GETTING GLAUCOMA SERVICES AT ANGEL EYES

Glaucoma Services at the Angel Eyes Lasik Centre provides specialized diagnostic, medical and surgical care for those diagnosed with glaucoma.  We understand being diagnosed with glaucoma can raise a lot of questions.  Our specialists can help answer your questions and provide you with medical and surgical treatment options.

Our panel of glaucoma experts fights the battle against this silent vision snatcher to ensure that you end up on the winning side. Our team is dedicated to the care and treatment of people who have glaucoma. Sophisticated, state-of-the-art diagnostic facilities include computerized visual field testing, optic nerve imaging, multiple methods of blood flow measurement and other specialized imaging modalities.

Glaucoma Services at Angel Eyes will entail the following steps:

1. Appointment
2. Consultation for detailed Glaucoma check-up (screening / follow-up) or Consultation for routine follow-up of glaucoma
3. Treatment
4. Follow-up

1. • APPOINTMENT:

The Glaucoma services operate on all the working days of our centre. You can visit the centre preferably after booking an appointment. When booking the appointment do specify whether you want a complete Glaucoma check-up done or you require a routine follow-up for Glaucoma treatment, as this will entail a different time scheduling than that complete Glaucoma Check-up.

1. • CONSULTATION:

You may consult the doctor at our centre for either of the two following services

1. 1. 1. Complete Glaucoma Check-up (glaucoma screening or yearly glaucoma check-up)
      2. Routine follow-up for known glaucoma cases without wanting to undergo a detailed glaucoma check-up.

1. Complete Glaucoma Check-up:

This is the complete detailed check-up for Glaucoma. It is of two categories:

a) Comprehensive Glaucoma Screening – done in Undiagnosed patients of glaucoma or patients at high risk of glaucoma, or just wanting a comprehensive eye health check-up. This is done at a prescribed time schedule.

b) Follow-up Glaucoma Check-up – done 6-12 monthly in patients already diagnosed with Glaucoma and are in follow-up care for it. This check-up is done to ascertain the exact status of Optic nerve as well as the field of vision. This helps us to monitor the progress of the disease and to tailor the treatment according to the particular status of the disease in your eyes.

1. a) Comprehensive Glaucoma Screening:

Glaucoma screening though is a must for all individuals above 40 years but its frequency is determined by the presence of certain factors. These factors point to a population at higher risk for developing Glaucoma so they need to be watched closely for the development of Glaucoma.

Risk factors for Glaucoma: Although anyone can develop glaucoma, some people are at higher risk than others. The following are suggested as risk factors for glaucoma:

1. 1. • Race: Glaucoma is the leading cause of blindness for African-Americans.
      • Age: Glaucoma is much more common among older people. You are six times more likely to get glaucoma if you are over 40 years old.
      • Family History of Glaucoma: The most common type of glaucoma, primary open angle glaucoma, is hereditary. If members of your immediate family have glaucoma, you are at a much higher risk than the rest of the population. Family history of glaucoma increases the risk of glaucoma four to nine times.
      • High intraocular pressure
        People with an elevated (greater than 21 mm Hg) intraocular pressure (IOP) are at an increased risk.
      • Indiscriminate use of Steroids: Studies indicate Steroids increase intraocular pressure. These could be in the form of Oral medications, Steroid Inhalers and Steroid Eye Drops used for long periods of time. Patients who are on long term steroid therapy for other diseases such as asthma, arthritis etc.
      • Injury to Eye: Injury to the eye may cause secondary open angle glaucoma. This type of glaucoma can occur immediately after the injury or years later.
      • Diabetes: Some diseases that impact the entire body, such as diabetes, anaemia, or hardening of the arteries, increase the risk of the condition. Persons who do not actually have diabetes, but have a strong family history of the problem, should have their eyes checked frequently for early development of the disease.

Other possible risk factors:

1. 1. • People having high minus or plus numbered glasses
      • Hypertension
      • Central corneal thickness less than 500 microns.
      • People who have undergone any kind of eye surgery.
      • People with thyroid gland related ailments.
      • People with over – mature cataracts.

Recommended Schedule for Glaucoma Screening:

The American Academy of Ophthalmology’s recommended intervals for eye exams are:

1. 1. • Age 20-29: Individuals of African descent or with a family history of glaucoma should have an eye examination every three to five years. Others should have an eye exam at least once during this period.
      • Age 30-39: Individuals of African descent or with a family history of glaucoma should have an eye examination every two to four years. Others should have an eye exam at least twice during this period.
      • Age 40-64: Individuals should have an eye examination every two to four years.
      • Age 65 or older: Individuals should have an eye examination every one to two years.

Investigations done at Angel Eyes Lasik Centre for Glaucoma Screening includes the following tests:

1. 1. • Vision testing
      • Tonometry
      • Pachymetry
      • Gonioscopy
      • Pupil dilation and Ophthalmoscopy
      • Visual Field (Perimetry)
      • GDxVCC – Retinal Nerve fibre Layer Analysis
      • Optical Coherence Tomography (OCT)

In patients where these tests conclusively point to a ‘glaucoma – free’ eye, the patient is advised to undergo next screening depending upon the risk factor present and the age of the patient. In patients where Glaucoma is detected, the patient will have to start one or the other form of treatment. In such cases the patient is advised to undergo detailed Glaucoma Check-up every 6 months to 1 year, besides the routine follow-up.

1. b) Follow-up Glaucoma Check-up:

This is done in cases where Glaucoma has already been diagnosed. These tests are necessary to ascertain the exact status of the optic nerve as well the field of vision. Based on these results we are able to judge the efficacy of our treatment. Any changes or adjustments in the treatment plan makes more sense if they are co-related with these results. These tests will also help to monitor the disease in a more objective way. Though essentially quite similar to Glaucoma screening, the basic difference will be in scheduling/frequency of these tests.

1. 1. • Tonometry: done on every visit to the centre.
      • Pachymetry: This test is will not be repeated if done earlier during screening.
      • Gonioscopy: done on every visit to the centre.
      • Pupil dilation and Ophthalmoscopy: done every 3 months.
      • Visual Field (Perimetry): recommended every 6 months to 1 year.
      • GDx VCC – Retinal Nerve fibre Layer Analysis: recommended every 6 months to 1 year.
      • Vision testing: done on every visit to the centre
      • Optical Coherence Tomography (OCT)

Procedure for getting Complete Glaucoma Check-up done at Angel Eyes:

1. 1. 1. To schedule a complete Glaucoma check-up of any category you have to book an appointment where you should clearly mention that you want to schedule a complete check-up for Glaucoma.
      2. The total time required for the check-up may be around 2 hours so you should come with this much time in hand. Do not try to hurry up the procedure as this may lead to doubtful results.
      3. As pupil dilating drops will be used, you must have someone to drive you back home after the tests.
      4. Please ensure that when you come for tests your eyes are in reasonably good health. Those suffering from any infectious disease like conjunctivitis or from allergic eye disease should wait before they come for the complete Glaucoma check-up.
      5. Once at our centre, after contacting the reception and registration, you will be administered the check-up in a step-wise manner as decided by the staff or consultant looking after you.
      6. You will need to move to different sections for tests by different equipment as described in our protocol.
      7. Almost all the reports are available immediately.
      8. Once the reports are available you will be seen by the consultant who will review the reports and inform you about the results.
      9. According to your results you will be either started on a treatment regime and advised about follow-up glaucoma check-up schedules (if diagnosed as having glaucoma).
      10. If the results are normal and you do not seem to have glaucoma, then you will b e advised to have next screening according the schedule for different age group and as per the presence of risk factors.

2. Routine Follow-up Consultation:

The aim of routine follow-up is to ascertain

1. The current intra-ocular pressure in your eyes.
2. The efficacy of the treatment being given to you.

Procedure for getting Routine Follow-up Consultation done at Angel Eyes:

1. You will be required to book an appointment as per the OPD schedule. Please mention that you just want a routine check-up and do not want a complete work-up.
2. Once you reach the centre, you will go through the routine process as for general patients.
3.  You will go through a series of examination as done for general patients namely auto refraction, manual refraction, non-contact tonometry, GDx VCC screening (basic only) and slit lamp examination.
4. Additionally, in known cases of glaucoma, applanation tonometry is also done by the consultant to determine your exact eye pressure. All this is included in the consultation charges.
5. The status of the IOP as checked by the applanation tonometry will guide the consultant as regards the efficacy of the treatment being given.
6. As long as the patient is complying with the medical treatment and the IOP is reasonably controlled at a level where there is no further deterioration in the optic nerve health and the field of vision, we can safely continue the medical (eye drops) treatment.
7. Once the medical treatment starts falling short of the desired results, the surgeon will advise and plan about Laser or Surgical treatment for glaucoma. (see below)

Though the status of your vision (ascertained by refraction) and the status of IOP (ascertained by applanation tonometry), will give us a fair idea of the efficacy of treatment, the best way to judge the efficacy is to quantify the status of the optic nerve and the status of your field of vision. The optic nerve fibre analysis is accomplished by doing GDx VCC examination. The status of field of vision is determined by Humphrey Field Analyser. These two tests are not included in the routine follow-up. Moreover, a six to twelve monthly examination of these two parameters is more than sufficient and is not recommended on every routine follow-up visit.

Description and Procedure for Various Diagnostic Tests for Glaucoma:

Tonometry: This determines the IOP in the eyes. This is done in two ways:

Non-Contact Tonometry – This is done by an equipment known as Non- contact tonometer. As the name suggests, the surface of the eye is not touched during examination. As the patient focuses on a given target, a puff of air is directed at the surface of the eye. This is then measured to find out the IOP. More for screening

Applanation Tonometry – This is a extremely accurate method of determining IOP. However, in this procedure a dye is instilled in the eye along with anaesthetic drop to anaesthetize the surface of the eye. The probe in this method touches the surface of the eye to record the IOP, so its sterility is a must. The process takes slightly more time than the non-contact method and can be performed only by the consultant.  At Angel Eyes, applanation tonometry is routinely done for all glaucoma patients on every visit.

Pachymetry: This investigation measures the thickness of the cornea. Drops are used to anaesthetize the surface of the eyes. The pachymeter probe is then brought in contact with the surface of the cornea to measure the thickness in various quadrants of the cornea. This test is done only once as the thickness of the cornea is not expected to change over time.

Gonioscopy: This is a diagnostic examination procedure done to assess the condition of the angles of the eye. This is done in known or suspected cases of Glaucoma. It is usually done at 6 -8 monthly interval. This is done under topical anaesthesia i.e. numbing drops are instilled in the eye before testing.  After numbing the eye, special type of lenses known as Gonio lenses are positioned on the eye and the angles are examined with the help of slit-lamp. Its importance lies in planning the treatment of glaucoma irrespective of it being medical/surgical/laser treatment.

Pupil dilation and Ophthalmoscopy: Dilating drops are instilled in the eye to dilate the pupil so that we can see the optic nerve and the retina. The dilating drops will keep the pupil dilated for around 4-5 hours and the vision will remain blurry for this duration. You must not drive or try to do fine work during this period.

Visual Field (Perimetry): We use Zeiss Humphrey Field Analyzer for this purpose. For those already diagnosed with Glaucoma, Perimetry is recommended every 6 to 12 months. To get perimetry done you will be required to book an appointment specifying that you need this test done as the time required for this test is approximately 1 hour and there may be patients already booked for this procedure. This test does not involve any drops to be instilled and is a no-touch test.

Retinal Nerve Fibre Analysis: We use Zeiss GDx VCC for doing this investigation. This is an essential test to pick up early cases of neuronal damage. It is a quick and comfortable test where a laser is used to obtain clear scanned images of the Retinal and Optic nerves, so we can see in amazing detail the structures involved in order to monitor Glaucoma like never before! This allows us to measure the size of your nerve, and ensure that any abnormal change is detected quickly, before any damage appears in your vision.
This is a very accurate method of determining the status as well as the amount of damage done by glaucoma to the eye. This test should be repeated every 12 months in known patients of glaucoma. Based on the results of this test and the perimetry, we can plan the treatment of glaucoma in a particular patient so as to preserve the optic nerve and vision as much as possible.

To get this test done you will be required to book an appointment specifying that you need this test as the time required for this test is approximately half an hour and there may be patients already booked for this procedure. This test does not involve any drops to be instilled and is a no-touch test.

OCT (Optical Coherence Tomography): Optical coherence tomography (OCT) is a non-invasive imaging test. OCT uses light waves to take cross-section pictures of your retina.

With OCT, your ophthalmologist can see each of the retina’s distinctive layers.  This allows your ophthalmologist to map and measure their thickness. These measurements help with diagnosis. They also provide treatment guidance for glaucoma and diseases of the retina. These retinal diseases include age-related macular degeneration (AMD) and diabetic eye disease.

 Today, optical coherence tomography has become a standard tool for diagnosing and monitoring glaucoma. As with many advanced technologies, there are several ways we can use OCT to help in diagnosis and management of Glaucoma cases.

OCT is most useful when a patient is either a glaucoma suspect or has early-to-moderate disease, as a tool for helping to detect damage and progression (or conversion from glaucoma suspect or ocular hypertensive to glaucoma). While there are many parallels between OCT technology and visual fields—for example, being able to use them for either event-based analysis or trend-based progression analysis—OCT is arguably a better tool for use in early disease, because when we test visual function with a visual field test, the plasticity and overlap inherent in the visual system tend to compensate for any early damage. As a result, early damage may be picked up by an OCT scan rather than by a visual field test. OCT gives us a wealth of data to work with, because it can provide structural information about many parts of the retina and optic nerve head.

To prepare you for an OCT exam, your ophthalmologist may put dilating eye drops in your eyes. These drops widen your pupil and make it easier to examine the retina.

You will sit in front of the OCT machine and rest your head on a support to keep it motionless. The equipment will then scan your eye without touching it. Scanning takes about 5 – 10 minutes. If your eyes were dilated, they may be sensitive to light for several hours after the exam.

The OCT test which is commonly performed for glaucoma and macular degeneration, can usually be done without pupil dilation, but it is commonly performed during the annual dilated exam.  A baseline test takes approximately 10 minutes. Repeat scans take approximately 5 minutes per eye.

• Treatment Options

At the outset, it is important to understand and remember certain facts regarding the treatment and follow-up of glaucoma:

1. Glaucoma cannot be cured.
2. The damaged part of the optic nerve and the drop-in vision due to this can never be regained by any amount of treatment.
3. Treatment is necessary to prevent any further damage to the optic nerve.
4. Just like in Diabetes, hypertension etc., the treatment and monitoring of glaucoma is a life-long process.
5. The monitoring of glaucoma is an essential part of treatment plan and the schedule should be followed strictly. Every year the perimetry and retinal nerve fibre analysis is a must to ensure that the treatment being given is actually appropriate for you.
6. Please do not be under the misconception that just by monitoring the IOP we can adequately control glaucoma. The level of IOP does not always co-relate well with the damage to the optic nerve.
7. The treatment modality may change as per your requirement and every patient warrants a different approach.
8. The medications should not be stopped in any case without consulting your doctor.
9. Regular follow-up as advised is mandatory.

Before starting specific treatment for glaucoma, the following factors are considered:

• Your age, overall health, and medical history
• Extent of the disease
• Your tolerance for specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference

The Modalities of Treatment:

1. Medical (Eye drops and tablets) 
2. Laser treatment
3. Surgery

• Medical treatment: –

We will initially prescribe you certain medications (Eye drops and tablets) so as to lower your eye pressure. These are the most common form of treatment to lower IOP. These are used once or several times a day depending upon the type and stage of glaucoma. In severe cases of glaucoma, medications may also be given orally or intravenously along with the eye drops for adequate control of IOP. It is very important that you use the medicines regularly as directed. You should not stop medicines even if you do not have symptoms. A regular follow up, as advised by your doctor, is mandatory.

• Laser treatment: –

If glaucoma is not controlled with the help of medicines, if the side effects of the medicines are not well tolerated and the patient is non-compliant, or cannot afford the cost of the medicines, the second option is LASER TREATMENT. There are various types of lasers that are used in the treatment of glaucoma.

Laser – If done early enough, the laser may prevent an acute attack of glaucoma and need for lifelong medications and surgery.

YAG Laser Peripheral Iridotomy

In ‘Angle Closure Glaucoma’, the most common treatment used is laser. The laser (YAG Laser) is used to create small holes (Peripheral Iridotomy) in iris (the part of the eye which gives it the colour). The holes form alternate channels for flow of aqueous fluid and prevents closure of the angle and the drainage of the eye.  A small opening is made in the iris so that the stagnant fluid finds a way to the anterior chamber, the front portion of the eye, and subsequently drained off. This is an OPD procedure, done under local anaesthetic drops and takes only a few minutes to be completed. After the laser, you can wash your eye with water and can lead a normal life.

• Operative procedures (Glaucoma Filtering Microsurgery or “By-pass” surgery of eye)

Operation for glaucoma is the only option left for patients in whom the eye pressure is not controlled with medication or laser. It is also the treatment of choice in non-compliant patients, and in infants and children with glaucoma. A surgery called Trabeculectomy is performed to control glaucoma. Filtering microsurgery involves creating a drainage hole with the use of a small surgical tool, to bypass the blockage in the eye’s trabecular meshwork (the eye’s drainage system). This opening helps increase the flow of fluid out of the eye and thereby reduce the eye pressure.

Tube shunt
This implantable drainage device creates an artificial pathway in the eye. It is made from a miniature, stainless steel tube, and can be implanted in less than five minutes. A tube shunt is usually selected after it is determined that a patient cannot benefit from conventional surgical treatments.

Must remember facts about Glaucoma

• There is no prevention for the development of glaucoma.
• Sometimes the symptoms of glaucoma are simply not noticeable.
• Glaucoma can silently snatch away your vision.
• Timely detection of glaucoma is a must.
• Timely treatment of glaucoma may prevent further loss of vision and blindness.

Immediately get in touch with us, if you experience any of the following:

• Severe eye pain
• Sudden loss of vision
• Coloured Halos
• Nausea and / or vomiting
• Poor night vision
• Persistent redness of the eye

• Follow-up:

No other eye disease warrants such strict life-long follow-up as does glaucoma.

1. Whether you are on medical treatment or have been in addition treated by surgical or laser procedure, follow the check-up schedules religiously.
2. Under no condition you must change/alter/stop any medication by yourself.
3. Even a change in the brand should be by doctors’ consent, as it may change the desired drug levels.
4. Discuss with your doctor if you are finding it difficult to follow your scheduled visits.
5. As far as possible do get detailed check-ups as advised (6 – 12 monthly) by your doctor.
6. At times the doctor may feel the need of more frequent visits or may order a repeat of some test, please comply. Even if you do not understand why this is happening, discuss it with your doctor. Do not just ignore the advice