Treatment options for glaucoma

The following medications are used in the form of eye drops:

• Beta blockers: increase the drainage of aqueous humor out of the eye and are often prescribed as first-line treatment.
• Prostaglandins: increase the drainage of aqueous humor out of the eye and, like beta blockers, are often prescribed as first-line treatment.
• Alpha-adrenergic agonists: lower the production of aqueous humor and at the same time increase its drainage.
• Carbonic anhydrase inhibitors: lower the production of aqueous humor.
• Cholinergic drugs: increase the drainage of aqueous humor.
• Rho kinase inhibitors: are supposed to lower intraocular pressure.

The most suitable medication will vary from person to person, depending on a number of factors – including age, amount of optic nerve damage, intraocular pressure and possible side effects.

If intraocular pressure can't be lowered enough by using a certain medication or there are side effects, it's possible to switch to another medication. Different medications can also be combined.

Eye drops can have a number of different side effects. All of them can irritate the eyes and, for instance, make them itch and go red. Some, such as the beta blockers, can affect your cardiovascular (heart and circulation) system and your breathing.

To reduce the likelihood of side effects, people are advised to close their eyes for three minutes after using the eye drops. You can also gently apply pressure to the inside corner of the eye with your fingers. Both of these things are done to make sure that the eye drops stay in the eye, and don't flow down into your nose and throat where they can be absorbed into the body through mucous membranes.

It is important to talk to a doctor if side effects occur and don't go away. But it's important to continue using the eye drops until your next doctor's appointment, if possible, rather than deciding to stop using them yourself.

It can be difficult to use eye drops one or several times a day for many years. And having to find a quiet spot to use the eye drops at work or while out and about is sometimes an inconvenience. Some people regularly forget to use them, or have the feeling that they aren't really working anyway, so they don't use them properly. And the fact that there's no immediate effect if you skip them once doesn't help. The benefits of using eye drops aren’t noticeable right away, and only become clear much later. But knowing that the medication will help to keep your eyesight over the long term can help motivate you.

Regular check-ups at the eye doctor's can help you stay on track with your treatment too. It is sometimes possible to change the treatment plan so you only need to use the drops once a day, for example, instead of three times a day. Using the eye drops at set times is also helpful (e.g. before breakfast, at dinner or before going to bed). Reminders – like sticking notes on your bathroom mirror or using an app – can also help.

Some people mainly have problems when they first start using the eye drops. If you've never used eye drops before, it's not always that easy to do. Older people also often have trouble using eye drops on their own. If you're not sure how to use them properly, you can always ask your doctor what exactly you need to do. Friends, family and support groups can help too. Support groups may offer practical courses on how to apply eye drops.

Glaucoma can also be treated with surgery or a laser procedure. These treatments are mainly only considered if medicine alone doesn't keep the intraocular pressure under control, or if the eye drops aren't well tolerated.

Glaucoma surgery is done to lower intraocular pressure permanently. The most common type of surgical treatment for glaucoma is called trabeculectomy. It involves cutting out a bit of the sclera (the white outer layer of the eye) and the iris in order to allow aqueous humor to flow out of the eye more easily, thereby lowering the pressure inside the eye. Possible adverse effects of this type of surgery include vision problems immediately after surgery, scarring and – over the long term – cataracts.

Intraocular pressure can also be lowered using a laser procedure, although this isn't usually as effective as surgery. Most laser procedures aim to improve the drainage of aqueous humor fluid from the eye. There are also laser procedures that reduce the production of this fluid. Laser treatment can be used in addition to eye drops as well. It can lead to short-term redness and dryness of the eye, as well as blurred vision.

Minimally invasive glaucoma surgery has increasingly been offered in recent years. It involves placing small implants (stents) in the trabecular meshwork. The stents help to drain fluid out of the eye, thereby reducing the pressure in the eye. This procedure is considered for the treatment of mild or moderate glaucoma. In Germany, statutory health insurers usually don't cover the costs of this minimally invasive procedure if it's done in an outpatient setting. There has not been any good-quality research on the advantages and disadvantages of various minimally invasive procedures compared to surgery or laser treatment.

Acupuncture is sometimes used in addition to other treatments for glaucoma, but it has not been tested in good-quality studies. The acupuncture needles aren't inserted directly into the eye, but into the skin between the eyebrows or at other points on the body. Dietary supplements are sometimes recommended too, but they haven't been proven to help either.

Medication can be used to try to prevent glaucoma if the intraocular pressure is high but the optic nerve and field of vision haven't yet been affected. Studies show that people who have high intraocular pressure but haven't yet developed glaucoma are less likely to develop problems with their field of vision if they use eye drops:

• After about five years, vision was found to be worse in 12 out of 100 people who used eye drops,
• compared to 17 out of 100 people who didn't use any eye drops or used a fake treatment (placebo).

Whether it makes sense to use preventive treatment also depends on the possible risk factors. You are a lot more likely to benefit from preventive treatment if your intraocular pressure is very high and you have close relatives with glaucoma.

It's important to treat glaucoma with medication in order to keep the intraocular pressure down and minimize loss of sight as much as possible. These medications are also used by people who have glaucoma without having high intraocular pressure.

One study looked at how newly diagnosed glaucoma develops with and without treatment. To do this, volunteers were randomly assigned to one of two groups. One group had laser treatment on their eye and used beta-blocker eye drops. The other group didn't have any treatment. After two years:

• Without treatment: The glaucoma got worse in 49 out of 100 people.
• With treatment: The glaucoma got worse in 30 out of 100 people.

Sometimes surgery can also help to lower intraocular pressure.