Glaucoma

Glaucoma is damage to the optic nerve that is that is the result of high intraocular pressure.  In most cases of glaucoma, patients are not aware of a functional loss because the damage happens slowly.  Peripheral vision is gradually lost, and only in the end stages does central vision and clarity diminish.  Because it happens at such a slow rate, it is important to be tested regularly if you at risk so that treatments that slow down this process can be initiated.  We offer complete diagnostic, medical and surgical care for glaucoma patients.  Our state of the art facility offers the most advanced in the early detection of glaucoma.  We can detect and prevent early glaucoma before you ever have a functional loss.  Given that vision loss and blind spots from glaucoma are permanent and irreversible, prevention becomes key.  The earlier you are able to detect disease, the more vision you can preserve for years to come.

Diagnosis

Dr. Leen and Dr. Nakamoto are both fellowship trained in glaucoma.  They will supplement thorough exams with state-of-the-art diagnostic tests available during your visit here.   Here are some of the technologies you may encounter:

  • Tonometry – measures fluid pressure within the eye
  • Pachymetry – measures of corneal thickness, which affects pressure readings
  • Humphrey Visual Field (HVF)  –  maps out any blind spots and can find small changes in peripheral vision over years
  • Cirrus Ocular Coherence Tomography (OCT) – Computerized cross-sectional thickness measurement and 3-D analysis of the optic nerve and the eye’s drainage system.  This is one of the most sensitive studies to detect early glaucoma before functional loss.

Your initial workup may or may not include these studies depending on your specific case.  We are careful to obtain studies at regular intervals so we can detect progression early.  A detection and treatment strategy will be designed for you personally based on your risk factors.

Treating Glaucoma

Glaucoma treatments generally target mechanisms to lower the pressure in the eye and preserve vision.  If untreated, abnormal eye pressure can damage the optic nerve leading to permanent loss of vision.  High eye pressure is just one of many risk factors that can cause progression of disease.

Dr. Leen and Dr. Nakamoto are medical doctors as well as surgeons and will make sure that your treatment is best for you, whether it be medical, laser, or surgical.  They offer all of these treatments personally, and they are the only glaucoma specialists in Kitsap County.

Most patients with early glaucoma can be controlled medically with eye drops alone.  Finding the right combination is often an artful balance and we can find a regimen that works for you as a patient keeping your schedule and health limitations in mind.

Many patients find that laser therapies are a better fit for them.

In advanced cases, or in cases in which medical and/or laser therapies have been exhausted, surgery is the next step.  Timely surgery often gives patients with moderate to severe glaucoma the best chance at keeping blind spots at bay.  There are more options than ever before, and your surgeon will guide you to a therapy that matches your situation.

Selective Laser Trabeculoplasty

Selective Laser Trabeculoplasty (SLT) is a in-office laser procedure in which the drainage system of the eye, the trabecular meshwork, is treated with a diffuse application of light energy.  The holes in the meshwork are made larger so that more intraocular fluid can flow out, thereby reducing your eye pressure.

Your laser appointment will take about 1.5 hours, though the actual laser takes 2 minutes.  We will answer your questions, prepare and numb your eye, perform your laser, and observe and examine your eyes afterward.  The treatment is painless for most, or mildly achy.  You may want to bring a driver with you.  You may be slightly blurry or achy for a day after, but you can get right back to your daily routine without restrictions.

Peripheral Iridotomy

A peripheral iridotomy (PI) is a small hole made in the iris to prevent narrow angle glaucoma.  Untreated, narrow drainage angles are a risk factor for acute glaucoma attacks, which can threaten vision in a single episode.  In a quick office procedure, a pressure differential between the front and the back of iris is relieved allowing greater access for the aqueous fluid to reach the trabecular meshwork, the drainage system of the eye.

When you having this procedure done, expect about a 1.5 hour visit.  We answer your questions, prepare the eye, make it numb, perform the laser, the observe you after your laser.  The actual laser takes about 5 minutes.  Expect blurry vision for a day or two.  You can get right back to your normal routine the day after.

iStent Microbypass Device

The Glaukos iStent is a “minimally invasive glaucoma surgery” (“MIGS”) which can be added to cataract surgery.  It is a minute stainless steel device that looks like a tiny snorkel.  It gets implanted in the delicate tissues of your natural eye drainage system to increase outflow and thus decrease intraocular pressures.  It carries one of the least side effect profiles of incisional glaucoma surgeries and is a option for mild or moderate glaucoma.  It does not exclude other more involved surgeries later if you should need it.

This procedure adds just a few minutes to your cataract surgery (total about 20 minutes).  This procedure is done under “conscious sedation” where you are awake but relaxed.  You may have transient blurring of vision after this procedure, which is often the sign of successful a microbypass.  In the majority of patients, there is no pain at all.

Neomedix Trabectome

The Neomedix Trabectome is a “minimally invasive glaucoma surgery” (“MIGS”) which can be added to cataract surgery.  Using a tiny probe, the meshwork that sits over your intraocular drainage system is cauterized and lifted away, thus allowing intraocular fluid directly into your drainage system.  It carries one of the least side effect profiles of incisional glaucoma surgeries and is a option for mild or moderate glaucoma.  It does not exclude other more involved surgeries later if you should need it.

This procedure adds just a few minutes to your cataract surgery (total about 20 minutes).  This procedure is done under “conscious sedation” where you are awake but relaxed.  You may have transient blurring of vision after this procedure, which is often the sign of successful Trabectome procedure.  Most patients have no pain or a mild transient ache.

Express Shunt

This is a common procedure for the treatment of moderate to severe glaucoma.  An Express shunt is a variation of traditional trabeculectomy surgery, where a new drainage system is created in the eye.  Extra aqueous fluid from the eye is diverted through a tiny stainless steel shunt to a reservoir (a “bleb”) on the top of your eyeball under your lower eyelid.  This is an excellent choice for those who need very low pressures, the drawback being the variable post-operative course.

This procedure takes about 45 minutes and done under “conscious sedation” (you are awake but comfortable).  It is best that you stop any aspirin or anticoagulation if its is safe for you to do so (we will counsel you on the risks).  You will go home with a patch.  There are activity restrictions on lifting and bending for a week or more, depending on your eye pressures.  You are typically seen about once a week in the early post operative period.  Sometimes adjustments are made manually or with laser in the office by your surgeon.

Glaucoma Drainage Tubes

A Glaucoma Drainage tube (Ahmed and Baerveldt)  is a common first or second line glaucoma surgery for moderate to severe glaucoma.  A silicone tube diverts extra fluid from your eye to a flexible plate that is tucked on the side of your eyeball.  There are different indications for each type of tube.  It is often offered in eyes that have or are at risk of scarring down an Express shunt.

This procedure takes about 45-60 minutes.  It is done under conscious sedation, where you are aware but obvious will not feel any pain in your eye.  You will go home with a patch that you will keep on until the next day.

Endoscopic Cyclophotocoagulation

Endoscopic cyclophotocoagulation (CPC) is a procedure in which a laser, mounted on a tiny probe, is used to stun the muscle in the eye that makes intraocular fluid.  This is enabled by a tiny camera that allows your surgeon to see inside your eye behind your iris.

This procedure takes about 15 minutes.  It is usually combined with other procedures.  You will go home with a patch.

Transcleral Cyclophotocoagulation

Cyclophotocoagulation (CPC) is a relatively non-invasive laser procedure for severe glaucoma.  The muscle inside the eye that makes fluid, the ciliary body, is targeted with a laser that can be applied without any incisions.   The most significant risk is blurry vision, the benefits are its non-invasiveness and easy post operative period.

This procedure takes about 5 minutes.  You will be briefly sedated, and during this short period your surgeon administers local anesthesia and completes the laser procedure.  You go home with a patch, which stays on until the next day.  Aching is normal during the first day, but you will be given pain medicine if you need it.   Pressure reductions are seen over the following weeks.

Micropulse MP3 Laser

The newest addition for mild to moderate glaucoma is the Iridex Cyclo G6 Micropulse MP3 laser.  It is often chosen for its minimal side effect profile.  The micropulse laser works by increasing uveoscleral outflow within the eye, and has the benefit of a quick recovery time.

A quick 5 minute laser procedure is done in the operating room.  You will be briefly sedated, and your surgeon will give you local anesthesia and complete the laser procedure.  You will go home with a patch that stays on until the next day.  Aching is normal during the first 24 hours.  Pressure reductions are usually seen in a matter of weeks.

For more information

Please note that this website is not all inclusive and that your surgeon will counsel you on risks, benefits, and alternatives of your procedure.  This is not intended to replace your preoperative appointment and specific recommendations of your surgeon or to provide medical advice, rather it is to make you comfortable what to expect with your procedure.  We will go over all of this and more at your appointment.  Bring your questions and an extra set of ears if you would like.

EyeSmart is an ophthalmologist-reviewed website with reliable, trustworthy eye health information about glaucoma.

Glaucoma information site sponsored by the American Glaucoma Foundation.

EyeWiki is the Wikipedia of eye diseases.

The American Glaucoma Society also has useful information for patients, as well as a referral database for patients moving out of town.

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