What is Glaucoma
Glaucoma is the leading cause of irreversible blindness in the world. It is caused by high pressure inside the eye, which leads to damage of the optic nerve that connects your eye to the visual centre in the brain.
Glaucoma affects your field of vision, normally in the periphery but central vision can also be affected. If untreated more and more vision is lost which can lead to irreversible blindness. Glaucoma can run in families so it is important to get checked if someone in your family has glaucoma.
Why does the eye pressure go up?
Clear fluid called aqueous is constantly being produced in the eye and is drained though a special membrane called the trabecular meshwork in the front chamber of the eye. In glaucoma the drainage is affected and so the pressure goes up.
Are there different types of Glaucoma?
There are two main types of glaucoma: open angle and closed angle glaucoma.
Open-angle glaucoma is the most common type of glaucoma in the UK. Eye pressure becomes high due to the drainage meshwork not working well enough to drain the fluid. Vision loss is often slow and painless so patients are not aware of the problem until the disease is already quite advanced.
Closed-angle glaucoma occurs when there is a blockage before the drainage meshwork. Eye pressure can rise quickly and can be accompanied with pain, blurred vision, haloes around lights, nausea and vomiting. This type of glaucoma requires prompt treatment to prevent rapid visual loss.
How is Glaucoma treated?
As damage from glaucoma is irreversible the key to treating glaucoma is early diagnosis. Treatment options include drops or laser initially with surgery usually reserved for more advanced cases. Laser for glaucoma is painless and effective and is now becoming used more and more as the initial treatment as people do not like putting eye drops which can sting or make the eye red. Mr Ratnarajan offers the latest glaucoma laser treatments to lower the eye pressure.
Glaucoma surgery is going though a period of innovation for which Mr Ratnarajan is leader in the field. Minimally invasive glaucoma surgeries (MIGS) are becoming safer and more predictable and Mr Ratnarajan can discuss if you are suitable for these. These surgeries can often be combined with cataract surgery, only adding a few minutes to the surgery.
If you would like to discuss the diagnosis and/or treatment for glaucoma you can book a consultation with Mr Ratnarajan here.
Treatment for Glaucoma
Glaucoma cannot be cured, and treatment is aimed at preventing it getting any worse. Regular eye examinations are very important to detect eye conditions early which means they can be controlled and vision loss prevented.
Treatment for glaucoma is going through a period of evolution and Mr Ratnarajan is an international leading authority on innovations in glaucoma treatment. Patients no longer need to be restricted to lifelong eye drops which can cause side effects such as redness, soreness as well as being difficult to put in.
Mr Ratnarajan is able to offer the latest laser and minimally invasive surgical treatments to prevent glaucoma progression and potentially get your off your eye drops.
If you would like to find out more about treatments available to you, or would like a consultation with Mr Ratnarajan please get in touch.
Selective Laser Trabeculoplasty (SLT)
What is Selective Laser Trabeculoplasty (SLT)?
SLT is a type of laser treatment used for the treatment of glaucoma or raised intraocular pressure.
How does SLT work?
SLT works by using a low energy pulsed laser to treat cells in the trabecular meshwork which leads to improved drainage of fluid from the eye, thereby lowering intraocular pressure.
What happens during the procedure?
SLT is an outpatient procedure performed under local anaesthetic. There is no preparation required and you may eat and drink as normal before your procedure.
The laser treatment is applied whilst you sit at a modified slit lamp similar to the one used to examine your eyes by the ophthalmologist. Local anaesthetic and pressure lowering drops are instilled into the eye being treated. A contact lens is then placed on the eye and laser applied. You will see a bright light but the treatment is painless.
The treatment takes approximately 15 minutes for each eye. You will have a pressure lowering drop immediately following the treatment.
Can SLT fail?
The treatment is more effective in certain types of glaucoma than others. The treatment can also be repeated.
If you would like more information or are interested in SLT please contact Mr Ratnarajan’s office.
Minimally Invasive Glaucoma Surgery (MIGS)
Mr Ratnarajan is a world authority and key opinion leader in the field of Minimally Invasive Glaucoma Surgery (MIGS). He has vast experience with MIGS and surgeons from all over of the world travel to learn from him.
What is MIGS?
As suggested by the name, MIGS is a minimally invasive glaucoma operation that offers both high levels of safety as well as rapid recovery compared to traditional glaucoma operations. MIGS has developed over the past decade and Mr Ratnarajan has pioneered many of these treatments in the UK. He is able to offer an unparalleled range of these surgeries, some of which are listed below. MIGS can be performed alongside cataract surgery or as a standalone operation.
If you are interested to see if you are suitable for MIGS please contact Mr Ratnarajan’s office.
The iStent Inject, at 0.4mm, is the smallest implant in the human body. It lowers the eye pressure by enabling aqueous humour to drain more effectively from the eye via its natural drainage channels. It is made of non-ferromagnetic titanium and is safe to use with MRI scans but you should let the radiographer know you have these implants. It is implanted through the trabecular meshwork into Schlemm’s canal with a pre-loaded inserter that fits through a small (1.5mm) incision. Usually 2 istents are implanted. The istent is extremely safe and the operation only takes a few minutes. Visual recovery is fast and the procedure is painless.
Endoscopic Cyclophotocoagulation (ECP)
ECP involves direct controlled application of diode laser energy to the ciliary processes to reduce aqueous production and lower the eye pressure. ECP can be used as a standalone procedure or combined with cataract surgery with a very good safety profile and rapid visual recovery.
Mr Ratnarajan has published a study in the British Journal of Ophthalmology which showed excellent outomes of ECP combined with istent. This novel surgery, which Mr Ratnarajan pioneered, was broadcast by the BBC and featured in an article in the Mail of Sunday. Click here if you are interested to find out more about this treatment.
This is a new MIGS and Mr Ratnarajan is one of only a few surgeons worldwide who has experience with the Microshunt. It is a MIGS for mild, moderate, and severe open angle glaucoma, with the potential to eliminate eye drop medications in most patients and can be considered as an alternative to performing trabeculectomy. It has shown great promise and has an excellent safety profile and quicker recovery compared to trabeculectomy. It can be implanted as a standalone or combined procedure with cataract surgery. The drainage implant consists of an extremely small micro-tube 8.5 mm long, about the size of an eyelash, and with a 70-µm lumen that shunts aqueous fluid from the anterior chamber of the eye.
The shunt is designed to be thin and soft to conform to the curvature of the eye. The device is made of proprietary material called SIBS (polystyreneblock-isobutylene-block-styrene) which is the most biostable thermoplastic elastomeric material currently in existence which has been used in cardiac stents and has been shown to cause minimal inflammation.
The Hydrus Microstent is an 8mm stent that lowers eye pressure by enabling fluid to drain more effectively from the eye. It works by both scaffolding Schlemm’s canal as well as bypassing the trabecular meshwork. It is made from a super-elastic, biocompatible alloy (nitinol®), which is a well-proven biomaterial that has already been used in over 1 million implants in a variety of medical devices. It is inserted via a preloaded injector that can fit through a small (1.5mm) incision. It has an excellent safety profile and allows for rapid visual recovery.
The Xen implant utilises the same mechanism as traditional glaucoma surgeries such as trabeculectomy and tube surgeries, by allowing outflow of aqueous from the anterior chamber into the subconjunctival space with bleb formation. However, it achieves this without dissecting or compromising the conjunctiva. The Xen implant is made of collagen derived gelatin that is soft and flexible when hydrated. It is inserted through a pre-loaded injector similar to that used for lens deliver in cataract surgery and injected through a small corneal incision (1.5mm).
Laser Peripheral Iridotomy (LPI)
What is LPI?
LPI is a laser treatment used to treat or prevent angle closure glaucoma which occurs when the drainage angle of the eye narrows and becomes blocked. This can lead to a rapid rise in eye pressure and can lead to visual loss unless treated quickly.
How does LPI work?
LPI involves creating a small opening in your iris to allow fluid to drain to the trabecular meshwork which is the eye’s natural drainage channels. Without this opening, fluid that is constantly being produced in the eye cannot drain away and the pressure rises
What happens during the procedure?
LPI is an outpatient procedure under local anaesthetic. There is no preparation required and you may eat and drink as normal before your procedure.
The laser treatment is applied whilst you sit at a modified slit lamp similar to the one used to examine your eyes by the ophthalmologist. Local anaesthetic and pressure lowering drops are instilled into the eye being treated. A contact lens is then placed on the eye and laser applied. You will see a bright light but the treatment is not painful.
The treatment takes approximately 5 minutes for each eye. You will have a pressure lowering drop immediately following the treatment and may require eye drops for one week after the treatment.
Can LPI fail?
The chance of having an acute angle closure attack of glaucoma after LPI is less than 1%. It is advised to still have regular eye examinations, even if on an annual basis, after the laser treatment.
The number of trabeculectomy operations performed worldwide is declining due to more modern treatments. In some cases, especially if a very low eye pressure is needed, a trabeculectomy may be required.
This surgery is performed under local or general anaesthetic and takes about 45 minutes. It involves creating a new passage for fluid to drain from the eye via a scleral flap. The use of anti-scarring medication is often needed as well as steroid drops for a few months after the surgery.
Like trabeculectomy, tube shunt surgery is reserved for glaucoma cases that cannot be controlled with drops, laser or MIGS. It involves placing a tube that allows fluid to be drained from the front chamber of the eye. The surgery takes about 45 minutes and can be performed under local or general anaesthetic.
FAQs Glaucoma Surgery
Mr Ratnarajan is one of the most experienced MIGS surgeon in the world. He will discuss treatment options with you during your consultation and help guide you which is the best treatment option for you.
A recent study, the Light Trial, showed that SLT is as effective as eye drops but does not have the potential side effects of eye drops. Mr Ratnarajan offers SLT as initial treatment or as an alternative to existing eye drops to appropriate patients.
Yes. It is common to have these surgeries performed at the same time. The glaucoma surgery usually only adds a few minutes to the cataract surgery.
This will depend on what glaucoma surgery you have. Mr Ratnarajan will guide you on this.
The visual recovery after MIGS is usually very quick. Some of the more invasive glaucoma operations may lead to slightly reduced vision for a few days as the eye recovers.
Mr Ratnarajan treats patients from all over the UK and abroad. A week 1 post-operative visit is important to assess the success of the operation. After this you may be asked to see Mr Ratnarajan again after 5 weeks but we can coordinate this review with your local eye surgeon or optometrist if you have travelled from far.