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DOCTOR, I HAVE A QUESTION.a guide for patients andtheir familiesTMWWW.GLAUCOMAFOUNDATION.ORG

TABLE OF CONTENTS1How Does the Eye Work?.................. 3-6What is Glaucoma?............................. 7-8 Types of Glaucoma....................... 8-20 Risk Factors ....................................... 20-21.Treatment ..................................... 28-49Glossary .......................................... 50-53About TGF ...................................... 54-55The Glaucoma Foundation’s mission is to fund groundbreaking research and to educate the public about glaucoma. The Foundation works to stimulate and support basic and applied research in glaucoma, to gain and disseminate new information about the biological causes and treatment of glaucoma, and to further eorts to identify and develop novel approaches to preserve visual function and reverse blindness caused by glaucoma.

2Robert Ritch, MD, Founder and Medical DirectorGregory K. Harmon, MD, Chairman of the BoardElena Sturman, President and CEOMedical Advisory BoardJillia E. Bird, OD, MS (Vision Sciences)Balwantray C. Chauhan, PhDPhilip P. Chen, MDRobert D. Fechtner, MDMurray Fingeret, OD, FAAODavid Greeneld, MDGregory K. Harmon, MDJost Jonas, MD, FARVOPaul L. Kaufman, MDJerey M. Liebmann, MDLouis Pasquale, MD, FARVORobert Ritch, MDAakriti Garg Shukla, MDThank you to Drs. Gregory K. Harmon, Paul L. Kaufman, Louis R. Pasquale, and Robert Ritch for their contributions to this book,and to Drs. Aakriti Garg Shukla, Sitara Hirji, and Sai Kurapatifor their 2023 edits.“Doctor, I Have A Question” is made possible by an educational grant from Thea.TM

3PROTECTING YOUR VISIONHaving a basic understanding of the structures of the eye and how they function is the rst step in understanding glaucoma. With this information, it will be easier to discuss your condition and treatment with your eye doctor. Working together, you and your doctor will be able to act as a team to protect your vision.HOW DOES THE EYE WORK?The eye is like a camera. It has a lens which focuses light, just like the lens of a camera. The focused image in a camera is recorded on lm or by digital technology. In the eye the focused image is formed on the retina, which is like a wallpaper covering the back of the eye. The image information (color, shape and movement) is then sent to the brain via the optic nerve, which acts like a computer cable connecting the eye to the brain, where the image is processed.In glaucoma, the lens and retina function normally, but the optic nerve is damaged and images cannot be transmitted to the brain.

4KEY PARTS OF THE VISIBLE EYELet’s look at the eye more closely. The sclera is the white outer surface of the eye; it is a thin, tough, protective outer shell covered by the conjunctiva (a clear outer skin of the eye that contains some blood vessels and coats the sclera). In the front of the eye in the center is the cornea, which is a clear window through which light rays enter the eye. It provides the eye with much of its light-focusing power.The pigmented (colored) portion of the eye is called the iris. It is responsible for eye color and controls the size of the pupil - the dark circular area in the center of the iris. Together, the iris and pupil act like

5the aperture of a camera. When there is a great deal of light, such as outdoors on a sunny day, the iris constricts the pupil, making it smaller and limiting the amount of light which passes through the pupil to the retina in the back of the eye. When there is little or no light, the iris dilates the pupil, widening it so that more light can enter the eye.The lens, located immediately behind the colored iris, adjusts its shape and thickness to focus the light rays that enter through the cornea and pupil onto the retina. Often, as we get older, the lens gets discolored or hazy, and it is then called a cataract. The retina, lining the back of the eye, delivers the image formed by the light rays via the optic nerve to the brain. The brain processes these signals into a visual image. The retina, lining the back of the eye, delivers the image as nerve impulses via the optic nerve to the brain. The brain processes these signals into a visual image.The space in the eye that is behind the cornea and in front of the iris is called the anterior chamber. It is lled with a water-like uid called the aqueous humor which nourishes the cornea and the lens, providing oxygen and vital nutrients. The aqueous humor also provides the necessary pressure to help maintain the shape of the eye. We call the pressure inside the eye the intraocular pressure (IOP).

6GLAUCOMA EYEMaintaining the right amount of pressure within the eye is very important to protecting your vision. Measuring the intraocular pressure is one of the ways your eye doctor tests for glaucoma.HEALTHY EYE

7WHAT IS GLAUCOMA?Glaucoma is a number of dierent eye diseases characterized by specic patterns of optic nerve damage. The only modiable risk factor in glaucoma is the pressure inside the eye, or intraocular pressure. Lowering the intraocular pressure usually slows the progression of glaucomatous optic nerve damage. Although lowering the intraocular pressure is important for preventing the worsening of glaucoma, the intraocular pressure can be high or normal in glaucoma. The intraocular pressure does not need to be elevated relative to the average normal intraocular pressure to receive a diagnosis of glaucoma. If you have glaucoma, your doctor may set a target intraocular pressure for your eye based on the level of optic nerve damage you have, the thickness of your corneas, your age, and other risk factors. Maintaining your intraocular pressure near this target range may be very important to protecting your vision and preventing the progression of glaucoma. Measuring the intraocular pressure is an important part of your glaucoma evaluation. Through early detection, diagnosis, and treatment, you and your doctor can help to preserve your vision.

108The aqueous humor in the eye is a uid that is constantly owing through the anterior chamber, nourishing the cornea and lens. It is produced by a tiny gland, called the ciliary body, which is located behind the iris. Aqueous humor exits the eye through a very tiny spongy tissue called the trabecular meshwork. Only one-ftieth of an inch wide, this spongy tissue is located in the angle of the eye, where the iris (colored part of the eye) and cornea (clear window of the eye) meet. The trabecular meshwork functions like a drain to let the aqueous humor leave the eye. When the drain becomes clogged, aqueous cannot leave the eye as fast as it is produced, causing the uid to back up and the IOP to reach levels that are unacceptable for your eye.TYPES OF GLAUCOMAPrimary Open-Angle GlaucomaThe term primary open-angle glaucoma (POAG) refers to the specic way in which the iris meets the cornea, forming an angle that is wide open. This is the same angle where the trabecular meshwork is located. Approximately three percent of all Americans have this type of glaucoma. It occurs mainly in the over-40 age group and is the most common form of glaucoma in the United States.

9There are typically no symptoms associated with early POAG. The optic nerve is damaged due to pressure increases in the eye that are unacceptable for an individual’s eye, and the cornea can adapt without swelling. Because it is painless and usually causes decits in the peripheral vision (side vision) rst, patients often do not realize they are slowly losing vision until the later stages of the disease. By the time vision is impaired, the damage is irreversible.In POAG, there is no visible abnormality of the trabecular meshwork. It is possible that something is wrong with the ability of the cells in the trabecular meshwork to carry out their normal function, or there may be fewer cells present. This may be a natural result of aging, or due to inammation or damage. Some believe it is due to a small structural defect of the eye’s drainage system that cannot be seen by the naked eye. Genetic factors are also known to contribute. These theories, and others, are currently being studied at research centers across the country and worldwide.Elevated intraocular pressure can be an important risk factor for glaucoma. Eye pressure is measured in millimeters of mercury (mm Hg). The average intraocular pressure in a population without glaucoma ranges from 9 mm Hg to 21 mm Hg. A pressure of 22 mm Hg or higher is considered suspicious and possibly abnormal.

10However, not all patients with elevated IOP develop glaucoma-related eye damage. Conversely, many people will develop glaucoma with pressures that are within the so-called normal range. What causes one person to develop damage while another does not is another topic of active research.POAG is a chronic, progressive disease, meaning that it gets worse over time. As more and more optic nerve cells are destroyed over time, blind spots begin to form in the eld of vision. Your eld of vision is everything you can see with your eye open. These blind spots usually develop rst in the peripheral eld of vision, the outer sides of the eld of vision. Usually, in later stages of the disease, central vision is aected. However, in some people, the central vision is aected prior to the peripheral vision. Once visual loss occurs, it is irreversible. This is because, as of the technology currently available, optic nerve cells cannot be restored once they have been destroyed. So it’s crucial that your eye doctor detect glaucoma in its earliest stages – ideally before any visual loss occurs. The treatment for POAG is to lower the intraocular pressure, initially usually by medication or laser treatment to the trabecular meshwork, the drainage system of the eye. Keeping the intraocular pressure under control is the key to preventing loss of vision from glaucoma.

11Normal-Tension GlaucomaNormal-tension glaucoma, also known as low-tension glaucoma, is characterized by progressive optic nerve damage and visual eld loss and is thought to lie within the spectrum of POAG. The damage in normal-tension glaucoma occurs with intraocular pressure levels that are usually considered to be within the normal range. The level of intraocular pressure often does not correlate with the degree of optic nerve damage or visual eld abnormality. Maintaining your eye pressure within the target range your eye doctor recommends is most important. In cases of normal-tension glaucoma, this target eye pressure may be lower than the range recommended for POAG. Normal-tension glaucoma is increasingly being diagnosed and may account for as many as one-third of all cases of open-angle glaucoma in the United States. It is thought to be related, in part, to poor blood ow to the optic nerve. Poor blood ow leads to death of the optic nerve cells which carry information from the retina to the brain. In addition, these eyes may also experience pressure-related damage even with intraocular pressure in the high normal range. Therefore, a pressure lower than normal is often necessary to prevent further visual loss. Studies suggest that sleep apnea and low blood pressure at night might be additional risk factors for normal-tension glaucoma. Research is ongoing about optic nerve blood ow and its role in glaucoma.

12Angle-Closure GlaucomaAngle-closure glaucoma aects nearly half a million people in the United States. Although it is less common than POAG, it is more likely to lead to blindness. There is a tendency for this disease to be genetic, and several members of a family will often inherit the disease. It is more common in people of Asian descent and people who are farsighted (hyperopic). However, people of any race can be aected. The trabecular meshwork, which functions as the eye’s drain, is situated in the angle formed where the cornea meets the iris. In most people, this angle is about 45 degrees. In primary angle-closure glaucoma, the angle is narrower than normal. The narrower the angle, the closer the iris is to the trabecular meshwork. With a narrow angle, aqueous humor is less able to pass between the iris and the lens on its way to the anterior chamber. This causes uid and pressure to build up behind the iris, which further narrows the angle. If the pressure behind the iris becomes suciently high, the iris is pushed against the trabecular meshwork, blocking drainage – this is similar to putting a stopper over the drain of a sink. When the trabecular meshwork becomes completely blocked, an angle-closure glaucoma attack (acute glaucoma) results. More commonly, this condition presents in its chronic form, which is can be silent process until signicant visual eld loss has taken place, similar to POAG.

13Acute Angle-Closure AttackUnlike POAG and chronic angle-closure glaucoma where the intraocular pressure increases slowly, in acute angle-closure the IOP increases suddenly. This rapid rise can occur within a matter of hours and become very painful. Symptoms of acute angle-closure glaucoma may include headaches, eye pain, nausea, vomiting, halos around lights at night, and very blurred vision.An acute attack is a medical emergency. If treatment is delayed, damage to the optic nerve may occur quickly and cause permanent vision loss. Scarring of the trabecular meshwork may also occur and result in chronic glaucoma which is much more dicult to control. Cataracts may also develop.Sometimes, these sudden attacks occur in darkened rooms, such as movie theaters, which cause the pupil to dilate or increase in size. When this happens, there is maximum contact between the eye’s lens and the iris, and uid pressure behind the iris builds up, further narrowing the angle. The pupil as also more likely to be dilated when one is excited or anxious, so these attacks can occur during periods of stress. Medications that dilate the pupil (for example, anti-depressants, cold medications, antihistamines, some medications to treat nausea, and other medicines with anticholinergic eects) can also lead to an attack.An acute attack may be stopped with a combination

14of drops that lower your eye pressure and constrict the pupil. Soon after the intraocular pressure has dropped to a safe level, your ophthalmologist will perform a laser iridotomy – this is a laser procedure that makes a small opening in the iris allowing the uid to ow more freely. Since it is common for both eyes to suer from narrowed angles, performing the same procedure on the unaected eye is absolutely necessary as a preventive measure, as this eye is at high risk of an acute angle-closure attack.With routine examinations using gonioscopy, a technique to view the angle between the iris and the cornea, patients with narrow angles can be warned of early symptoms so that they can seek immediate treatment.In laser iridotomy, a small hole is placed in the iris, typically in the upper portion where it is hidden by the eyelid.

15Pigmentary GlaucomaPigmentary glaucoma is a type of inherited open-angle glaucoma which is more common in men than women, and Caucasian people are more likely to be aected compared to other races. Nearsighted patients are more typically aicted, and the anatomy of the eye appears to play a key role.Myopic (nearsighted) eyes have a concave-shaped iris which creates an unusually wide angle. This causes the pigment layer of the iris to rub on the lens, causing small pieces of iris pigment to shed into the aqueous humor and coat neighboring structures, such as the trabecular meshwork. When pigment is released into the anterior chamber, the condition is called pigment dispersion syndrome.Most patients with pigment dispersion will not develop pigmentary glaucoma. However, in some patients the pigment may plug the pores of the trabecular meshwork, causing it to clog, and thereby increasing the intraocular pressure. If the intraocular pressure is high and the optic nerve is damaged, then it has become pigmentary glaucoma.Medical therapy and laser treatment (selective laser trabeculoplasty) of the trabecular meshwork are often eective in lowering the pressure in these patients. Laser iridotomy (the laser treatment used for angle-closure patients) is currently being used in some

16centers to change the shape of the iris and slow the release of pigment. This preventative step may change the anatomy of the iris but has not yet been shown to be eective in treating pigmentary glaucoma.Exfoliation Syndrome (XFS)Exfoliation syndrome is an age-related disease characterized by the production and progressive accumulation of a whitish material in many parts of the eye. XFS may also cause instability in the structures that support the lens of the eye, and can be associated with complications during cataract surgery. The exfoliation material that collects on the lens is rubbed o by the movement of the iris against the lens. This may cause pigment and exfoliation material to clog the trabecular meshwork leading to higher than desired IOP.About 25% of persons with XFS develop elevated intraocular pressure, and one-third of that group of patients develop glaucoma. However, if you have XFS syndrome, your chances of developing glaucoma are about six times higher than if you don’t. Exfoliation glaucoma behaves more aggressively than open-angle glaucoma and can be more dicult to control. Therefore it is important to be closely monitored if you have XFS syndrome, even if you do not have glaucoma.

17The exfoliation material often appears in one eye long before the other. If you have glaucoma in one eye only, this is a possible cause. It can be detected before the glaucoma develops, so the patient can be more carefully observed and the chances of vision loss minimized.XFS does not just aect the eyes – it is a systemic disease, meaning it involves many parts of the body, wherever the exfoliation material collects. An increasing list of associations with cardiac and neurologic diseases makes XFS a condition of general medical importance. Recently described associations include stroke, heart dysfunction, Alzheimer’s Disease, and hearing loss. Genetic abnormalities in the lysyl oxidase gene is strongly associated with XFS. However, the vast majority of patients’ disease cannot be explained by genetic abnormalities alone.Trauma-Related GlaucomaA blow to the eye, chemical burn, or penetrating injury may lead to the development of glaucoma, either acute or chronic. This can be due to a physical change within the eye’s drainage system. It is therefore crucial for anyone who has suered eye trauma to have their eyes examined at regular intervals throughout their life, because glaucoma can develop much later than the time of the initial trauma.

18Steroid-Associated GlaucomaSeveral dierent drugs have the potential to cause elevated intraocular pressure. Steroid-induced glaucoma is a form of open-angle glaucoma usually associated with steroid use that is topical (eye drops and ointments), peri-ocular (injection into, near, or beyond the eyeball), or systemic (oral, inhaled, intravenous, injected).This type of glaucoma resembles POAG, but intraocular pressure elevations usually occur within a few weeks of beginning steroid therapy. In the majority of cases, the intraocular pressure lowers spontaneously within a few weeks to months after stopping the steroid use, but can also remain elevated even after stopping the steroid drug.The eects of steroids on IOP partially depends on whether the patient has glaucoma. Individuals with POAG are far more likely to have steroid-related elevations in IOP than individuals without glaucoma. In steroid-induced glaucoma, the intraocular pressure increase is usually short term. However, the longer the exposure, the greater the chance that the elevation will continue after stopping the steroid use. The bottom line: steroids should be used cautiously and patients should consult their ophthalmologists about their usage and have their eyes examined and IOP measured regularly.

19Childhood GlaucomaPrimary congenital glaucoma results from abnormal development of the ocular drainage system. It aects about 1 out of every 10,000 births in the United States. It is the most common form of glaucoma in infants and an important cause of childhood blindness. Ten percent of patients with primary congenital glaucoma are diagnosed at birth, and 80% are diagnosed during the rst year of life. The pediatrician or family rst notices eye signs of glaucoma, including clouding and/or enlargement of the cornea. The elevated IOP can cause the eyeball itself to enlarge and cause swelling of the cornea, which gives the eye a cloudy appearance. Important early symptoms of glaucoma in infants and children are poor vision, light sensitivity, tearing, and blinking.Secondary childhood glaucomas may result from disorders of the body or eye and may or may not be genetic. Examples include glaucoma related to trauma, congenital cataracts, Sturge-Weber syndrome, Axenfeld-Rieger Syndrome, and neurobromatosis. Pediatric glaucoma is treated dierently than adult glaucoma. Most patients require surgery, and this is typically performed early. Approximately 80-90% of babies who receive prompt surgical treatment and ongoing care will do well. When childhood glaucoma is not recognized and treated promptly, permanent visual loss will result.

20WHO IS AT RISK?Glaucoma aects people of all ages and all races. Everyone should get regular eye exams because early detection and treatment of glaucoma is the only way to prevent vision impairment and blindnessBut some people are at greater risk than others:n People with elevated intraocular pressuren People over the age of 40While glaucoma can develop in younger patients, it occurs more frequently as we get older.

21n People with thin central corneasn People who have suered a previous serious eye injuryn People who have a family history of glaucomaThose with a rst-degree relative with glaucoma have an up to nine times greater chance of being aected by glaucoma. However, just because someone in your family has glaucoma does not mean that you will necessarily develop the disease.n People of African American, Hispanic, or Asian American descentAfrican-Americans and Hispanics have a greater tendency for developing primary open-angle glaucoma than do people of other races. Asian-Americans are more prone to develop angle-closure glaucoma and normal-tension glaucoma.n People who used steroids for a prolonged period of timen People with myopia (nearsightedness) or hyperopia (farsightedness)Diabetes, and extremely high or low blood pressure are other potential risk factors.

22• If you are under the age of 40, you should have a comprehensive eye examination every three to four years.• If you are under 40, with one of the risk factors (pages 20-21), you should get tested every one to two years.• Everyone 40 years or older should have a comprehensive eye examination every one to two years.• If you are 40 and have an additional risk factor, get tested annually.WHEN TO GET TESTED

23DIAGNOSING GLAUCOMAYour eye doctor has a variety of diagnostic tools that aid in determining whether or not you have glaucoma – even before you have any symptoms. Here is a summary of these tools and what they do.The TonometerThe tonometer measures the pressure in your eye. Your doctor places a numbing eye drop in your eye. Then you sit at a slit-lamp, resting your chin and forehead on a support that keeps your head steady. The lamp, which lets your doctor see a magnied view of your eye, is moved forward until the tonometer, a plastic prism, barely touches the cornea to measure your intraocular pressure. The test is quick, easy, and painless. Rebound tonometry is a newer type of tonometry that does not require eye drops.OphthalmoscopyUsing an instrument called an ophthalmoscope, your eye doctor can look directly through the pupil at the optic nerve. Its color and appearance can indicate whether or not damage from glaucoma is present and how extensive it is. This technique remains an important tool in diagnosing and monitoring glaucoma.

24The PachymeterThe pachymeter measures central corneal thickness (CCT). Like the tonometer, your doctor will rst anesthetize your eyes with a numbing drop. Then, a small probe will be placed perpendicular to the central cornea. CCT is an important measure and helps your doctor interpret your intraocular pressure levels. Some people with thin central corneal thickness will have pressures that are actually higher than when measured by tonometry. Likewise, those with thick CCT will have a true intraocular pressure that is lower than that measured. Measuring your central corneal thickness is also important since recent studies have found that thin CCT is a strong predictor of developing glaucoma in patients with high intraocular.Optic Nerve Imaging TechnologySophisticated image analysis systems are available to evaluate the optic nerve, retinal nerve ber layer, and ganglion cell layer - the areas of the eye damaged by glaucoma. The Optical Coherence Tomography (OCT) is one such system that measures the reection of light o the retina, much like an ultrasound measures the reection of sound. The OCT directly measures the thickness of the nerve ber layer surrounding the optic nerve and in the macula. This sensitive test can diagnose nerve cell loss early on in glaucoma and also monitor the disease’s progression.

25Additionally, color fundus photographs of the optic nerve are useful because they allow for extended evaluation of the nerve, and document changes of its appearance over time. GonioscopyYour doctor will perform gonioscopy to closely examine the trabecular meshwork and the angle where uid drains out of the eye. After numbing the eye with anesthetic drops, the doctor places a special type of hand-held contact lens with internal mirrors on the eye. The mirrors enable the doctor to view the interior of the eye from dierent directions. In this procedure, the doctor can determine whether the angle is open or narrow. As explained earlier, individuals with narrow angles have an increased risk for a sudden closure of the angle, which can cause an acute glaucoma attack. Gonioscopy can also determine if anything, such as abnormal blood vessels or excessive pigment, might be blocking the drainage of the aqueous humor out of the eye. Visual eld testingVisual eld is an important measure of the amount of damage to your optic nerve from glaucoma. In glaucoma, it is the peripheral (side) vision that is most commonly aected rst, but some patients have central vision loss prior to peripheral visual eld involvement.

26Testing your visual eld lets your doctor know if vision is being lost. There are several methods of examination available to your doctor. Visual eld testing has advanced signicantly in recent years.In computerized visual eld testing, you are asked to place your chin on a stand in front of a computerized screen. Your eyes are to remain focused on a point straight ahead for the entire test. Whenever you see a ash of light appear, you press a buzzer. At the end of this test, your doctor will receive an analysis of your eld of vision. Another option is virtual reality visual eld testing. In this test, one wears virtual reality goggles to perform the visual eld. This form of testing can be done anywhere, even in your own home.Your doctor is able to analyze these tests to monitor whether your glaucoma is getting worse and causing more loss of your visual eld.

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28Glaucoma may be treated with eye drops, pills, laser surgery, traditional incisional surgery, minimally invasive surgical procedures, or a combination of these methods. The goal of any treatment is to prevent loss of vision, as vision loss from glaucoma is irreversible. The good news is that glaucoma can be managed if detected early, and that with medical and/or surgical treatment, most people with glaucoma will not lose their sight.To prevent vision-threatening damage, it is crucial to take your medications as prescribed, attend all recommended examinations in a timely fashion, and discuss any side eects with your doctor.TREATING GLAUCOMA

29EYE DROPSIt is important to take your medications regularly and exactly as prescribed in order to keep your eye pressure at a safe level for your vision. Since a small amount of your eye drops are absorbed into your bloodstream, you must tell your doctor about all other medications you are currently taking. Ask your doctor and/or pharmacist if the medications you are taking together are safe. Some drugs can be dangerous when mixed with other medications. To minimize absorption into the bloodstream and maximize the amount of medication absorbed in the eye, close your eye for one to two minutes after administering the drops and press your index nger lightly against the inner corner of your eyelid near your nose. This helps decrease the amount of medication that absorbs into your bloodstream. While many eye drops may cause an uncomfortable burning or stinging sensation at rst, the discomfort should only last for a few seconds.

30Prostaglandin AnalogsBimatoprost (Lumigan®)Latanoprost (Xalatan®)Travaprost (Travatan® & Travatan Z®)Tauprost (Zioptan™)Latanoprostene bunod (Vyzulta™)Latanoprost- Netarsudil xed combination (Rocklatan™)In this type of medication, IOP is lowered by opening up an alternative pathway by which uid ows out of the eye. This drug typically has the most eective IOP-lowering results of any eye drop and is convenient for patients, as it needs to be taken only once a day. In addition to containing latanoprost, Vyzulta, which was released in 2017, has a second component, a nitric oxide donator, which relaxes the trabecular meshwork to improve the ow of uid. Rocklatan (also discussed under combination drugs) was approved by the FDA in 2018. It contains latanoprost plus netarsudil. Netarsudil increases outow of aqueous humor through the trabecular meshwork.TYPES OF EYE DROPS

31Possible Side EectsWith long-term use, these medications may darken the color of the iris (for example, from green to brown), as well as the skin around the eyes. This class of drug may also cause the eye lashes to grow darker, longer and thicker. This type of medication may cause mild redness of the eyes. This drug is used with caution in patients with active inammation of the eye.Beta-BlockersBetaxolol (Betoptic®)(Betoptic® S)Carteolol (Ocupress®)Levobunalol (Betagan®)Timolol (Timoptic-XE®) (Istalol®) (Betimol®)This type of medication reduces production of uid (aqueous humor) within the eye.Possible Side EectsThis type of medication may worsen lung disease (e.g. asthma), cause diculty breathing, slow the pulse, and/or lower blood pressure. It may cause dizziness, fatigue, and/or diculty with strenuous exercise. Uncommon side eects include impotence, depression, hair loss, and/or decreased libido. You should advise your doctor if you have asthma, emphysema, chronic obstructive pulmonary disease (COPD), or other lung or heart diseases before starting this class of medicine.

32Alpha-2 Adrenergic AgonistsBrimonidine (Alphagan®) (Alphagan®P)This type of medication is a highly selective alpha-2 adrenoceptor agonist. It reduces intraocular uid (aqueous humor) production and increases drainage of intraocular uid.Apraclonidine (Iopidine®)This is a highly selective alpha-2 adrenoceptor agonist. It reduces aqueous humor production and increases drainage of intraocular uid.Possible Side EectsThis class of drug may produce allergic reactions and itching in the eyes.Brimonidine should be avoided in infants and young children since the drug may cause excessive drowsiness and lethargy in these patients.Advise your doctor if you are taking monoamine oxidase inhibitors or tricyclic antidepressants, as these medications may interact with your eye drops.TYPES OF EYE DROPS

33MioticsPilocarpine (Isopto®Carpine) (Pilocar®) Available in dierent concentrations, this helps open the eye’s drain and increase the rate of uid owing out of the eye. Possible Side EectsThis medication may cause pain around/inside the eye or brow ache for the rst few days of use. Symptoms of blurred vision and extreme nearsightedness are most common in younger patients. As miotics reduce the size of your pupil and prevent normal dilation, dim vision, especially at night or in dark rooms, may occur. Stuy nose, sweating, increased salivation, and occasional gastrointestinal problems may occur with stronger doses of miotics.Topical Carbonic Anhydrase InhibitorsBrinzolamide (Azopt®) Dorzolamide (Trusopt®)This class of medication decreases the production of uid inside your eye. Possible Side EectsThis medication can be associated with burning upon instillation.

34 TYPES OF EYE DROPSRho Kinase InhibitorsNetarsudil (Rhopressa®)Rhopressa reduces IOP specically by improving the ow of uid through the trabecular meshwork, the drain through which most of the uid inside the eye exits.Possible Side EectsThis medication causes eye redness in 70% of people who use it. It may sometimes burst blood vessels on the eye surface. The eye redness is not dangerous to the eye. This medication may also cause some material to deposit on the cornea (the front window of the eye), but these deposits do not seem to aect vision.Cholinesterase Inhibitor

35Echothiophate (Phospholine Iodide®)This medication reduces pressure in the eye by increasing the amount of uid that drains from the eye.Possible Side EectsEchothiophate can make your pupil very small. Some patients get headache and eye ache (similar to the side eects of miotics). It can also cause cataracts, and therefore is not used in patients unless they have had cataract surgery. For those who have had cataract surgery, it is an eective and useful drug.Fixed Combination Glaucoma DrugsBecause many patients need more than one type of medication to lower their eye pressure to a safe level, some companies have produced combination drops that include two dierent medicines in the same bottle.Brimonidine & Timolol (Combigan®)Possible Side EectsSide eects of Combigan® include the symptoms of alpha-agonists and beta-blockers (pages 31-32).

36TYPES OF EYE DROPSDorzolomide & Timolol (Cosopt®)Possible Side EectsSide eects of Cosopt® include the symptoms of topical carbonic anhydrase inhibitors and beta-blockers (pages 31 and 33).Brinzolamide/Brimonidine(Simbrinza® Suspension)Possible Side EectsSide eects of Simbrinza include symptoms of topical carbonic anhydrase inhibitors and alpha-agonists (pages 32 and 33).Netarsudil & Latanoprost (Rocklatan)Possible Side EectsSide eects of Rocklatan include symptoms of topical prostaglandin analoges and rho-kinase inhibitors (pages 30 and 34).

37Preservative-Free DropsMany drops contain preservatives that may be irritating to the surface of the eye and cause an allergic reaction in some patients. Because preservatives have been linked to damage to the eye surface, some companies have produced preservative-free drops to help patients who experience eye irritation from preservatives. The following eye drops are preservative-free versions of some of the eye drops listed above:Cosopt®PF (dorzolamide-timolol ophthalmic solution 2%/0.5%)Zioptan™ (tauprost ophthalmic solution 0.0015%)Timoptic® in Ocudose (timolol maleate ophthalmic solution 0.25% and 0.5%)Iyuzeh™ (latanaprost ophthalmic solution 0.005%)

38PILLSWhen eye drops don’t suciently control IOP, you may also be prescribed pills to reduce uid in the eye. These medicines have more systemic side eects than drops. It is important to discuss your medications with all of your doctors so that they can prescribe against potentially dangerous interactions. These pills, which have more side eects than drops, lower the production of uid inside the eye, similar to turning down a faucet. These medications are usually taken between one to four times daily. If you are prescribed a pill for your eye pressure, it is important to share this information with all your other doctors in order to prevent interactions with your other medications. The following are some commonly prescribed pills for lowering eye pressure and their more common side eects.Oral Carbonic Anhydrase InhibitorsAcetazolamide (Diamox®)Methazolamide (Neptazane®)These should be taken with meals or milk and bananas

39or apple juice should be added to the diet to minimize potassium loss.Possible Side EectsFrequent urination, tingling sensation in ngers and toes, rashes, and/or kidney stones may occur. Potassium loss when taken with digitalis, steroids, or cholorothiazide diuretics. Depression, fatigue, and lethargy are common. Gastrointestinal upset, metallic taste to carbonated beverages, impotence, and weight loss are other potential side eects. A rare but serious side eect is aplastic anemia. IN-OFFICE LASER PROCEDURESLaser procedures in glaucoma are recommended in the following settings: Open-angle glaucoma: When medication does not achieve the desired eye pressure or has intolerable side eects, your doctor may suggest a laser procedure.Narrow-angle/angle-closure glaucoma: When your doctor nds that the angle of the eye is narrow and there is some risk of developing scarring in the angle, elevation in IOP, or glaucoma.

40Selective Laser Trabeculoplasty (SLT) — for open-angle glaucomaSelective laser trabeculoplasty (SLT) is most common type of laser procedure performed for open-angle glaucoma. SLT uses very low levels of energy and is termed “selective” since it leaves portions of the trabecular meshwork intact. For this reason, it is believed that SLT, unlike other types of laser surgery, may be safely repeated. An older form of trabeculoplasty is argon laser trabeculoplasty (ALT).SLT has become increasingly popular as another option besides medications and traditional incisional surgery, although the long-term success rates are variable. It can be performed as the rst glaucoma treatment you receive, or if drops are not working well enough to lower the eye pressure. This procedure takes 5 minutes, is painless, and can be performed in either a doctor’s oce or an outpatient facility. The laser light beam is focused upon the eye’s drain, the trabecular meshwork.Contrary to what many people think, the laser does not burn a hole through the eye. Instead, the eye’s outow system is changed in very subtle ways so that aqueous uid is able to pass more easily out of the trabecular meshwork (drainage system of the eye), thus lowering IOP.IN-OFFICE LASER SURGERIES

41You may go home and resume your normal activities following this laser procedure. Your doctor will check your IOP 30 to 60 minutes following laser surgery. After this procedure, many patients respond well enough to be able to avoid or delay surgery, or use fewer medications. While it may take a few weeks to see the full pressure-lowering eect of this procedure, during which time you may have to continue taking your medication, some patients are eventually able to discontinue some of their medications. This, however, is not true in all cases. Your doctor is the best judge in determining whether or not you will still need medication. Risk of complications from this type of laser is minimal, which is why the procedure has become increasingly popular.Laser Peripheral Iridotomy (LPI)— for angle-closure glaucomaThis procedure is used to make a small opening through the iris, allowing aqueous uid to ow from behind the iris directly to the anterior chamber of the eye, which is the space between the cornea and the iris. This allows the uid to bypass its normal route. LPI is the preferred method for managing a wide variety of angle-closure glaucomas that have some degree of pupillary blockage. It is most often used to treat an anatomically narrow angle and prevent angle-closure glaucoma attacks.

42Cycloablation — for open-angle and angle-closure glaucomasTwo laser procedures involve reducing eye pressure by using laser energy to destroy part of the ciliary body, which produces the uid inside your eye. The eye pressure is lowered by decreasing the amount of aqueous humor inside the eye. These treatments are usually reserved for use in eyes that either have elevated IOP after having failed other more traditional treatments, including ltering surgery, or those in which ltering surgery is not possible or advisable due to the shape or other features of the eye. This procedure is eective for both open-angle and angle-closure glaucomas.Transscleral cyclophotocoagulation uses a laser to direct energy through the outer layer of the eye to reach and destroy portions of the ciliary processes inside the eye, without causing damage to the overlying tissues. With endoscopic cyclophotocoagulation (ECP), the instrument is placed inside the eye through a surgical incision, so that the laser energy is applied directly to the ciliary body tissue.IN-OFFICE LASER SURGERIES

43TRADITIONAL INCISIONAL SURGERIESTrabeculectomyIn cases when medications and laser therapies do not adequately lower eye pressure, doctors may recommend conventional surgery. The most common of these operations is called a trabeculectomy, which is used in both open-angle and closed-angle glaucomas. In this procedure, the surgeon creates a passage in the sclera (the white part of the eye) for draining excess eye uid. A ap is created that allows uid to escape but which does not deate the eyeball. A small bubble of uid called a “bleb” often forms over the opening on the surface of the eye, which is a sign that uid is draining out into the space between the sclera and conjunctiva. Occasionally, the surgically created drainage hole begins to close and the IOP rises again. This happens because the body tries to heal the new opening, as if it was an injury.Many surgeons perform trabeculectomy with an anti- brotic agent that is placed on the eye during surgery and reduces scarring during the healing period. The most common anti-brotic agent is Mitomycin-C. Another is 5-Fluorouracil, or 5-FU.About 50 percent of patients no longer require glaucoma medications after surgery for a signicant length of time. Thirty-ve to 40 percent of those who

44still need medication have better control of their IOP. Occasionally, the surgically-created drainage trapdoor begins to close and the intraocular rises again. This happens because the body tries to heal the new opening, as if it was an injury. A trabeculectomy is usually an outpatient procedure. The number of post-operative visits to the doctor varies, and some activities, such as driving, reading, bending and heavy lifting must be limited for two to four weeks after surgery.Drainage Implant SurgerySeveral dierent devices, sometimes called aqueous shunts (e.g. Baerveldt and Ahmed shunts), have been developed to aid the drainage of aqueous humor out of the anterior chamber and to lower IOP. All of these drainage devices share a similar design which consists of a small silicone tube that extends into the anterior chamber of the eye. The tube is connected to one or more plates, which are sutured to the surface of the eye, usually not visible. Fluid is collected on the plate and then absorbed by the tissues in the eye. This type of surgery is thought to lower IOP less than trabeculectomy but is preferred in patients whose IOP cannot be controlled with traditional surgery or who have previous scarring. TRADITIONAL INCISIONAL SURGERIES

The Express mini glaucoma shunt is a stainless steel device that is inserted into the anterior chamber of the eye and placed under a scleral ap. It lowers IOP by diverting aqueous humor from the anterior chamber.Minimally Invasive Glaucoma Surgery (MIGS) is the new frontier of glaucoma management and includes a variety of procedures. These are appropriate for some individuals with glaucoma. The goal of MIGS is to oer innovative therapeutic options that are eective at lowering IOP, possess a good safety prole, and are well-tolerated by patients. Each MIGS procedure involves bypassing or optimizing a naturally existing drainage channel in the eye or creating a new drain for the eye, thus reducing eye pressure. Today there are numerous FDA-approved MIGS procedures. Those that target the trabecular meshwork, the conventional path of aqueous humor outow, are microstent devices, goniotomy, gonioscopy-assisted transluminal trabeculotomy (GATT), and ab-interno canaloplasty. Others, including the Xen Gel Stent, are bleb-forming procedures.45MINIMALLY INVASIVE SURGICAL ALTERNATIVES

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49Trabecular Bypass MicroStent Surgery For people with glaucoma considering cataract surgery, a trabecular bypass microstent (such as the iStent or Hydrus) procedure may help control eye pressure. The iStent device is made of two or three tiny tubes and the Hydrus is made of one longer curved tube. These devices are passed through the incisions made for cataract surgery and are placed into the natural drain of the eye (trabecular meshwork). This creates a path for uid inside the eye to bypass blockages in the drainage channels and lower eye pressure. These procedures add about 15 minutes to the surgery but do not extend the expected postoperative recovery and are considered a low-risk addition to cataract surgery. Clinical trials have shown that glaucoma medications or additional surgical procedures may be needed over time in some people after trabecular bypass stent surgery. This is dependent on individual needs for target eye pressure, scarring following surgery, the type of glaucoma, and more.MINIMALLY INVASIVE SURGICAL ALTERNATIVES47

48Goniotomy, Gonioscopy Assisted Transluminal Trabeculotomy (GATT), and Canaloplasty When eye drops or lasers are unable to lower eye pressure, other methods such as goniotomy, gonioscopy-assisted transluminal trabeculotomy (GATT), and canaloplasty oer promising alternatives to bleb-forming glaucoma surgeries or tube shunts. Goniotomy involves the creation of an opening into the eye’s natural drainage system (trabecular meshwork) to improve uid outow and lower eye pressure. In the GATT procedure, a similar goniotomy incision is made. A hair-thin catheter is inserted into the Schlemm’s canal through this, threaded (cannulated) fully around, and used to make a 180° or 360° opening in the trabecular meshwork. This opens the eye’s natural drain system and increases uid outow. The canaloplasty also involves 360° cannulation of the Schlemm’s canal, but no tissue removal. Instead, the drainage channels are cleaned and widened with an injected gel material. Sometimes, GATT and canalooplasty procedures are performed during the same surgery.The goniotomy, GATT, and canaloplasty typically take around 15 minutes. They are all considered MINIMALLY INVASIVE SURGICAL ALTERNATIVES

49low-risk procedures and may reduce the need for glaucoma medications after surgery. After GATT, some patients may have small amounts of blood in the eye, which usually resolves within two weeks.Xen Gel Stent ImplantationXen Gel Stent implantation may be recommended to manage glaucoma in some patients when medications and lasers are ineective. The Xen is a small tube (about the length of an eyelash) designed to stay in the eye permanently. It creates a small channel in the eye to drain uid that is then reabsorbed by the tissues surrounding the eye. This escaping uid raises the conjunctiva (clear membrane covering the white part of the eye) creating a “ltering bleb,” which is rarely seen or felt.The Xen is less invasive compared to traditional glaucoma surgery (trabeculectomy and shunt), but may not provide the same benecial pressure-lowering eect as traditional surgery. Some patients may have an exaggerated healing process and scar formation which may block the Xen stent. In case of early failure, breaking the scar around the Xen and injection of anti-scarring medication around the implant may be required. If Xen fails and eye pressure is elevated, the traditional glaucoma surgery (trabeculectomy or tube) can be performed.

50GlossaryAnterior chamberSpace in the front portion of the eye between the cornea and the iris. It is lled with a clear uid called aqueous humor.Aqueous humorLiquid produced by a structure inside the eye called the ciliary body that nourishes the cornea and the lens and provides necessary eye pressure (dierent from tears that are produced outside the eye).ConjunctivaClear-colored outer skin of the eye that contains some blood vessels (covers the white sclera).CorneaThe outer, clear dome-like front window of the eye that covers the colored iris and pupil. Light rays enter the eye through the cornea.GlaucomaA number of dierent eye diseases, many of which are characterized by elevated intraocular pressure and all of which result in damage to the optic nerve. Can lead to blindness if left untreated.

51GonioscopyExam that is used to closely examine the angle where uid drains out of the eye. Exam that is used to detect which type of glaucoma a person may have.Intraocular pressure (IOP)The pressure within the eye. High intraocular pressure is an important risk factor for glaucoma.IrisPigmented (colored) portion of the eye that regulates the amount of light entering the eye by adjusting the size of the pupil.LensThe part of the eye immediately behind the iris that performs focusing of light rays upon the retina (back of the eye).OphthalmoscopeMedical device used to view the inside of the eye, including the optic nerve.Optic nerveBundle of nerve bers that take information from the retina and deliver it to the brain, where the information is interpreted as a visual image.

52Glossary PachymeterMedical device that measures central corneal thickness (CCT).Posterior chamberThe space in the eye behind the iris and in front of the lens. Fluid produced from the ciliary body enters the posterior chamber rst, then ows forward through the pupil into the anterior chamber of the eye, and then drains in the angle.PupilDark opening in the center of the colored iris that controls how much light enters the eye.RetinaThe layer of the eye that lines the back of the eye. Contains the nerve cells that capture and transmit visual images through the optic nerve to the brain.ScleraThe white outer surface of the eye.Slit-lamp examMicroscope with a high-intensity light that is used to examine the inside and outside of the eye.

53TonometryA standard eye test that determines the uid pressure inside the eye.Trabecular meshworkSpongy, mesh-like drainage structure located inside the angle between the cornea and iris. The drain through which the aqueous uid leaves the eye. Proper drainage helps keep eye pressure at an acceptable level. Failure of this system leads to a rise in intraocular pressure, as in certain types of glaucoma.TrabeculectomyFiltering surgery that increases the outow of aqueous humor through a trapdoor passage in the sclera, lowering IOP.Visual eldThe entire area you can see while looking at a xed point. With glaucoma, the visual eld often shrinks, usually beginning with the peripheral (side) vision.

54FUNDING CUTTING-EDGE RESEARCH & EDUCATING THE PUBLICThe mission of The Glaucoma Foundation (TGF) is to fund groundbreaking research and to educate the public about glaucoma and the importance of early detection to prevent blindness.Founded in 1984 by Dr. Robert Ritch, TGF is one of the premier not-for-prot organizations dedicated to improving the lives of people with glaucoma.The Foundation’s Grant-in-Aid Program has awarded millions of dollars in seed money for cutting-edge research projects. Preliminary data from these projects have frequently been used to support proposals for larger grants from entities such as the National Institutes of Health and National Eye Institute.

55Since 1994, TGF’s interdisciplinary International Scientic Think Tank has brought together some of the world’s top scientists and clinicians to work on the problem of glaucoma and set the course for future research. TGF serves patients across the globe through glaucomafoundation.org and APUP, an on-line support group. Our newsletters and webinars keep patients and their families informed about research, treatment, and living with glaucoma. Our biennial medical education seminars for optometrists and ophthalmologists address diagnostics, treatments, advances in research, and unmet needs of patients.SUPPORT TGFTGF relies on the public’s generous support to carry out these initiatives. The Glaucoma Foundation is a 501 (c)(3) organization and contributions to it are tax-deductible.To donate online: www.glaucomafoundation.orgTo donate by phone, please call 212-651-2501To donate by mail, please send a check payable to The Glaucoma Foundation80 Maiden Lane, Suite 700 New York, NY 10038

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59WE CANNOT STRESS IT ENOUGH.Regular eye exams are vital to protect the health of your eyes! If your ophthalmologist or optometrist detects glaucoma, early treatment and close monitoring can help prevent the loss of your vision.Talk to your doctor, and don’t be afraid to ask questions. Together, you can tailor a treatment regimen that suits your needs and that works with your lifestyle.

60TM80 Maiden Lane, Suite 700New York, NY 10038www.glaucomafoundation.orginfo@glaucomafoundation.org212 285 0080