New Glaucoma Lasers and MIGS Micro Invasive Glaucoma Surgery

Glaucoma is an eye disease that involves damage to the optic nerve, which sends signals to the brain. No one knows exactly what causes this damage, but pressure buildup in the eye is one of the major risk factors associated with glaucoma. When the optic nerve is damaged by high intraocular pressure, some signals from the eye aren't transmitted to the brain. This can result in visual field loss and, if not managed, could eventually lead to blindness.

Glaucoma is the leading cause of preventable blindness in the U.S. However, most Americans may be unaware of it because glaucoma does not cause pain or have any noticeable symptoms. People who are at a greater risk for glaucoma usually have the following conditions:

  • At least 45 years old without regular eye exams
  • A family history of glaucoma
  • Abnormally high eye pressure
  • African descent
  • Nearsightedness
  • Diabetes
  • Previous eye injury
  • Regular, long-term use of cortisone/steroid products

Although glaucoma cannot be cured, it can be detected early and controlled. To detect glaucoma, your physician will test your visual acuity, visual field, dilate your pupils, and test the pressure in your eyes. Regular and complete eye exams help to monitor the changes in your eyesight and will help to determine whether you may develop glaucoma.

A procedure called Selective Laser Trabeculoplasty (SLT) is one of the greatest advances in the surgical treatment of intraocular pressure (IOP) in patients with open-angle glaucoma. Prior to its introduction, medications and Argon Laser Trabeculoplasty (ALT) were the Ophthalmologist's primary tools.

SLT (selective laser trabeculoplasty) Better than Drops for Glaucoma

What do SLT and MIXTO have in common?  The answer may surprise you.  SLT (selective laser trabeculoplasty) is a laser procedure used to lower eye pressure within the eye for patients with glaucoma. MIXTO is a facial laser procedure to tighten and rejuvenate skin.  Both use laser light energy in specific areas to build collagen, making the target treatment areas look and act younger.

Glaucoma is often a disease of aging. Many things get stiffer as we age and our trabecular meshwork, or the drain within the eye, is one of them.  More resistance means that fluid inside the eye has more trouble crossing the drain and glaucoma can result when pressure builds inside the eye.

Years ago, we used another laser, ALT (argon laser trabeculoplasty) to lower eye pressure. It worked, but collateral damage scarred the eye so that patients could only be treated a few times before the procedure lost effectiveness.  The SLT however, is the next generation of ALT and I describe it as a “smart bomb.”  Because the SLT targets the drain of the eye, there is no scar tissue formation and the SLT can be repeated as often as needed to keep  eye pressure down over your lifetime.  Best of all, studies have shown us that every time we use the SLT, we can expect the same amount of pressure-lowering each time (about 4-8 points) without any loss of effectiveness over time.

SLT is also better than drops because drops wear off over time and people don’t always get the same amount of medication in their eyes each time. We know that even the most dedicated patients forget their drops, don’t get them in at the same time every day or go a few days before refilling.  Once performed, SLT lasts 1-4 years and works all day every day, eliminating the small gaps of time that pressure might sneak up.  This is why clinical studies consistently show that SLT preserves vision better than drops. 

Most patients can eliminate at least one drop from their daily treatment after SLT. This saves money, time at the pharmacy and convenience. Reducing or eliminating glaucoma drops also improves vision and symptoms of dry eye by improving the ocular surface. Daily doses of glaucoma medication and the accompanying preservatives necessarily irritate the ocular surface causing dryness which people often describe as blurriness, scratchiness or grittiness.

The new smarter technology SLT has now become the first line glaucoma treatment in the US as well as Europe.  Patients undergo a simple, quick in-office procedure (covered by most insurances) and avoid or reduce the number of eye drops that they are taking for glaucoma. In addition to eye pressure lowering, patients experience many other benefits including reduced prescription cost, convenience and improved ocular surface With no downtime or restrictions, patients can drive themselves to and from the appointment.

New Non Invasive Glaucoma Laser  Cyclo G6 Taking the Place of Surgery

You’ve heard of going from 0-60 in 6 seconds but what if I could take you from 50 to 18 in 160 seconds? I’m not talking about the latest automotive advance but instead about reducing the pressure in glaucoma patients with a new, in-office laser procedure that is light years from traditional glaucoma surgery.

We’ve been using the Iridex diode laser in retina surgery because it is the first and only retinal laser that is safe to use directly on the fovea, the most sensitive tissue in the eye.  Before the Iridex retinal laser, we could not treat the fovea directly and even had to be careful about the tissues near the fovea because of the collateral damage the other lasers caused. This laser, however, has revolutionized the way we are treating diabetes, macular swelling and even macular generation and studies are currently underway looking at the way this may change our treatment protocols for these diseases.

For glaucoma, we have long known that the MLT and SLT are less invasive but equally effective in improving pressure in glaucoma patients by increasing the way the eye gets rid of extra fluid.  It generates literally no inflammation or collateral damage compared to previous lasers.  The Iridex Cyclo G6 MicroPulse P3 system is the next step up.  Instead of working on the outflow, it works by slowing down the production of fluid inside the eye.

After just one treatment, patients eye pressures are reduced, on average by 40% and even in some cases 50% , and most patients were able to eliminate 2 drops from their regimen and avoid more invasive surgery.  This is important for anyone who finds drops inconvenient, is unable or unwilling to put drops in everyday, or can’t afford drops (some of them run into the hundreds of dollars – even generic brands).  Patients who suffer from dry eye are another group of patients that will benefit from this procedure as all glaucoma medications (and the preservatives that accompany them) are guaranteed to worsen dry eye.

The Iridex Cyclo G6 procedure is a comfortable, in office procedure.  After the eye is numbed, the laser is applied for approximately 160 seconds and patients are ready to head home.  Results are seen as quickly as one week (my first patient went from 50 mm Hg to 18 in just 7 days) but may take as long as one month.  Patients can be re-treated to gain the desired results.  At this point, the pressures are staying stable for 18 months (and counting) and patients were able to stop, on average, at least 2 of their glaucoma medications after the procedure.  This procedure is covered by most major insurances.

There are additional surgical options available for IOP management for patients who are unresponsive to laser and topical medication treatment, one of the most effective surgical alternatives is MIGS - Microinvasive Glaucoma Surgeries.

Do you or someone you know have glaucoma?  Over 2.8 million Americans do and it often runs in families.  Traditionally, people have taken eyedrops to reduce the eye pressure and to prevent vision loss, but there are many reasons that drops are a less than perfect solution.

1. Drops are expensive.  Everyone with a chronic disease will tell you that they spend more than they want to at the pharmacy.  Some of the best glaucoma medicines costs hundreds of dollars for only a few milliliters of medicine and insurance doesn’t always cover the expense.
2. Drops need to be taken at the same time of day every day for maximal effectiveness. The medicine in drops wears off over time.  It isn’t always as effective at night as it is in the morning or the other way around. Plus, the effect depends on if you got a big drop in or a small one, if you blinked out most of your drop after putting it in or if your eye watered and rinsed out most of it.
3. Glaucoma drops cause dry eye.  25 million Americans (most of them women) already suffer from dry eye. Glaucoma medicines and their preservatives will 100% of the time worsen or create dry eye situations and in some cases can cause inflammation that make glaucoma surgeries less effective.

Because of these reasons and more, Micro Invasive Glaucoma Surgeries (MIGS) have quickly become one the most exciting areas in ophthalmology.  MIGS surgeries are safer than previous glaucoma surgeries with less chance of complications and problems and are often done at the same time as cataract surgery. They often reduce patient’s need for glaucoma drops or in some cases, can eliminate them entirely.

The iStent is one such device.  It is a titanium stent used to open the drainage canal inside the eye at the time of cataract surgery. It is the smallest FDA device at 0.3 mm x 1 mm. Covered by most insurances, implanting the iStent at the time of cataract surgery has been proven to lower the eye pressure more than just cataract surgery alone. The iStent is used in people with cataract needing surgery  with mild or moderate disease.

The Express Mini Shunt is another device that is used in more advanced glaucoma patients that uses stent or shunt technology to maintain a way for additional fluid to drain out of the eye and lower the pressure. Also covered by most insurances, it allows patients a faster return to baseline visual acuity, lower rates of complications and decrease in use of glaucoma medications. Smaller than a grain of rice, it is an efficient and effective alternative for controlling eye pressure in patients with glaucoma.

At Toyos Clinic, we work hard to stay abreast of current trends and technologies so that our patients have access to the best our field has to offer. Microinvasive Glaucoma Surgery (MIGS) is an exciting way for patients to preserve their vision while using fewer medications.  Call today to schedule your free consultation to see if MIGS is right for you.