Adult Glaucoma

About Adult Glaucoma

The eye produces a nourishing fluid called the aqueous humour. This fluid circulates around the tissues of the eye and drains away through outflow channels. ‘Normal’ Eye pressure is when the amount of fluid produced is balanced by the amount of fluid draining away. If the fluid in the eyes is not ‘balanced’ then the pressure inside the eye rises and this can lead to a glaucoma.

Glaucoma, if left untreated, causes damage to the optic nerve at the back of the eye, ultimately resulting in loss of vision.

Causes

Glaucoma occurs when the drainage tubes (trabecular meshwork) within the eye become slightly blocked, preventing the fluid which is produced by the eye – known as the aqueous humour – from draining normally . It can also occur if there is an obstruction within the eye such as a blood vessel blocking the trabecular meshwork.

When the fluid cannot drain properly, it results in increased pressure inside the eye which can cause damage to the optic nerves, and the nerve fibers from the retina.

There are various other factors that can lead to glaucoma. These are listed below.

Age – chronic glaucoma becomes more common with age.
Ethnic origin – people of African, or Afro-Caribbean origin, tend to have a greater chance of developing chronic glaucoma. Also, people of Asian origin are more likely to develop acute glaucoma.
Short sightedness – short-sighted people are more likely to develop chronic glaucoma.
Family history – Having a Family history of Glaucoma also have increases the chances developing the condition. Regular eye screening is highly recommended in this case.
Medical history – Diabetics are more likely to develop glaucoma than those without the condition.

Symptoms

Glaucoma does not present symptoms until late stages, when it can cause damage to your field of vision. This means that the edge of your peripheral vision can start to disappear causing your vision to narrow. It treatment is delayed these defects can severely affect your vision and can cause tunnel vision.

Treatment for glaucoma aims to reduce the pressure in the eye either by helping fluid drain away or reduce the amount of fluid being produced.

The usual treatment for glaucoma is eye drops however in cases where it is resistant to drops, treatment through surgery or laser may need to be performed.

Surgery

Aqueous Shunts

Aqueous shunts are devices that are used to reduce the eye pressure in glaucoma by draining the aqueous humour (natural fluid of the eye) from inside the eye to a small blister or bleb behind the eyelid. Draining the aqueous humor, using a shunt, reduces the pressure on the optic nerve that causes loss of vision in glaucoma. The purpose of lowering the eye pressure is to prevent further loss of vision. Control of the eye pressure with an aqueous shunt will not restore vision already lost from glaucoma. Aqueous shunts have various other names such as tube implants, glaucoma tube shunts, glaucoma drainage devices and glaucoma drainage implants. These all refer to the same thing. Although there are many types of shunts available, three main types are in use at Moorfields Eye Hospital Dubai and Abu Dhabi and they function in a similar fashion.
These are called the Ahmed Glaucoma Valve, The PAUL implant and The Baerveldt Glaucoma Implant.

Indication

For advanced glaucoma patients with other ocular comorbidities
Patients that have had other conventional glaucoma surgery that is no longer efficacious
Patients with drops allergy and side effects

Enhanced Trabeculectomy

Trabeculectomy is a surgical operation that creates an alternative drainage channel, to help aqueous fluid (natural fluid of the eye) drain from your eye. This operation creates a bypass for the blocked natural drain (trabecular meshwork) of your eye. Your eye pressure is reduced because fluid can now drain more easily through the newly created drainage channel.

Indication

Patients with advanced glaucoma that continues to progress despite medication use

Patients that need a low pressure to stop progression of glaucoma

Patients with drops allergy and side effects

MIGS

The recent most increased interest in glaucoma surgery has been in Minimally Invasive Glaucoma Surgery (MIGS) with formidable results in mild to moderate glaucoma. These are designed to improve the safety of surgical intervention for glaucoma. Although initially coined minimally invasive, the term micro seems more appropriate because it truly differentiates these microscopic ophthalmic procedures from other minimally invasive surgical procedures (i.e., general surgery). Most MIGS procedures enhance physiologic outflow and are aimed at a different patient population than traditional filtration surgery. As opposed to competing with traditional filtering surgery, MIGS seems to be more of an alternative to medical therapy in an effort to address adherence challenges, adverse events, and qualityof-life (QOL) issues with topical medications.

Istent

The iStent Trabecular Micro-Bypass Stent (Glaukos, Laguna Hills, CA) received FDA approval in 2012. The device is a heparin-coated, non-ferromagnetic titanium stent with a snorkel shape to facilitate implantation. The device is placed using a singleuse, sterile inserter through a 1.5mm corneal incision. The iStent itself is the smallest FDA approved device, measuring at 0.3mm in height and 1mm in length. The iStent is a safe minimally invasive glaucoma surgery (MIGS) procedure that can reduce the need for daily use of glaucoma eye drops. A small (1mm) titanium drainage stent is inserted into the eye’s natural drainage channel to lower intraocular pressure. Most clinical trials concluded that iStent implantation with phacoemulsification resulted in a significantly lower, long-term decrease in IOP and number of medications used compared to phacoemulsification alone. No major complications have been reported.

XEN Implant

The XEN Glaucoma Implant (AqueSys Implant) was created by AqueSys Inc acquired by Allergan. The implant itself is made out of a soft, collagenderived, gelatin that is known to be noninflammatory. The Xen Gel Stent aims to reduce intraocular pressure by inserting a small drainage tube into the eye. The stent allows fluid to drain from the anterior chamber into a reservoir (bleb) under the conjunctiva. The goal of implantation is to create an aqueous humor outflow path from the anterior chamber to the subconjunctival space. The implant is injected through a small corneal incision with the use of an inserter similar to those used for IOLs. Similar to other implants, it can be performed in conjunction with cataract surgery.

All shunts perform approximately the same function of lowering the eye pressure. It’s important to note that no treatment is guaranteed to completely eliminate the need for eye drops, but the strong results seen in the use of either the Istent or XEN Gel Stent give the right patients a very strong choice for eliminating the need for them.

Indication:

Patients with mild to moderate glaucoma
To reduce drops dependence

Laser

Peripheral Iridotomy

This laser treatment uses a YAG laser to make a microscopic hole in the peripheral iris to help passage of fluid resulting in a structural improvement in the access to the trabecular meshwork which are the drains of the eye helping the fluid to pass and reducing the risk of angle closure glaucoma. The procedure does not require admission to hospital and is carried out in the outpatients department.

Indication:

Patients with closed or narrow angle glaucoma
To prevent angle closure acute glaucoma in patients that have narrow angles and are at risk

Selective Laser Trabeculoplasty

Selective Laser Trabeculoplasty (SLT) is a safe, quick, simple and non-invasive treatment option used to treat glaucoma. It works by reducing the pressure inside the eye. The eye pressure is known as intraocular pressure (IOP). The procedure does not require admission to hospital and is carried out in the outpatients department.

Indication:

Reduction in eye pressure without the use of drops

Micropulse Cyclodiode Laser Treatment

Indication:

Patients where conventional glaucoma surgery is risky
To help reduce drops burden

The diode laser is a highly concentrated beam of light, which can be used to target and treat a selected area. Often, laser treatment is recommended in order to avoid the need for more invasive surgery. The diode laser is used to produce very small burns in the ciliary body, which produces the watery fluid called aqueous humour, and is situated behind the iris (coloured part of your eye).

Adult Glaucoma Specialists

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Dubai
Abu Dhabi

Dr. Salman Waqar

Consultant Ophthalmologist in adult and paediatric glaucoma and cataract surgery

Dr. Salman Waqar is an experienced consultant ophthalmologist specialising in the treatment of adult and paediatric glaucoma and cataracts at Moorfields Eye Hospital Dubai in Dubai Healthcare City. His areas of expertise include medical, laser and surgical treatments for glaucoma (including minimally invasive implants and aqueous shunt devices). He also offers cataract surgery using the latest small incision technology, and with a range of intraocular lenses (Toric, Multifocal and Extended Depth of Field), tailored to the patients individual needs. Dr. Waqar graduated from Pakistan and has over 15 years’ experience of work in the United Kingdom. He holds a Certificate of Completion of Training from the UK, and is a Fellow of the Royal College of Ophthalmologists. He has worked in various prestigious eye units including the West of England Eye Unit (Exeter), where he completed his sub-specialty training in glaucoma. In his career, he has been appointed as a consultant across a wide range of leading medical institutions such as the Royal Eye Infirmary (Plymouth), Nuffield Health, Medical Eye Clinic and Newmedica. In addition to his clinical work, he has also performed with distinction as director of clinical governance and for the glaucoma service. Dr. Waqar’s research interests include optimizing patient outcomes with minimally invasive surgery, using virtual reality simulation to investigate surgeon performance and the development of innovative surgical instruments to improve patient safety. He has published extensively in peer-reviewed journals, such as the British Journal of Ophthalmology and the Journal of Cataract and refractive Surgery, and presents regularly at national and international meetings. He holds memberships with the United Kingdom and Eire Glaucoma Society, the European Society of Cataract and Refractive Surgeons and the American Academy of Ophthalmology. In his capacity as an Honorary Fellow with Plymouth University, he has been involved in training the doctors and surgeons of our future. In 2019, his work was recognized with a nomination for a regional Trainer of the Year Award by the Peninsula School of Ophthalmology. In addition, he has been the recipient of numerous research grants, and has co-authored two medical textbooks. Other accolades include invitations as a surgical skills instructor at minimally invasive glaucoma surgery courses, and to the microsurgical skills course with the Royal College of Ophthalmologists. In his spare time he is an avid reader, aspiring author and motivated triathlete.

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Dr. Ziad Khoueir

Visiting Consultant Ophthalmologist in Adult Glaucoma and Cataract surgery

Dr. Ziad Khoueir is a visiting Consultant ophthalmologist specialising in adult glaucoma and cataract surgery at Moorfields Eye Hospital Dubai in Dubai Healthcare City. He holds a medical degree from the Saint-Joseph University in Beirut, Lebanon (2008) and completed his ophthalmology residency at the Hotel-Dieu de France Hospital (2013). He then completed postdoctoral clinical and research fellowships at the Glaucoma Institute, UPMC-Sorbonne University in Paris, France (2014) and at the Massachusetts Eye and Ear Infirmary, Harvard Medical School in Boston, USA (2016). He is also a laureate of the Glaucoma Subspecialty Diploma of the European Board of Ophthalmology. He has more than seven years of both regional and international experience in glaucoma, one during which he has practised clinical and research work in leading medical institutions such as the Glaucoma Institute at the Paris Saint-Joseph Hospital (France), the Massachusetts Eye and Ear Infirmary (USA), the Beirut Eye & ENT Specialist Hospital (Lebanon) and the Muscat Eye Laser Center (Oman). Dr. Ziad currently holds the position of associate director of the Glaucoma division at the Beirut Eye and ENT Specialist Hospital. He is a clinical instructor and lecturer at the Saint-Joseph University Medical School in Beirut, Lebanon. His research focuses on innovative techniques in managing and diagnosing glaucoma, such as minimally invasive glaucoma surgery (MIGS), glaucoma lasers and the use of Optical Coherence Tomography imaging in glaucoma. He has published more than 35 research papers and chapters on those topics in leading ophthalmology journals. He has been invited to lecture and present his work in regional and international meetings in more than 20 countries over the last few years. He is currently a research collaborator at the Mayo Clinic Ophthalmology Department in Jacksonville, Florida, USA. He is the co-chair of the associate advisory board of the World Glaucoma Association and a member of the associate advisory board of the International Society of Glaucoma Surgery.

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