What treatments are the right ones? Drops, laser, scissors

Take Home Points

In this section, we’ll talk about the present mainline therapy for glaucoma, lowering the eye pressure. With due respect to the old game of rocks, paper, scissors each has advantages over the other, but also each has a downside or two. The 3 methods are daily eye drops, laser treatment to the angle, or various forms of surgery. Which method to lower eye pressure is best for you to start with? This discussion applies whether you have open angle glaucoma, or you are an open angle suspect who chooses therapy, or if you have angle closure or angle closure glaucoma after iridotomy, and even for others with miscellaneous forms of glaucoma (see section Secondary glaucoma).

The scientists in the crowd would say that all three treatments have been tested in big studies and they all work. Yes, that is correct. You wouldn’t be wrong to start with drops, with laser, or with surgery. The big organization that eye surgeons belong to, the American Academy of Ophthalmology, has guidelines called preferred practice patterns. These are written by committees that put together the best information for doctors to present to patients. The practice pattern says that every new glaucoma patient should be told the upsides and downsides of each of these methods, and that it’s fine to start with any one of the three. Every new patient in our practice runs through the following discussion with us before the mutual decision about how to start treatment is made.

More patients begin treatment by taking daily eye drops than the other treatments. Perhaps this shows that patients think that medicines are safer than procedures. Perhaps it is because doctors have been most often telling patients that they should start with drops. It is true that many persons can have safe eye pressure lowering by taking daily drops. When we look at large studies, about half of those who start with drops will reach their goal pressure with taking one kind of drop per day, while another quarter will need two kinds of drops every day (two different bottles put in separately), and the final quarter will not find any combination of drops that works well enough and is tolerable enough for them to take.

The strong points of drops are that they usually don’t do anything permanently bad to the patient or the eye, and they work as indicated the majority of the time. Also in their favor is that you can start them and if you don’t like it, you can stop and switch to something else, mostly without any ill effects. The two weak points are: side effects and adherence problems. Soon after starting or in the longer term, some side effect or allergy can develop that keeps the drop from being usable. The specific problems with individual drop types are given below. Side effects vary from annoying and temporary to lasting and serious. Rarely, medicines for glaucoma can affect the heart and lungs and we know that a very small number of people have even died from taking drops. But, it is surely true that more people have died from taking aspirin than glaucoma medicines. Our experience is that about 10% of people taking any eye drop will suffer a side effect that leads them to stop taking it. It is important to tell your eye doctor that you are having a problem and make a different choice.

The second problem with taking drops is that we forget to take them or do not take them as prescribed. This is a much bigger issue than most patients believe. Once you know you have glaucoma, you will think that as a reasonable person, knowing your vision is on the line, you’ll take the drops. You try your best. Unfortunately, careful observation of patients shows that it doesn’t happen ideally. People who start the drops and fill some prescriptions will actually take drops on 3 out of 4 days. We’ll deal with this issue in a whole section below (How to succeed at eye drop treatment: It’s all in your hands).

Presently, there aren’t ways to tell whether you will respond with a low enough pressure to a particular kind of drop. Some investigators have suggested extensive genetic testing to find out ahead of time who will have a good lowering from a certain type of drop. This approach is not presently possible and even though it sounds elegant, in a couple of weeks we can find out if your pressure fell by having you try a bottle, and that’s cheaper.

The Food and Drug Administration has approved an injectable version of one of the glaucoma medications. So, a person can choose whether they want to instill eye drops on their own each day or go in to see their doctor every 3 months for a glaucoma medication injection. How this will work when you need injections in both eyes is still being worked out.

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