LASERS - Questions and Answers with Drs. Bindlish, Kherani, and You

My optometrist has detected narrow angles in my eyes and wants me to have laser surgery to prevent glaucoma. Is this necessary?

Narrow angles may lead to angle closure glaucoma and laser surgery may lower the risk of developing angle closure.

To assess whether the angles are open or closed and determine if laser surgery is required, an ophthalmologist will perform a comprehensive eye exam. Laser surgery is a relatively safe procedure with small risk for bleeding, inflammation, eye pressure spike or glare.

I have been diagnosed with narrow angles. My eye doctor recommended an iridotomy. I understand that the location of the iridotomy is linked to a side effect of ghosting or streak of light. What is the best location for an iridotomy?

Glare or a horizontal grey line is an uncommon side effect of YAG laser iridotomy. Based on current research, it appears that a lower percentage of individuals experience linear dysphotopsia with a temporal iridotomy compared to a superior iridotomy.

I was successfully treated for an eye infection and inflammation. My doctor is recommending that I undergo a laser treatment to prevent glaucoma. Since glaucoma is not present and I have no cataracts, is it wise to undergo this treatment?

It sounds as if you have been diagnosed with primary angle closure (PAC) which means the internal drain of your eye is narrowed. This condition is usually picked up during a routine eye exam for glasses or in situations like yours where you have another eye condition that resulted in a thorough eye exam.

In PAC, as you age the drain becomes progressively more narrow and may either suddenly block off resulting in very high eye pressure associated with eye pain, headache, blurred vision and nausea, or slowly close resulting in glaucoma damage to the optic nerve and visual field.

If your doctor feels the drain of your eye is sufficiently narrowed that you are at risk for PAC, you should consider a YAG laser iridotomy.

Since undergoing a laser iridotomy, I’m seeing double when looking at lights. My doctor recommended a corneal tattoo. Is this a normal procedure?

A ghosting or streak of light occurs when light strikes your tear meniscus at the eyelid margin, then goes through the small laser opening. The location of the iridotomy is linked to this side effect. If the disturbance persists, it can be treated by shrinking/closing the iridotomy with sutures or a corneal tattoo so less light can penetrate the small opening.

I am 85 years old in good health except for hypertension which is under control. An optometrist tested my eyes and told me I needed an iridotomy for narrow-angle glaucoma. I went for a second opinion and that optometrist could not see why I would need an iridotomy. An ophthalmologist did many tests including a gonioscopy and said that on a scale of 4 to 1, I was 2 in one eye and 1.5 in the other and that I should have surgery. What should I do?

Gonioscopy is performed during an eye exam to evaluate the internal drainage system of the eye and diagnose narrow-angle glaucoma. We usually recommend treatment for narrow angles when the drain of the eye (trabecular meshwork) is not visible. There is a risk of angle closure glaucoma without treatment. Treatment for narrow angles is a YAG laser iridotomy that makes a small opening in the iris.

Recently, cataract surgery (removal of the natural lens) has been shown to improve narrow angles and the cause for the narrowing is the large lens (cataract) crowding the inside of the eye. If you have minimal cataract or minimal visual issues then laser may be a more conservative approach. In your case, I would ask the optometrist or ophthalmologist to refer you to a glaucoma specialist to confirm if you have a significantly narrow-angle.

At my last six month examination, the pressure in both my eyes had increased – left eye 20, right eye 24. I was given the option of an additional drop for my right eye and laser for the left, or laser for both. I have opted to have laser treatment for both. Have I made the right decision? What could cause the sudden increase in pressure in both eyes?

It is difficult to comment on glaucoma management for specific cases. Generally, laser is a good option. It may improve your eye pressure and remove the burden of using extra eye drops.

The pressure elevation could be related to poor compliance with glaucoma meds or else just worsening glaucoma. It may also be the underlying mechanism of the glaucoma including Pseudoexfoliation.

I have both types of glaucoma, one in each eye. My doctor has told me I will probably have to get laser eye surgery in a couple of years. I’m a synchronized swimmer. I was wondering what the recovery would be like. Will I be able to swim? Will I have to wear an eye patch? When will I be able to get back to school?

Selective laser trabeculoplasty (SLT) is applied to the trabecular meshwork (the drainage system of the eye) to improve its function and lower eye pressure in open-angle glaucoma. Laser peripheral iridotomy makes a small hole in the iris to open access to the drainage area in patients at risk of or who have narrow/closed angle glaucoma.

I don’t foresee any issues with school or swimming as both types of laser surgery are done on an out-patient basis with no prep and quick recovery. The eye is not bandaged and there is minimal downtime.

My doctor recommends Selective Laser Trabeculoplasty (SLT) for my narrow-angle glaucoma. I read that this treatment is usually used for patients with open-angle glaucoma. Has it proved effective in treating narrow-angle glaucoma?

If the angle is narrowed, you might need a YAG laser iridotomy prior to SLT to open the angle. Once open, SLT can be used to “clean” the internal trabecular meshwork (TM) of the eye to lower eye pressure. It can be done in any type of glaucoma as long as the angle is open wide enough for angle laser surgery to be performed.

My doctor has recommended laser treatment for glaucoma, how well does it work?

Because it can be difficult for patients to use multiple eye drop medications and because of less damaging side effects with current laser treatment, we are using laser treatment earlier.

Selective Laser Trabeculoplasty (SLT) has a pressure lowering effect of about 20% – comparable to adding another medication. Laser however, is not a “cure” for glaucoma – it doesn’t always work, its effect may not last, and your ophthalmologist must still continue to monitor your eye pressure.

How is the success of ALT and SLT measured?

Studies show that both ALT (Argon Laser Trabeculoplasty) and SLT (Selective Laser Trabeculoplasty) are similarly effective. We have been doing both lasers for decades. ALT is a more universal laser. SLT is a stand-alone laser without any other applications.

Both require applying laser treatment to the internal drain of the eye. The way they work is different. ALT makes a burn mark with shrinkage, opening up the area in between the burn marks to create more drainage. SLT incites inflammation in the drain, recruiting cells to help clean up debris in the drain, so it works better.

Once 360 degrees of the drain is treated with ALT – essentially two treatments – no more can be done. SLT is non-destructive, can be repeated, and is less likely to cause inflammation.

Do you give sedation when performing a laser treatment?

Generally, we don’t give a sedative for a laser procedure. We need the patient to be co-operative and not move. With a sedative, you may become drowsy and your head may fall back from the laser causing injury. Talk it over with your surgeon.

My father has glaucoma and can’t drive. Could laser surgery help his vision?

A certain amount of peripheral (side) vision is needed in order to drive. This may be specific to the jurisdiction you reside in.

Advanced glaucoma causes a restricted visual field. Other eye conditions that may make driving difficult include cataracts, macular degeneration or stroke.

Treatments for glaucoma include eye drops, laser and surgery. Although controlling eye pressure can slow the worsening of glaucoma, there is no cure nor any means of bringing back lost vision.

I have had glaucoma for 15 years and controlling it with drops. Is laser surgery safe or I should keep using drops?

If eye drops are working well to control your eye pressure, I would not recommend surgery at this point.

If your ophthalmologist is concerned about your eye pressure or you are having side effects from your present medications, then surgery may be an alternative treatment. Its effectiveness is the same as adding another eye drop, but it doesn’t always work or its effect may not last.