How Modern Glaucoma Treatment Can Protect Your Vision Long Term

What Glaucoma Does to Your Vision Over Time

Interviewer: So your eye doctor says you have glaucoma, and now what? The scary part is that glaucoma damage can't necessarily be reversed, but the good news is that we have some excellent ways to slow it down and protect your vision long term.

Today, I'm here with Dr. Rachel Simpson, an ophthalmologist, glaucoma specialist, and the vice chair of education at the University of Utah's John A. Moran Eye Center, where she specializes in the medical and surgical treatment of glaucoma.

Now, Dr. Simpson, let's start with just the very basics, just kind of a brief introduction to what is a glaucoma. What is happening?

Dr. Simpson: I find most patients have heard the word glaucoma, but don't really understand what it means. So I do try and take time . . . every time I'm talking about glaucoma with a patient for the first time, I try and start with the basics. And what I tell them is glaucoma is a disease of the optic nerve where you lose optic nerve tissue over time.

Because the optic nerve is the cable that connects your eye to your brain, as you're losing that optic nerve tissue, your eye is no longer able to send signals to your brain. And if your brain isn't getting those signals, your brain can't see. So even if the eye is working, if there's some kind of problem in that cable, then the brain is not going to receive the images the way that it should.

The more damage there is to the optic nerve, the more you lose that optic nerve tissue over time, the less signal your brain is going to receive.

And so I tell them it is essentially nerve damage, and everyone fundamentally understands right now, once a nerve is damaged, we can't fix it. We see that with spinal cord injuries. And so patients have a fundamental understanding of that.

So our job as glaucoma specialists is to try and catch the disease as early in the disease process as we can, maybe when that damage to the optic nerve is just beginning, and then try and prevent them from having any more damage over time.

And right now, the only way we have of doing that is by lowering the pressure inside the eye. We have a number of tools at our disposal to be able to do that. We have laser procedures, we have medications, and we also have a number of different surgical procedures, all of which are designed to help us lower pressure inside the eye and protect the optic nerve.

Early Detection Is the Only Way to Protect Your Sight

Interviewer: How does someone even test for this? Is this that puff of air that is done in the eye exam, or how do we know what is going on with the pressure of the eye?

Dr. Simpson: That is one of the best-known ways of checking pressure, and probably perhaps one of the most hated ways of checking pressure. I know patients are like, "You can do anything to me, but please don't shoot that puff of air in my eye." So, yes, that is one.

The eye has vital signs, just like when you go to your primary care doctor, and they check your blood pressure and your heart rate. Eye pressure is the vital sign of the eye, along with your visual acuity and a couple of other things that we check every time. So when you're going to your eye doctor, regardless of whether you're seeing an optometrist or an ophthalmologist, they are checking these vital signs of the eye, one of which is pressure.

Interviewer: Got you.

Dr. Simpson: The easiest way we have of detecting glaucoma is that your pressure is elevated. And that is very common in the most common form of glaucoma, which is primary open-angle glaucoma, where we see pressure very significantly elevated.

But pressure is not the only thing that we use to detect glaucoma. The appearance of the optic nerve is another one. And then we also have some tests that we do in clinic, a visual field test, and something called an OCT, an ocular coherence tomography, which measures the thickness of the optic nerve.

Sometimes you can have glaucoma, even if your pressures are normal. And so it takes more than just a pressure screening to detect glaucoma. It takes pressure plus someone who knows what to look for when they're taking a look at your optic nerve and knows what tests to order when they're examining you.

What Vision Loss from Glaucoma Can Look Like Without Treatment

Interviewer: Now, let's move on to some of the treatments. To begin with, I'm sure people hear the term "nerve damage" or "irreversible," and they kind of just jump straight to thinking, "I'm going blind." How do we frame the risk and kind of set expectations for treatments before we go into some of the specifics?

Dr. Simpson: So I try and give patients a picture of what the natural process of glaucoma looks like if it's untreated, because patients will wonder, "Well, what does treatment look like? And what does it look like if I don't do anything?"

Of course, most people's minds do go to the worst-case scenario, "I'm going blind. I'm going blind quickly." And I usually tell them, "For most people with glaucoma, if it's untreated, it is a slowly progressive disease, which means, yes, you will continue to lose vision over time." That process is very variable from patient to patient. So some patients might lose vision at a fairly rapid rate, where we're talking months to just a few years. Some patients, that rate is very, very slow, where it's decades of slowly progressive vision loss.

I also tell them, usually, in early-stage glaucoma, when they lose vision, it tends to be their peripheral vision, their vision very far out on the edges of their vision, which they're not personally able to tell when they're losing it, which is one of the reasons why it's really important to continually check in with your eye doctor.

With glaucoma, you're not able to detect your vision loss yourself. You really are dependent on us coming in and doing these specific tests to tell you whether or not you're losing vision.

And then I tell them, "That's what glaucoma looks like without treatment. We know that it is slowly progressive and it will continue to affect you for the rest of your life."

My job as a glaucoma specialist is to take that slowly descending line and make it a flat line. I want to arrest your disease process right where it is and stop you from losing any additional vision. So my job is to prevent any further vision loss and keep you on the trajectory, that kind of straight, steady trajectory of no additional losses.

I always tell them, "I can't get you back what we've lost in the past, but that's why we're going to be so protective of what you still have." My job is to make sure that from here on out, we don't lose any more vision at all. And we do that by, like I said, lowering eye pressure through a number of different ways.

Laser Therapy as First Step in Glaucoma Care

Interviewer: So let's go into some of those ways. I mean, historically, I've heard a lot of patients with thick eye drops. I also have heard about a laser-first approach. So when it comes to flattening that line, what tools do you have at your disposal, and how do we go about step by step?

Dr. Simpson: This is really one of the most exciting paradigm shifts that we've seen in glaucoma over the last 10 years. So I did my residency training not all that long ago, I'd like to think. It was in the mid-2010s. And at that point, we really were preaching a drops-first, laser-second approach, which meant when you came to your eye doctor, if your pressure was high, or even if your pressure wasn't high, but you had signs of glaucoma, we would start you on an eye drop.

And then if you came back in and we still didn't like where you were, we would start you on a second eye drop. Sometimes we would start you on a third or a fourth eye drop.

And only when we were at the transition between going from a medication approach to a surgical approach would we kind of squeeze you into this little category of a laser. We'd say, "Well, your medications right now are not enough to control your pressure. We're probably looking at surgery, but let's try this laser as a last-ditch effort to try and save you from having to do something surgical to address your glaucoma."

That paradigm has dramatically shifted over the last 10 years. We now have repeatable, very good data to show us that the laser that we were kind of saving until last resort is much more effective and also much more patient-friendly than medication.

And so we've really turned that paradigm on its head and now laser . . . The laser specifically is called SLT, or selective laser trabeculoplasty. But this laser is now essentially a first-line treatment. And I offer this to every patient who is a candidate for it before I offer them medication.

One of the advantages of it is that we've realized that eye drops, while very benign on paper . . . You don't think you're incurring much risk at all by using a medication every day. We know there are long-term effects to using medication every day inside the eye.

First and foremost, the biggest one is that it's going to cause a lot of dry eye. And specifically for us in this climate where we live here in Utah, almost everybody already has dry eye. So I'm taking an eye that's already really dry and a little bit uncomfortable, and I'm making it a little bit worse.

And then there are cosmetic side effects. There are even some systemic side effects with some of these medications.

So we tend to think of medications as being very benign, but in reality, we know there are significant side effects.

The nice thing about this laser is it's as effective as a drop, it is as safe as a drop, and it works for almost every patient.

Now, it's not a permanent solution. I always warn people, "You're going to get about three to five years of impact from this laser." But it's repeatable up to about three or four times. So if you get a good result, and say you make it that 5 years before we have to repeat it, we're looking at possibly 20 years of saving you from having to use a medication.

Eye Drops and Their Long-Term Tradeoffs

Interviewer: Are there any downsides to the laser over the drops? I mean, it sounds like there have been quite a few studies, and I've read a couple of them, that it's as safe, if not safer, than the eye drops.

Dr. Simpson: With everything, there's always risk. Just like we talked about, there's risk with eye drops. There, of course, are some risks with the laser. The biggest risk is that it doesn't work. And I'd say that happens maybe for 5% of our patients. We'll do the laser and nothing happens, and that's really the biggest thing.

There are some patients who just are not a good candidate for it, patients who have a history of inflammation inside the eye. The laser can be mildly inflammatory, and so we don't want to risk reactivating some kind of inflammatory condition in the eye. But for most people, there really are very few, if any, negative consequences of doing this laser.

And I'll tell you one of the things for me that was the most telling about how things have changed in ophthalmology is there was a study that was done among ophthalmologists where we were asked the question, "If you yourself were diagnosed with glaucoma and your eye doctor gave you the choice of starting a drop or doing a laser, which one would you choose?" Ninety-five percent of ophthalmologists chose laser-first.

Interviewer: That's a clever way to test that. I like that.

Dr. Simpson: Yeah, it's very telling.

When Minimally Invasive Procedures Become the Next Step

Interviewer: Yeah. The laser-first is the new paradigm. You talked about we have drops, we have laser, now we're doing laser-first. But what about procedures? What happens if we can't quite control or flatten that line like we are hoping?

Dr. Simpson: Another great question, and again, one of the areas where we've seen really a dramatic increase in options that we have to offer our patients.

So if we were in this scenario 20 years ago, I would tell you that we would do drops first, and then we would do laser, and then the choices that we would have available to us were two major surgeries. When I say major, major for the eye means like an hour to an hour and a half long with very significant follow-up. You have to come back and see us every week, every other week for months on end.

We are making a large incision inside the eye. And even though all eye surgeries are relatively safe, in the world of eye surgery, the larger the surgery, the larger the risk. And so we were taking kind of a dramatic leap from drops and laser all the way up to two very invasive eye surgeries.

One thing that has happened in the last 15 years is the introduction of this concept called MIGS, or minimally invasive glaucoma surgery. And this is probably the most rapidly growing surgical space in all of ophthalmology.

The idea is that we were taking a giant leap from being able to treat glaucoma in clinic to having surgical options, and MIGS is what gives us steps in between medical treatment and really invasive surgical treatment.

So now we might say, "Hey, we can't control you with drops alone and laser, but there is this small procedure that we can do." We bring you to the operating room. It takes 5 or 10 minutes. We put a stent in that helps improve the flow of fluid out of the eye, so that it helps lower pressure. It takes five minutes. There's really no additional risk other than the normal risk you would have if we were doing, say, cataract surgery.

And the other nice thing is that a lot of these procedures are designed to be done in combination with cataract surgery. So I'll tell patients, "Hey, you have a cataract that's getting worse. It's starting to impact your vision. You also have glaucoma. This is an opportunity for a two-for-one. We're going to already be inside the eye removing your cataract, and now we have the opportunity to also treat your glaucoma surgically at the same time."

So there are probably right now 8 to 10 different options in that MIGS space, and it is rapidly expanding. Soon, I think there'll probably be 20 different options that we'll have to offer patients beyond those two very traditional old-school invasive surgical options, which are still also very good options if that's what you need, but it is a bit like using a grenade when all you need is a bow and arrow.

Interviewer: Wow. And so, I guess, just in my layperson research, are you talking about all these different things like iStent, GATT, XEN Gel? There were a whole bunch of them that I kind of came across.

Dr. Simpson: Exactly. There's iStent, there's iTrack, there's OMNI, there's the XEN Gel Stent, there's Hydrus. It's a huge space, and every year new things are added to it.

Interviewer: Cool. Kind of exciting to hear that there are just so many new options for that.

Dr. Simpson: I feel very lucky to be a glaucoma specialist right now, where there are so many more tools available to me as a glaucoma specialist than there were to my predecessors 20 or 30 years ago. It really is a very fortuitous time to be a glaucoma specialist. And honestly, for patients who have glaucoma, it's a pretty good time to have glaucoma as well.

How a Strong Doctor Relationship Protects Your Long-Term Vision

Interviewer: Wow. I like that line, that it's the best time to be having glaucoma. But for someone who maybe was listening right now and either they or maybe a loved one just got diagnosed, it's a little different than just hearing it from the outside. What message do you want to leave those people with that kind of reassures them that we have options to save their vision?

Dr. Simpson: I find that information is power, and I also think the other thing that is really important is you need to have a good relationship with the doctor that is going to be on this journey with you. And I really do see it as a journey.

Unlike a lot of other specialties in ophthalmology, where we see a patient maybe once a year or even every other year, or sometimes we just take their cataract out and never see them again, the relationship you build with your glaucoma specialist is . . . I'm seeing these patients every two or three months. I know them pretty intimately, and they know me pretty intimately, and they also know that they can trust me.

So I think the first thing is to find a doctor that you can trust and that you can establish a really good rapport with, and then have a conversation with that doctor and ask the questions. Ask them the things that you are most worried about. I guarantee you a good glaucoma specialist will be able to reassure you.

It is a serious disease, and it requires serious treatment. We take the disease very seriously. But for most people with a diagnosis of glaucoma who are able to access glaucoma care, you will not go blind, and you will have a doctor who will be with you on that journey every step of the way.

Just make sure it's someone that you feel comfortable asking all the questions to, and you have a good rapport with, and you feel like you can trust. That's the most critical thing.