Editing Glaucoma (section)

==Treatment==
The goal of glaucoma management for patients with increased intraocular pressure is to decrease the intraocular pressure (IOP), thus slowing the progression of glaucoma and preserving the quality of life for patients, with minimal side-effects.<ref name=Necker2006>{{cite journal | vauthors = Noecker RJ | title = The management of glaucoma and intraocular hypertension: current approaches and recent advances | journal = Therapeutics and Clinical Risk Management | volume = 2 | issue = 2 | pages = 193–206 | date = June 2006 | pmid = 18360593 | pmc = 1661659 | doi = 10.2147/tcrm.2006.2.2.193 | doi-access = free }}</ref><ref name=Parikh2007>{{cite journal | vauthors = Parikh RS, Parikh SR, Navin S, Arun E, Thomas R | title = Practical approach to medical management of glaucoma | journal = Indian Journal of Ophthalmology | volume = 56 | issue = 3 | pages = 223–230 | date = 1 May 2008 | pmid = 18417824 | pmc = 2636120 | doi = 10.4103/0301-4738.40362 | doi-access = free }}</ref><ref name=":4"/> This requires appropriate diagnostic techniques and follow-up examinations, and judicious selection of treatments for the individual patient. Although increased IOP is only one of the major risk factors for glaucoma, lowering it via various pharmaceuticals and/or surgical techniques is currently the mainstay of glaucoma treatment. 

Vascular flow and neurodegenerative theories of glaucomatous optic neuropathy have prompted studies on various neuroprotective therapeutic strategies, including nutritional compounds, some of which may be regarded by clinicians as safe for use now, while others are on trial.<ref name="DOI10.1016/B978-0-323-88442-6.00039-X">Yu Jun Wo, Ching‐Yu Cheng, Rachel S. Chong: ''Vascular health and glaucoma.'' In: Kevin Gillmann, Kaweh Mansouri (Eds.): ''The Science of Glaucoma Management. From Translational Research to Next-Generation Clinical Practice'', Elsevier 2023, ISBN 978-0-323-88443-3, p.&nbsp;63–79, {{doi|10.1016/B978-0-323-88442-6.00039-X}}, [https://books.google.com/books?id=Sn-HEAAAQBAJ&dq=glaucoma+%22vascular+health%22&pg=PA74 preview Google Books].</ref><ref name="pmid34575340">{{cite journal| author=Konieczka K, Flammer J| title=Treatment of Glaucoma Patients with Flammer Syndrome. | journal=J Clin Med | year= 2021 | volume= 10 | issue= 18 | page=4227 | pmid=34575340 | doi=10.3390/jcm10184227 | doi-access=free | pmc=8467118 }} </ref><ref name="pmid32282348">{{cite journal |author1=Labkovich M |author2=Jacobs EB |author3=Bhargava S |author4=Pasquale LR |author5=Ritch R | title=Ginkgo Biloba Extract in Ophthalmic and Systemic Disease, With a Focus on Normal-Tension Glaucoma. | journal=Asia Pac J Ophthalmol (Phila) | year= 2020 | volume= 9 | issue= 3 | pages= 215–225 | pmid=32282348 | doi=10.1097/APO.0000000000000279 | pmc=7299225 }} </ref> Mental stress is also considered as consequence and cause of vision loss which means that stress management training, [[autogenic training]] and other techniques to cope with stress can be helpful.<ref>{{cite journal | vauthors = Sabel BA, Wang J, Cárdenas-Morales L, Faiq M, Heim C | title = Mental stress as consequence and cause of vision loss: the dawn of psychosomatic ophthalmology for preventive and personalized medicine | journal = The EPMA Journal | volume = 9 | issue = 2 | pages = 133–160 | date = June 2018 | pmid = 29896314 | pmc = 5972137 | doi = 10.1007/s13167-018-0136-8 }}</ref><ref name="pmid26449918">{{cite journal| author=Bertelmann T, Strempel I| title=[Self-relaxation techniques for glaucoma patients. Significance of autogenic training, hypnosis and music therapy]. | journal=Ophthalmologe | year= 2016 | volume= 113 | issue= 2 | pages= 102–10 | pmid=26449918 | doi=10.1007/s00347-015-0139-y | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26449918  }} </ref>

===Medication===
{{Main|Glaucoma medication}}
There are several pressure-lowering medication groups that could be used in lowering the IOP, usually eyedrops. The choice of medication usually depends on the dose, duration and the side effects of each medication. However, in general, [[prostaglandin analogue]]s are the first-line treatment for glaucoma.<ref name=":4">{{Cite journal |last1=Weinreb |first1=Robert N. |last2=Aung |first2=Tin |last3=Medeiros |first3=Felipe A. |date=2014-05-14 |title=The Pathophysiology and Treatment of Glaucoma: A Review |journal=JAMA |language=en |volume=311 |issue=18 |pages=1901–1911 |doi=10.1001/jama.2014.3192 |pmid=24825645 |pmc=4523637 |issn=0098-7484}}</ref><ref name=":3">{{Cite journal |last1=Schuster |first1=Alexander K. |last2=Erb |first2=Carl |last3=Hoffmann |first3=Esther M. |last4=Dietlein |first4=Thomas |last5=Pfeiffer |first5=Norbert |date=2020-03-27 |title=The Diagnosis and Treatment of Glaucoma |journal=Deutsches Ärzteblatt International |volume=117 |issue=13 |pages=225–234 |doi=10.3238/arztebl.2020.0225 |pmid=32343668 |pmc=7196841 |issn=1866-0452}}</ref>

Prostaglandin analogues, such as [[latanoprost]], [[bimatoprost]] and [[travoprost]], reduce the IOP by increasing the aqueous fluid outflow through the draining angle. It is usually prescribed once daily at night. The systemic side effects of this class are minimal. However, they can cause local side effects including redness of the conjunctiva, change in the iris color and eyelash elongation.<ref name=":4" /><ref name=":3" />

There are several other classes of medications that could be used as a second-line in case of treatment failure or presence of contraindications to prostaglandin analogues.<ref>{{Cite journal |last1=Wagner |first1=Isabella V. |last2=Stewart |first2=Michael W. |last3=Dorairaj |first3=Syril K. |date=December 2022 |title=Updates on the Diagnosis and Management of Glaucoma |journal=Mayo Clinic Proceedings: Innovations, Quality & Outcomes |language=en |volume=6 |issue=6 |pages=618–635 |doi=10.1016/j.mayocpiqo.2022.09.007|pmid=36405987 |pmc=9673042 }}</ref><ref name=":3" /> These include:

* Topical [[beta-adrenergic receptor antagonists]], such as [[timolol]], [[levobunolol]], and [[betaxolol]], decrease aqueous humor production by the epithelium of the [[ciliary body]].
* [[Alpha2-adrenergic agonist]]s, such as [[brimonidine]] and [[apraclonidine]], work by a dual mechanism, decreasing aqueous humor production and increasing uveoscleral outflow.
* Less-selective [[Alpha-adrenergic agonist|alpha agonists]], such as [[epinephrine]], decrease aqueous humor production through vasoconstriction of ciliary body blood vessels, useful only in open-angle glaucoma. Epinephrine's mydriatic effect, however, renders it unsuitable for closed-angle glaucoma due to further narrowing of the uveoscleral outflow (i.e. further closure of trabecular meshwork, which is responsible for absorption of aqueous humor).
* [[Miosis|Miotic agents]] ([[parasympathomimetic]]s), such as [[pilocarpine]], work by contraction of the [[ciliary muscle]], opening the [[trabecular meshwork]] and allowing increased outflow of the aqueous humour. [[Echothiophate]], an acetylcholinesterase inhibitor, is used in chronic glaucoma.
* [[Carbonic anhydrase inhibitors]], such as [[dorzolamide]], [[brinzolamide]], and [[acetazolamide]], lower secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body.

Each of these medicines may have local and systemic side effects. Wiping the eye with an absorbent pad after the administration of eye drops may result in fewer adverse effects.<ref name="Xu">{{cite journal | vauthors = Xu L, Wang X, Wu M | title = Topical medication instillation techniques for glaucoma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 2 | pages = CD010520 | date = February 2017 | pmid = 28218404 | pmc = 5419432 | doi = 10.1002/14651858.CD010520.pub2 }}</ref> Initially, glaucoma drops may reasonably be started in either one or in both eyes.<ref name="BMC Ophthalmol">{{cite journal | vauthors = Leffler CT, Amini L | title = Interpretation of uniocular and binocular trials of glaucoma medications: an observational case series | journal = BMC Ophthalmology | volume = 7 | pages = 17 | date = October 2007 | pmid = 17916260 | pmc = 2093925 | doi = 10.1186/1471-2415-7-17 | doi-access = free }}</ref>

==== Adherence ====
Poor [[Adherence (medicine)|compliance with medications]] and follow-up visits is a major reason for treatment failure and disease progression in glaucoma patients. Poor adherence could lead to increased complication rates, thus increasing the need of non-pharmacological interventions including surgery. Patient education and communication must be ongoing to sustain successful treatment plans for this lifelong disease with no early symptoms.<ref>{{Cite journal |last1=Quaranta |first1=Luciano |last2=Novella |first2=Alessio |last3=Tettamanti |first3=Mauro |last4=Pasina |first4=Luca |last5=Weinreb |first5=Robert N. |last6=Nobili |first6=Alessandro |date=October 2023 |title=Adherence and Persistence to Medical Therapy in Glaucoma: An Overview |journal=Ophthalmology and Therapy |language=en |volume=12 |issue=5 |pages=2227–2240 |doi=10.1007/s40123-023-00730-z |pmid=37311908 |pmc=10441906 |issn=2193-8245}}</ref>

===Laser===
Argon laser [[trabeculoplasty]] (ALT) may be used to treat open-angle glaucoma, but this is a temporary solution, not a cure. A 50-μm argon laser spot is aimed at the trabecular meshwork to stimulate the opening of the mesh to allow more outflow of aqueous fluid. Usually, half of the angle is treated at a time. Traditional laser trabeculoplasty uses a thermal argon laser in an [[argon]] laser trabeculoplasty procedure.

Nd:YAG laser peripheral iridotomy (LPI) may be used in patients susceptible to or affected by angle closure glaucoma or [[pigment dispersion syndrome]]. During laser iridotomy, laser energy is used to make a small, full-thickness opening in the iris to equalize the pressure between the front and back of the iris, thus correcting any abnormal bulging of the iris. In people with narrow angles, this can uncover the trabecular meshwork. In some cases of intermittent or short-term angle closure, this may lower the eye pressure. Laser iridotomy reduces the risk of developing an attack of acute angle closure. In most cases, it also reduces the risk of developing chronic angle closure or of adhesions of the iris to the trabecular meshwork. [[Computational fluid dynamics]] (CFD) simulations have shown that an optimal iridotomy size to relieve the pressure differential between the anterior and posterior side of the iris is around 0.1&nbsp;mm to 0.2&nbsp;mm.<ref>{{Cite journal |last1=Cai |first1=Jian-Cheng |last2=Chen |first2=Yan-Ling |last3=Cao |first3=Yue-Hong |last4=Babenko |first4=Andrii |last5=Chen |first5=Xi |date=2022-02-01 |title=Numerical study of aqueous humor flow and iris deformation with pupillary block and the efficacy of laser peripheral iridotomy |url=https://www.sciencedirect.com/science/article/pii/S0268003322000092 |journal=Clinical Biomechanics |language=en |volume=92 |pages=105579 |doi=10.1016/j.clinbiomech.2022.105579 |pmid=35085976 |s2cid=246361118 |issn=0268-0033}}</ref> This coincides with clinical practice of LPI where an iridotomy size of 150 to 200 microns is commonly used. However, larger iriditomy sizes are sometimes necessary.

===Surgery===
[[File:Conventional surgery to treat glaucoma EDA11.JPG|thumb|Conventional surgery to treat glaucoma makes a new opening in the [[trabecular meshwork]], which helps fluid to leave the eye and lowers intraocular pressure.]]
{{Main|Glaucoma surgery}}

Both [[Laser surgery|laser]] and conventional surgeries are performed to treat glaucoma. Surgery is the primary therapy for those with [[congenital]] glaucoma.<ref>{{OMIM|231300|Glaucoma, Congenital: GLC3 Buphthalmos}}</ref> Generally, these operations are a temporary solution, as there is not yet a cure for glaucoma.

====Canaloplasty====
[[Canaloplasty]] is a nonpenetrating procedure using micro[[catheter]] technology. To perform a canaloplasty, an incision is made into the eye to gain access to the [[Schlemm's canal]] in a similar fashion to a viscocanalostomy. A microcatheter will circumnavigate the canal around the iris, enlarging the main drainage channel and its smaller collector channels through the injection of a sterile, gel-like material called [[viscoelastic]]. The catheter is then removed and a suture is placed within the canal and tightened.

By opening the canal, the pressure inside the eye may be relieved, although the reason is unclear, since the canal (of Schlemm) does not have any significant fluid resistance in glaucoma or healthy eyes. Long-term results are not available.<ref>{{cite journal | vauthors = Shingleton B, Tetz M, Korber N | title = Circumferential viscodilation and tensioning of Schlemm canal (canaloplasty) with temporal clear corneal phacoemulsification cataract surgery for open-angle glaucoma and visually significant cataract: one-year results | journal = Journal of Cataract and Refractive Surgery | volume = 34 | issue = 3 | pages = 433–440 | date = March 2008 | pmid = 18299068 | doi = 10.1016/j.jcrs.2007.11.029 | s2cid = 23904366 }}</ref><ref>{{cite journal | vauthors = Lewis RA, von Wolff K, Tetz M, Korber N, Kearney JR, Shingleton B, Samuelson TW | title = Canaloplasty: circumferential viscodilation and tensioning of Schlemm's canal using a flexible microcatheter for the treatment of open-angle glaucoma in adults: interim clinical study analysis | journal = Journal of Cataract and Refractive Surgery | volume = 33 | issue = 7 | pages = 1217–1226 | date = July 2007 | pmid = 17586378 | doi = 10.1016/j.jcrs.2007.03.051 | s2cid = 36397585 }}</ref>

====Trabeculectomy====
The most common conventional surgery performed for glaucoma is the [[trabeculectomy]]. Here, a partial thickness flap is made in the scleral wall of the eye, and a window opening is made under the flap to remove a portion of the trabecular meshwork. The scleral flap is then sutured loosely back in place to allow fluid to flow out of the eye through this opening, resulting in lowered intraocular pressure and the formation of a bleb or fluid bubble on the surface of the eye.

Scarring can occur around or over the flap opening, causing it to become less effective or lose effectiveness altogether. Traditionally, chemotherapeutic adjuvants, such as [[mitomycin C]] (MMC) or [[5-fluorouracil]] (5-FU), are applied with soaked sponges on the wound bed to prevent filtering blebs from scarring by inhibiting fibroblast proliferation. Contemporary alternatives to prevent the scarring of the meshwork opening include the sole or combinative implementation of nonchemotherapeutic adjuvants such as the Ologen collagen matrix, which has been clinically shown to increase the success rates of surgical treatment.<ref>{{cite journal | vauthors = Dada T, Sharma R, Sinha G, Angmo D, Temkar S | title = Cyclodialysis-enhanced trabeculectomy with triple Ologen implantation | journal = European Journal of Ophthalmology | volume = 26 | issue = 1 | pages = 95–97 | year = 2016 | pmid = 26044372 | doi = 10.5301/ejo.5000633 | s2cid = 83593 }}</ref><ref>{{cite journal | vauthors = Yuan F, Li L, Chen X, Yan X, Wang L | title = Biodegradable 3D-Porous Collagen Matrix (Ologen) Compared with Mitomycin C for Treatment of Primary Open-Angle Glaucoma: Results at 5 Years | journal = Journal of Ophthalmology | volume = 2015 | issue = 637537 | pages = 637537 | year = 2015 | pmid = 26078875 | pmc = 4452460 | doi = 10.1155/2015/637537 | doi-access = free }}</ref><ref name="pmid23640614">{{cite journal | vauthors = Tanuj D, Amit S, Saptorshi M, Meenakshi G | title = Combined subconjunctival and subscleral ologen implant insertion in trabeculectomy | journal = Eye | volume = 27 | issue = 7 | pages = 889 | date = July 2013 | pmid = 23640614 | pmc = 3709396 | doi = 10.1038/eye.2013.76 }}</ref><ref>{{cite journal | vauthors = Cillino S, Casuccio A, Di Pace F, Cagini C, Ferraro LL, Cillino G | title = Biodegradable collagen matrix implant versus mitomycin-C in trabeculectomy: five-year follow-up | journal = BMC Ophthalmology | volume = 16 | issue = 24 | pages = 24 | date = March 2016 | pmid = 26946419 | pmc = 4779569 | doi = 10.1186/s12886-016-0198-0 | doi-access = free }}</ref>

Collagen matrix prevents scarring by randomizing and modulating fibroblast proliferation in addition to mechanically preventing wound contraction and adhesion.

====Glaucoma drainage implants====
{{Main|Glaucoma valve}}
The first glaucoma drainage implant was developed in 1966.<ref>{{cite web |url=http://www.glaucoma.org.nz/memberFiles/Eyelights11-05.pdf |title=Eyelights Newsletter: About Glaucoma New Zealand |publisher=Glaucoma.org |access-date=20 February 2014 |url-status=live |archive-url=https://web.archive.org/web/20150113141756/http://glaucoma.org.nz/memberFiles/Eyelights11-05.pdf |archive-date=13 January 2015 }}</ref> Since then, several types of implants have followed on from the original: the Baerveldt tube shunt, or the valved implants, such as the Ahmed glaucoma valve implant or the ExPress Mini Shunt and the later generation pressure ridge Molteno implants. These are indicated for glaucoma patients not responding to maximal medical therapy, with previous failed guarded filtering surgery (trabeculectomy). The flow tube is inserted into the anterior chamber of the eye, and the plate is implanted underneath the conjunctiva to allow a flow of aqueous fluid out of the eye into a chamber called a [[bleb (medicine)|bleb]].

*The first-generation Molteno and other nonvalved implants sometimes require the ligation of the tube until the bleb formed is mildly fibrosed and water-tight.<ref name=VicrylTie>{{cite journal | vauthors = Molteno AC, Polkinghorne PJ, Bowbyes JA | title = The vicryl tie technique for inserting a draining implant in the treatment of secondary glaucoma | journal = Australian and New Zealand Journal of Ophthalmology | volume = 14 | issue = 4 | pages = 343–354 | date = November 1986 | pmid = 3814422 | doi = 10.1111/j.1442-9071.1986.tb00470.x | doi-access = free }}
</ref> This is done to reduce postoperative hypotony—sudden drops in postoperative intraocular pressure.
* Valved implants, such as the Ahmed glaucoma valve, attempt to control postoperative hypotony by using a mechanical valve.
* Ab interno implants, such as the Xen Gel Stent, are transscleral implants by an ab interno procedure to channel aqueous humor into the non-dissected Tenon's space, creating a subconjunctival drainage area similar to a bleb.<ref>{{cite journal | vauthors = Lewis RA | title = Ab interno approach to the subconjunctival space using a collagen glaucoma stent | journal = Journal of Cataract and Refractive Surgery | volume = 40 | issue = 8 | pages = 1301–1306 | date = August 2014 | pmid = 24943904 | doi = 10.1016/j.jcrs.2014.01.032 }}</ref><ref>{{cite web|title=Xen Gel Stent|url=http://www.aquesys.com/xen.aspx|website=AqueSys|access-date=27 June 2015|url-status=dead|archive-url=https://web.archive.org/web/20150629022832/http://aquesys.com/xen.aspx|archive-date=29 June 2015}}</ref> The implants are transscleral and different from other ab interno implants that do not create a transscleral drainage, such as iStent, CyPass, or Hydrus.<ref>{{cite news|title=Advances in Glaucoma Filtration Surgery|url=http://glaucomatoday.com/2014/04/advances-in-glaucoma-filtration-surgery|access-date=27 June 2015|publisher=Glaucoma Today|url-status=live|archive-url=https://web.archive.org/web/20150629194028/http://glaucomatoday.com/2014/04/advances-in-glaucoma-filtration-surgery|archive-date=29 June 2015}}</ref><ref>{{cite journal | vauthors = Otarola F, Virgili G, Shah A, Hu K, Bunce C, Gazzard G | title = Ab interno trabecular bypass surgery with Schlemm´s canal microstent (Hydrus) for open angle glaucoma | journal = The Cochrane Database of Systematic Reviews | volume = 2020 | issue = 3 | pages = CD012740 | date = March 2020 | pmid = 32147807 | pmc = 7061024 | doi = 10.1002/14651858.cd012740.pub2 }}</ref>

The ongoing scarring over the conjunctival dissipation segment of the shunt may become too thick for the aqueous humor to filter through. This may require preventive measures using antifibrotic medications, such as 5-fluorouracil or mitomycin-C (during the procedure), or other nonantifibrotic medication methods, such as collagen matrix implant,<ref>{{cite journal | vauthors = Rosentreter A, Schild AM, Dinslage S, Dietlein TS | title = Biodegradable implant for tissue repair after glaucoma drainage device surgery | journal = Journal of Glaucoma | volume = 21 | issue = 2 | pages = 76–78 | date = February 2012 | pmid = 21278584 | doi = 10.1097/IJG.0b013e3182027ab0 | s2cid = 40206358 }}</ref><ref name="Capsule excision and Ologen implant">{{cite journal | vauthors = Rosentreter A, Mellein AC, Konen WW, Dietlein TS | title = Capsule excision and Ologen implantation for revision after glaucoma drainage device surgery | journal = Graefe's Archive for Clinical and Experimental Ophthalmology = Albrecht von Graefes Archiv für Klinische und Experimentelle Ophthalmologie | volume = 248 | issue = 9 | pages = 1319–1324 | date = September 2010 | pmid = 20405139 | doi = 10.1007/s00417-010-1385-y | s2cid = 10384646 }}</ref> or biodegradable spacer, or later on create a necessity for revision surgery with the sole or combinative use of donor patch grafts or collagen matrix implant.<ref name="Capsule excision and Ologen implant"/>

====Laser-assisted nonpenetrating deep sclerectomy====
The most common surgical approach currently used for the treatment of glaucoma is trabeculectomy, in which the sclera is punctured to alleviate intraocular pressure.

Nonpenetrating deep sclerectomy (NPDS) surgery is a similar, but modified, procedure, in which instead of puncturing the scleral bed and trabecular meshwork under a scleral flap, a second deep scleral flap is created, excised, with further procedures of deroofing the Schlemm's canal, upon which, percolation of liquid from the inner eye is achieved and thus alleviating intraocular pressure, without penetrating the eye. NPDS is demonstrated to have significantly fewer side effects than trabeculectomy.<ref>{{cite journal | vauthors = Chiselita D | title = Non-penetrating deep sclerectomy versus trabeculectomy in primary open-angle glaucoma surgery | journal = Eye | volume = 15 | issue = Pt 2 | pages = 197–201 | date = April 2001 | pmid = 11339590 | doi = 10.1038/eye.2001.60 | doi-access = free }}</ref> However, NPDS is performed manually and requires higher level of skills that may be assisted with instruments<!-- to achieve a lengthy learning curve-->.{{Citation needed|date=May 2009}}   In order to prevent wound adhesion after deep scleral excision and to maintain good filtering results, NPDS as with other non-penetrating procedures is sometimes performed with a variety of biocompatible spacers or devices, such as the Aquaflow collagen wick,<ref>{{cite journal |url=https://www.reviewofophthalmology.com/article/making-the-case-for-nonpenetrating-surgery |title=Making the Case for Nonpenetrating Surgery|journal=Review of Ophthalmology| vauthors = Ahmed IK |volume=12|issue=9|date=1 September 2005}}</ref> ologen Collagen Matrix,<ref name="pmid23640614" /><ref>{{cite journal | vauthors = Aptel F, Dumas S, Denis P | title = Ultrasound biomicroscopy and optical coherence tomography imaging of filtering blebs after deep sclerectomy with new collagen implant | journal = European Journal of Ophthalmology | volume = 19 | issue = 2 | pages = 223–230 | year = 2009 | pmid = 19253238 | doi = 10.1177/112067210901900208 | s2cid = 22594085 }}</ref><ref>{{cite conference | vauthors = Matthew SJ, Sarkisian S, Nathan B, James MR  |title=Initial experience using a collagen matrix implant (ologen) as a wound modulator with canaloplasty: 12 month results |url=http://www.abstractsonline.com/Plan/ViewAbstract.aspx?mID=2866&sKey=aa4eef9a-b55d-43a5-a9f7-c71c79616c08&cKey=7035e4dc-493a-4f51-adae-eedc3adbe114&mKey=%7BF0FCE029-9BF8-4E7C-B48E-9FF7711D4A0E%7D |date=May 2012 |conference=ARVO |location=Ft. Lauderdale }}</ref> or Xenoplast glaucoma implant.<ref>{{cite web |vauthors=Anisimova SY, Anisimova SI, Larionov EV |title=Biological drainage – Xenoplast in glaucoma surgery (experimental and 10-year of clinical follow-up) |url=http://www.oic.it/~egscopenaghen2012/posters/june18/P2.24/poster.pdf |date=2012 |publisher=EGS Congress |location=Copenhagen |url-status=live |archive-url=https://web.archive.org/web/20131017051726/http://www.oic.it/~egscopenaghen2012/posters/june18/P2.24/poster.pdf |archive-date=17 October 2013 }}</ref>

Laser-assisted NPDS is performed with the use of a CO<sub>2</sub> laser system. The laser-based system is self-terminating once the required scleral thickness and adequate drainage of the intraocular fluid have been achieved. This self-regulation effect is achieved as the CO<sub>2</sub> laser essentially stops ablating as soon as it comes in contact with the intraocular percolated liquid, which occurs as soon as the laser reaches the optimal residual intact layer thickness.

==== Clear lens extraction ====
{{main|Clear lens extraction}}
For people with chronic closed-angle glaucoma, lens extraction can relieve the block created by the pupil and help regulate the intraocular pressure.<ref>{{cite journal | vauthors = Ong AY, Ng SM, Vedula SS, Friedman DS | title = Lens extraction for chronic angle-closure glaucoma | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 3 | pages = CD005555 | date = March 2021 | pmid = 33759192 | pmc = 8094223 | doi = 10.1002/14651858.CD005555.pub3 }}</ref> A study found that CLE is even more effective than laser peripheral [[iridotomy]] in patients with angle closure glaucoma.<ref>{{Cite journal |last1=Tanner |first1=Luke |last2=Gazzard |first2=Gus |last3=Nolan |first3=Winifred P. |last4=Foster |first4=Paul J. |date=January 2020 |title=Has the EAGLE landed for the use of clear lens extraction in angle-closure glaucoma? And how should primary angle-closure suspects be treated? |journal=Eye |language=en |volume=34 |issue=1 |pages=40–50 |doi=10.1038/s41433-019-0634-5 |pmid=31649349 |issn=1476-5454|pmc=7002615 }}</ref> A systematic review comparing lens extraction and laser peripheral [[Iridectomy|iridotomy]] for treating acute primary angle closure found that lens extraction potentially provides better [[intraocular pressure]] control and reduces medication needs over time. However, it remains uncertain if it significantly lowers the risk of [[Relapse|recurrent episodes]] or reduces the need for additional [[Surgery|operations]].<ref>{{Cite journal |last1=Ong |first1=Ariel Yuhan |last2=McCann |first2=Paul |last3=Perera |first3=Shamira A |last4=Lim |first4=Fiona |last5=Ng |first5=Sueko M |last6=Friedman |first6=David S |last7=Chang |first7=Dolly |date=2023-03-08 |editor-last=Cochrane Eyes and Vision Group |title=Lens extraction versus laser peripheral iridotomy for acute primary angle closure |journal=Cochrane Database of Systematic Reviews |language=en |volume=2023 |issue=3 |pages=CD015116 |doi=10.1002/14651858.CD015116.pub2 |pmc=9994579 |pmid=36884304}}</ref> 

=== Treatment approaches for primary glaucoma ===
'''Primary angle closure glaucoma:''' Once any symptoms have been controlled, the first line (and often definitive) treatment is laser [[iridotomy]]. This may be performed using either Nd:YAG or argon lasers, or in some cases by conventional incisional surgery. The goal of treatment is to reverse and prevent contact between the iris and trabecular meshwork. In early to moderately advanced cases, iridotomy is successful in opening the angle in around 75% of cases. In the other 25%, laser iridoplasty, medication (pilocarpine) or incisional surgery may be required.

'''Primary open-angle glaucoma:''' Prostaglandin agonists work by opening uveoscleral passageways. Beta-blockers, such as timolol, work by decreasing aqueous formation. [[Carbonic anhydrase inhibitor]]s decrease bicarbonate formation from ciliary processes in the eye, thus decreasing the formation of aqueous humor. Parasympathetic analogs are drugs that work on the trabecular outflow by opening up the passageway and constricting the pupil. Alpha 2 agonists ([[brimonidine]], [[apraclonidine]]) both decrease fluid production (via inhibition of AC) and increase drainage. A review of people with primary open-angle glaucoma and ocular hypertension concluded that medical IOP-lowering treatment slowed down the progression of visual field loss.<ref name="Vass2007" />

=== Neovascular glaucoma ===
[[anti–vascular endothelial growth factor therapy|Anti-VEGF agents]] as injectable medications, along with other standard of care treatment for decreasing intraocular pressure, may improve pressure in people with neovascular glaucoma for short periods of time.<ref name=":0">{{Cite journal |last1=Rittiphairoj |first1=Thanitsara |last2=Roberti |first2=Gloria |last3=Michelessi |first3=Manuele |date=2023-04-03 |title=Anti-vascular endothelial growth factor for neovascular glaucoma |url= |journal=The Cochrane Database of Systematic Reviews |volume=4 |issue=4 |pages=CD007920 |doi=10.1002/14651858.CD007920.pub4 |issn=1469-493X |pmc=10069372 |pmid=37010901 }}</ref> Evidence suggests that this improvement may last 4–6 weeks.<ref name=":0" /> There is no sufficient evidence to suggest that anti-VEGF medications are effective either for short-term or for longer-term treatment.<ref name=":0" /> The short, medium, and long-term safety of anti-VEGF treatment has not been well investigated.<ref name=":0" />

=== Other ===
*[[Cannabis]] is not suggested for treatment of glaucoma by the [[American Glaucoma Society]] for adults or for children.<ref>{{Cite journal |last1=Grossman |first1=Adriana L. |last2=Javitt |first2=Matthew J. |last3=Moster |first3=Steven J. |last4=Grajewski |first4=Alana L. |last5=Beck |first5=Allen D. |last6=Blieden |first6=Lauren S. |last7=Bitrian |first7=Elena |last8=Chang |first8=Ta C. |last9=Freedman |first9=Sharon F. |last10=Hodapp |first10=Elizabeth |last11=Joos |first11=Keren M. |last12=Reiser |first12=Bibiana J. |last13=Tanna |first13=Angelo P. |date=2019-11-01 |title=American Glaucoma Society Position Statement on Cannabinoid Use in Pediatric Glaucoma Patients |url=https://www.sciencedirect.com/science/article/pii/S2589419619302492 |journal=Ophthalmology Glaucoma |language=en |volume=2 |issue=6 |pages=365–366 |doi=10.1016/j.ogla.2019.07.007 |pmid=32672568 |s2cid=214292703 |issn=2589-4196}}</ref><ref>{{cite journal |vauthors=Jampel H |date=February 2010 |title=American glaucoma society position statement: marijuana and the treatment of glaucoma |journal=Journal of Glaucoma |volume=19 |issue=2 |pages=75–76 |doi=10.1097/ijg.0b013e3181d12e39 |pmid=20160576}}</ref>
*[[Sepetaprost]], investigational new drug