Nils Loewen, MD, PhD, measures a patient’s intraocular pressure. High pressure within the eye can damage the optic nerve.
(November 2010) When Richard Klosek had his first glaucoma surgery at the Yale Eye Center two decades ago, the results were outstanding. “The left eye was so perfect, they put a picture of it in a textbook,” Klosek recalls. The recovery period, however, was an inconvenience. He remembers wearing an eye patch for days, not being able to drive and, while not feeling pain, having a general sense of that eye being “uncomfortable.”
Recently, he needed surgery to manage the glaucoma in his other eye and remove a cataract. This time ophthalmologist Nils Loewen, MD, PhD, performed a Trabectome® procedure, a new, less invasive option that speeds recovery and reduces long-term complications. The Yale Eye Center is the only practice in Connecticut that does the procedure.
The difference between the old and new surgeries was “like night and day,” Klosek says. He took time off from his job as a cashier at a warehouse club, but only because he had vacation time to use. “That was my choice,” he says. “I was fine the next day.” After the ride home, he didn’t need an eye patch.
Loewen and a colleague discuss a high-resolution three-dimensional volume measurement of the optic nerve to detect glaucoma damage.
Klosek is one of nearly 3 million Americans living with glaucoma, a leading cause of blindness. Poor drainage of fluid leads to high pressure within the eye, which can damage the optic nerve. This damage is irreversible, so screening and treating for glaucoma to control pressure is essential. Screening is especially crucial because people do not perceive the vision loss as it is happening.
The first line of defense against glaucoma is medication, which will control pressure well for most people. But in about 30 percent of cases, that’s not practical, explains Loewen, either because the medicated drops interact badly with other prescriptions or because they are simply ineffective. With the advent of more sophisticated surgical procedures, these patients have new options to safeguard their sight without disrupting their lives.
“Treating glaucoma with microsurgery is very gratifying,” says Loewen. “You’re helping the patient preserve vision with almost no discomfort.”
Loewen uses a model to demonstrate a minimally invasive technique to treat early to moderate glaucoma.
In 1991, Klosek had a trabeculectomy, which remains the most common operation for glaucoma. A trabeculectomy treats the disease by surgically removing tissue to create a better drainage route for fluid in the eye, thus lowering pressure. The trabeculectomy gets its name from the eye’s trabecular meshwork, part of which is removed in the surgery.
In Trabectome® surgery, the incision is 1.7 millimeters wide. The surgeon uses an electrosurgical pulse to excise diseased tissue and open up the eye’s drainage system. The channel is flushed with a saline solution to remove debris. The entire procedure takes only about 15 minutes and is easily combined with cataract removal through the same incision. Cataracts are common in people with glaucoma. As with traditional trabeculectomy, patients are awake and do not need to stay overnight in the hospital.
Loewen favors the new procedure because, unlike traditional surgery, it does not leave behind a bleb, a small pocket of fluid, almost like a minute blister on the eye. They are prone to infection, so eliminating blebs reduces the risk of complication. Blebs also create an uneven surface on the eye, thus contact lenses cease to be an option, added Klosek. He was happy to report, however, that since his recent surgery he sees well enough that he’s stopped wearing eyeglasses around the house.
Loewen was the first Connecticut doctor to perform canaloplasty to lower pressure by widening the drainage canal.
In addition to the Trabectome® procedure, the Yale Eye Center offers canaloplasty, a surgery that Loewen was the first Connecticut doctor to perform. Canaloplasty may be best understood as “angioplasty for the eye.” It is frequently used for patients who have had a failed traditional trabeculectomy. Loewen makes a micro-incision and inserts a tiny catheter that will snake through the eye’s drainage system.
Loewen described the canal he must navigate in the canaloplasty procedure as “hideously complex,” but the instruments he uses give him precision control. He removes the catheter, leaving behind a widened drainage canal that, for most patients, lowers pressure so effectively that medication is no longer necessary. Canaloplasty is also an outpatient procedure and does not create a bleb.
For patients like Richard Klosek, glaucoma microsurgery can ease the fear of complications, while offering a fast and comfortable treatment. What most amazes him is how much things have changed since his original surgery, which was state-of-the-art back in 1991. “It seems so Stone Age,” he says with a chuckle.
Story by Colleen Shaddox
Photos by Robert Lisak
Yale Eye Center
Temple Medical Center
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Yale Eye Center ophthalmologist Nils Loewen, MD, is participating in a national trial of a suprachoroidal shunt implant. The device has been effective in managing difficult cases of glaucoma where pressure is extremely high and other treatments have failed.
Through a micro-incision, an implant is inserted into the eye’s interior to direct drainage outward. Yale is one of only four centers nationally to offer the technology to its patients.
Loewen is also interested in solving the puzzles surrounding low-pressure glaucoma. While the disease is usually characterized by high pressure in the eye, some people with lower-than-normal intraocular pressure also experience optic nerve damage. He is conducting research on how sleep position affects pressure in these patients.
Participants in his study simply wear a cell phone-sized monitor to bed. The instrument records their tossing and turning, giving Loewen new information to unravel the mystery – and work toward better treatments.
For information about participating in these or other clinical trials in opthalmology at Yale, Please call Jennifer Dupont at 203-785-6150 or Bonnie Dunlap at 203-785-2062.