Glaucoma

Glaucoma is the name for a group of eye diseases in which the optic nerve is damaged. In the worst cases, the damage can lead to blindness, but this need not happen if glaucoma is detected and treated early.

The most common type, called open angle glaucoma (or chronic simple glaucoma), affects around two in every hundred people over the age of 40, and becomes more common with increasing age.

The normal eye

The eyeball is filled with a watery fluid called aqueous humour, which creates pressure and helps maintain the shape of the eyeball (see the diagram, below).

The aqueous humour that fills the anterior chamber (front part of the eye) is produced by the ciliary body, just behind the iris. The fluid drains back into the bloodstream through sieve-like channels called the trabecular meshwork. Normally, the amount of fluid produced is balanced by the amount draining away, so the pressure in the eye stays constant.

Increased pressure

In most people with glaucoma, it is raised pressure inside the eye that causes optic nerve damage. The increase in pressure usually happens because the aqueous humour doesn’t drain away properly.

However, the cause of glaucoma is not completely understood. Some people have high internal eye pressure but do not develop optic nerve damage, while in others the nerve becomes damaged despite normal internal eye pressure.

Other factors, such as poor blood supply to the optic nerve or a weakness in the nerve, may also be involved.

Types of glaucoma

There are two main types of glaucoma, open angle glaucoma and closed angle glaucoma.

Open angle glaucoma is the most common form and results when the trabecular meshwork becomes blocked over several years, leading to gradual increase in pressure and worsening of vision.

The build up of pressure inside the eye is painless as well as slow. But, if it isn’t treated, as the optic nerve is gradually damaged, the field of vision is reduced, so that eventually only a small area of central vision remains (tunnel vision) before sight is lost completely. Most people do not notice any symptoms until they have some loss of vision, and by this time the optic nerve may be damaged. This is why regular screening tests are important over the age of 40 (see Detecting glaucoma, below).

Closed angle glaucoma (also called acute glaucoma) is much less common. It involves a sudden, complete blockage of the trabecular meshwork, and can result in permanent blindness if not treated promptly. Symptoms usually affect only one eye, which becomes red and extremely painful. This may be accompanied by a headache, blurred vision and vomiting. Closed angle glaucoma needs immediate treatment in hospital. This usually involves medicine to reduce the pressure in the eye, followed by laser treatment or surgery (see Treatment, below). The other eye is usually treated at the same time, because there is a strong chance it will develop the same problem. If treated quickly there can be almost complete and permanent recovery of vision.

There are two other uncommon types of glaucoma: secondary glaucoma, in which the rise in internal eye pressure is the result of another eye condition, and congenital glaucoma due to a physical abnormality of the eye present at birth.

Risk factors

Open angle glaucoma is around six times more likely to develop in someone who has a close relative (parents, siblings or grandparents) with the condition. People of Afro-Caribbean origin, very short-sighted people and those with diabetes are also more at risk.

Detecting glaucoma

Screening tests are important to detect glaucoma before there is significant loss of vision. An optometrist (optician) can do these during a sight test. Ideally, everyone over 40 should have their eyes checked for glaucoma every two years. People aged 40 or over who have a family history of glaucoma are entitled to free eye tests.

There are three types of simple, painless tests that an optometrist can do:

People who are found to have glaucoma can be referred to a specialist eye doctor (an ophthalmologist) for assessment and treatment.

Treatment

Treatment for glaucoma aims to lower the internal pressure of the eye and prevent any loss of vision, or any further deterioration in vision. Options include medicine given as eye drops, laser treatment and surgery. Treatment cannot reverse any existing optic nerve damage, so it won’t improve sight if that has already deteriorated.

Medicine

There are several different types of medicine available for treating glaucoma. They help lower the internal pressure of the eye by increasing the flow of fluid out through the trabecular meshwork, or by reducing production of fluid. A beta-blocker (such as betaxolol) is often tried first.

Several other types of drugs are available in drop and tablet form, as alternatives or in addition to beta-blockers.

It is important that any prescribed eye drops are used every day as advised by your doctor, or the pressure in the eye will rise again. There are combination eye drops available that might be more convenient for those who need to use two different medicines.

Side-effects: all the eye drops can cause some irritation to the eyes. In addition, beta-blockers can cause itching and dry eyes. Side-effects of other types of medicine may include taste disturbance, darkening of the iris, thickening and lengthening of eye lashes, headaches and blurred vision.

Laser treatment

A laser can be used to open the holes in the trabecular meshwork. The procedure is usually quick and causes little discomfort. No general anaesthetic is required and there is no need for an overnight stay in hospital. The success of this type of treatment varies from person to person, and it may be necessary to continue using eye drops after laser treatment, though often at a lower dose.

Surgery ( trabeculectomy)

The effectiveness of newer medications for glaucoma has recently reduced the amount of traditional surgery for glaucoma. However, surgery is an option when medicines and/or laser treatment have failed to adequately lower pressure in the eye.

The operation is straightforward and involves creating a tiny opening in the eye wall, which allows fluid to escape into the loose tissue under the conjunctiva (the clear membrane that covers the white of the eye). From there it is absorbed back into the bloodstream. The operation often makes further treatment with eye drops or tablets unnecessary, but about one in five people need to keep using them.