lens on the eye, which focuses the laser beam, after anaesthetic eye drops and a protective gel have been applied. Usually painless, it can cause mild discomfort (a feeling like being poked with a pin) and dazzling from the flashes of light. Total duration: a few minutes.
- 01
YAG laser iridotomy
Angle-closure glaucomaIt involves making a small hole in the iris that connects the two compartments of the eye, behind and in front of the iris (the posterior and anterior chambers). It helps the fluid in the eye flow towards the filter and prevents the sudden closure of the drainage angle.
It is performed in angle-closure glaucoma and, as a preventive measure, in patients at risk of developing an acute attack: it is performed in the second eye of someone who has had an acute attack in the first. In these cases it may help to avoid surgery.
- 02
Laser trabeculoplasty (SLT)
Open-angle glaucomaIt stimulates the drainage filter for aqueous humour to work better, thereby reducing eye pressure. Today selective laser trabeculoplasty (SLT) is mostly used, as it leaves no scarring and can be repeated; the older version, with an argon laser (ALT), is now rarely used.
The target is the trabecular meshwork — the filter at the drainage angle, between the iris and the cornea, which does not work properly in people with open-angle glaucoma. That is where the name of the technique comes from.
Possible results
In most cases, laser produces a reduction in eye pressure. The extent of the reduction depends on many factors — it is not possible to predict either the final result or whether it will be enough to prevent further damage. Sometimes the reduction is only temporary; in cases treated successfully, however, it can postpone surgery for a long time and reduce or avoid the need for eye drops, although the effect may wear off over the years and sometimes needs to be repeated. Laser is an additional measure in managing a chronic disease that lasts a lifetime — even after a good reduction in pressure with laser, it is essential to continue the planned check-ups.
Surgical procedures
When laser and medicines are not enough, incisional surgery is used: the ophthalmologist creates a new drainage channel so that the aqueous humour can leave the eye. The technique is called trabeculectomy, or 'filtering' surgery.
The operation is recommended to avoid damage to the optic nerve that would otherwise progress relentlessly. It is recommended when laser or drug treatment has not proved effective in lowering intraocular pressure. Serious complications are uncommon, but they can happen: your ophthalmologist will explain them before the operation.
It creates an efficient drainage route as an alternative to the 'diseased' ones, connecting the space between the iris and the cornea with the space under the conjunctiva — the membrane that covers the eyeball.
As well as trabeculectomy, there are valve implants (small drainage devices) and minimally invasive techniques (MIGS), often carried out at the same time as cataract surgery. In angle-closure glaucoma, removing the lens may also be recommended.
There is no 'ideal' pressure
There is no ideal pressure value in an absolute sense. All efforts are directed at preventing damage from occurring or getting worse. Surgery may be specifically indicated for different patients who, even with the same intraocular pressure, are in situations of different severity.
After surgery
After glaucoma surgery, you need to follow precise rules of conduct to protect the eye and get the best result. The following are examples only: always follow those given by the centre that operated on you.
What to do
- To clean your face, use the cleanser recommended by the centre, taking care around the eye.
- Put in your eye drops as directed in your discharge letter.
- During the day, protect the operated eye with glasses that cover it well (any type).
- At night, if the centre prescribes it, protect the eye with a plastic eye shield for the period the centre specifies — it protects against rubbing and knocks during sleep.
- Clean the eyelids gently as the centre advises, without pressing on the eyeball.
- Ask the centre when you can go back to reading, writing and watching TV.
What to avoid
- DO NOT bandage the eye.
- Do not bring hands, towels or tissues close to the operated eye.
- DO NOT sleep on the side of the operated eye.
- No physical exertion and no lifting, including picking up children, for the period the centre specifies.
- Do not drive until the centre says it is allowed.
Important to remember
Both laser treatments and surgery require regular post-operative check-ups. Long-term success depends on how well the patient follows medical advice and attends the scheduled check-ups. Do not hesitate to contact your ophthalmologist if you have sudden pain, a marked drop in vision, persistent redness or any unusual symptom after the procedure.