Glaucoma — Assessment and Management in Miranda

Most people who come to see Dr Hunt about glaucoma arrive one of three ways: their optometrist picked up raised pressure or an unusual-looking optic nerve at a routine check, they have a family history of glaucoma and want to be assessed, or they already have a diagnosis and are looking for ongoing care. A small number present urgently with the severe pain, headache, and blurred vision of acute angle-closure glaucoma.

Whichever route brings you in, the first visit is about working out whether glaucoma is present, how far it has progressed, and what treatment (if any) you need. Dr Adrian Hunt assesses and manages glaucoma at Eye Surgeons Miranda in Miranda.

What Is Glaucoma?

Glaucoma damages the optic nerve — the nerve that carries vision from the eye to the brain. The damage is usually driven by pressure inside the eye being higher than that particular nerve can tolerate, and in most cases it develops slowly and painlessly. Peripheral vision is affected first, and central vision is generally preserved until late, which is why significant damage can occur before anything feels wrong.

Vision already lost to glaucoma cannot be recovered, but lowering eye pressure prevents further loss. That is the aim of every treatment described below.

What Does a Glaucoma Diagnosis Mean?

Will I lose my sight? Most people with glaucoma, when it is picked up early and treatment is followed consistently, keep useful vision for the rest of their lives. The outcome depends on how much damage has already occurred at diagnosis, how well the pressure is controlled, and how regularly the eye is reviewed — which is why monitoring matters as much as the treatment itself.

Will I have to use drops forever? If drops are the chosen treatment, then yes — they are ongoing, because stopping lets the pressure rise again. That said, drops are not the only option. SLT laser can replace drops as a first treatment for many patients and avoids the need to remember a daily routine altogether.

Types of Glaucoma

• Primary open-angle glaucoma — the most common form. The eye's drainage works less efficiently than it should, pressure gradually rises, and damage builds up silently over years.
• Normal tension glaucoma — optic nerve damage occurs despite eye pressure being in the normal range. Treatment is the same as open-angle glaucoma: lowering pressure further still slows progression.
• Angle-closure glaucoma — the drainage angle is narrow or blocked. It usually develops slowly, but in its rare acute form it is the emergency described in the urgent care box above.
• Secondary glaucoma — raised pressure caused by another condition, such as inflammation, eye trauma, or long-term steroid use.

Who Is at Risk of Glaucoma?

The main risk factors for glaucoma are:

• A parent or sibling with glaucoma
• Age over 60
• Known raised eye pressure
• Short-sightedness, particularly strong short-sightedness
• Long-term use of steroid drops, tablets, or inhalers

Having one or more of these does not mean glaucoma is present, but it does mean it is worth being checked. A family history in a parent or sibling is the single most important reason to have a full assessment.

Dr Hunt can also advise on newly available genetic tests that give a more personalised estimate of your risk of developing glaucoma, which can help guide how closely you should be monitored.

How Is Glaucoma Detected?

A glaucoma assessment is a painless outpatient appointment. No single test is enough on its own — Dr Hunt looks for consistent evidence across several findings:

• Eye pressure measurement — quick and painless after numbing drops.
• Examination of the optic nerve — usually with the pupils dilated so the nerve can be seen clearly.
• OCT scan — a detailed photograph of the optic nerve that can pick up early thinning before it shows up on other tests.
• Visual field test — measures peripheral vision and shows whether any nerve damage has started to affect how the eye sees.
• Gonioscopy — a quick check of the drainage angle to confirm which type of glaucoma is present.

Treatment

The aim of glaucoma treatment is to reduce intraocular pressure to a level that prevents further optic nerve damage. The target pressure is individualised based on the degree of existing damage, the rate of progression, and the patient's life expectancy.

Eye Drops

Eye drops are the most common first-line treatment. They lower pressure either by reducing how much fluid the eye produces or by helping it drain more easily. Many patients do well on a single drop once a day; others need a combination to reach a safe target pressure.

The drops only work if they are used consistently. Missing doses lets pressure rise and allows the disease to progress, so building them into a daily routine matters as much as the drop itself.

Selective Laser Trabeculoplasty (SLT)

SLT is a quick in-rooms laser that helps the eye drain fluid more efficiently. It can be used instead of drops as a first treatment, or added later if drops alone are not enough. Large clinical trials have shown SLT to be as effective as drops for most patients starting treatment, with the advantage that it doesn't rely on remembering a daily routine. The effect typically lasts three to five years and can be repeated.

Peripheral Iridotomy (PI) for Narrow Angles

Patients identified as having narrow drainage angles — at risk of angle-closure glaucoma — are typically treated preventively with peripheral iridotomy: a small opening created in the periphery of the iris using the YAG laser. The procedure is performed in the consulting rooms and reduces the risk of pressure rises caused by the iris blocking outflow.

Minimally Invasive Glaucoma Surgery (MIGS)

For patients with mild to moderate open-angle glaucoma who also need cataract surgery, Dr Hunt performs MIGS using the iStent inject W at the time of the cataract operation. Two microscopic trabecular bypass stents are placed through the same corneal incision used for the cataract procedure, improving the eye's natural drainage of fluid and lowering pressure — both conditions treated in a single operation with a single recovery.

Dr Hunt has completed the manufacturer's surgical training and accreditation for iStent and has performed these procedures since the original device was introduced in Australia in 2014, progressing through the iStent inject to the current iStent inject W.

In clinical trials, around two-thirds of patients who received an iStent at the time of cataract surgery were able to reduce or stop their glaucoma drops. Cataract surgery is the natural opportunity to address both conditions together, with minimal additional risk and an unchanged recovery.

Complex Glaucoma Surgery

When drops, laser, and MIGS are not sufficient, more complex glaucoma surgery — such as trabeculectomy or a drainage tube — may be needed. Dr Hunt refers these cases to a dedicated glaucoma subspecialist.

Monitoring

Glaucoma is a chronic condition requiring long-term monitoring. Even when IOP is well controlled, review appointments are needed to confirm that visual fields are stable, OCT nerve fibre measurements are not deteriorating, and that treatment is being tolerated and administered correctly. Review frequency depends on disease severity and stability — from three-monthly for patients with advanced or unstable disease to twelve-monthly for patients with early, stable glaucoma on treatment.

Patients who are off treatment but being monitored as glaucoma suspects or ocular hypertensives also require regular review, usually every twelve months.

Common Questions

Is glaucoma curable?

No. Glaucoma cannot be cured in the sense of restoring damage already done — nerve fibres that have been lost cannot be grown back. It can, however, be controlled. Lowering eye pressure with drops, laser, or surgery stops progression, and most people whose glaucoma is picked up early and treated consistently keep useful vision for life.

What is the difference between glaucoma and ocular hypertension?

Ocular hypertension means the eye pressure is higher than average, but the optic nerve still looks normal and the visual field is intact. Glaucoma means nerve damage has begun — either because pressure has been too high for too long, or because the nerve is unusually vulnerable to pressure. People with ocular hypertension don't always need treatment, but they do need regular monitoring.

Is SLT laser painful?

No. SLT is done in rooms after numbing drops and takes only a few minutes per eye. Patients see bright flashes during the treatment and may notice mild grittiness for a day or so afterwards. There is no cutting, no stitches, and no recovery period — most people drive home and return to normal activities the same day.

Can I still drive if I have glaucoma?

Most people with early or moderate glaucoma meet the vision requirements for a private driver's licence without restriction. Advanced glaucoma, particularly when both eyes are affected, can reduce peripheral vision enough to affect driving — this is assessed on an individual basis using visual field results.

Does glaucoma skip generations?

No — the idea that glaucoma "skips" generations isn't supported by how it actually runs in families. If you have a parent, sibling, or child with glaucoma, your own risk is substantially higher regardless of whether intermediate generations were affected. A full assessment is worthwhile for anyone with a first-degree relative who has glaucoma. Dr Hunt can also advise on newly available genetic tests that give a more personalised estimate of your individual risk.

What is MIGS?

MIGS stands for minimally invasive glaucoma surgery. It refers to a group of procedures that lower eye pressure through tiny implants or incisions, with less risk and faster recovery than traditional glaucoma surgery. The iStent inject W is one of the most widely used MIGS devices — two microscopic stents are placed inside the eye at the time of cataract surgery to improve the natural drainage of fluid and reduce eye pressure.