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Glaucoma Surgery and Modern Treatment Methods

What is glaucoma surgery and when is it necessary?

Glaucoma surgery includes surgical treatments that aim to reduce intraocular pressure,
protect the optic nerve and slow disease progression.
Glaucoma surgery may be considered when eye pressure cannot be adequately controlled
with medication, when medications cannot be used because of side effects, or when regular
use of medication is not possible. Surgical treatments aim to control intraocular pressure
either by increasing aqueous outflow or, in some laser methods, by reducing fluid
production.


Glaucoma surgeries include different surgical and laser methods performed to reduce intraocular pressure. These methods can generally be classified into two main groups: conventional glaucoma surgeries and microinvasive glaucoma surgeries — MIGS.

The surgical option is individualized according to the type and stage of glaucoma, target intraocular pressure, eye structure and previous treatments.

Conventional glaucoma surgeries

Conventional glaucoma surgeries are generally preferred in more advanced glaucoma or in patients in whom sufficient pressure control cannot be achieved with medications or laser treatment.

In trabeculectomy, a new drainage pathway is created to allow fluid inside the eye to pass in a controlled manner under the conjunctiva, the tissue covering the eye surface. This aims to reduce intraocular pressure and slow the progression of optic nerve damage.

In seton surgery or glaucoma drainage implant surgery, a special implant is placed on the outer part of the eye. Through a thin tube connected to this implant, intraocular fluid is directed outward in a controlled way. This method may be considered particularly in refractory, previously operated or complex glaucoma cases.

Transscleral diode laser is a laser method that aims to reduce production of intraocular fluid. Laser energy applied from outside the eye is used to reduce the activity of the tissues producing the fluid. It may be considered as an alternative or supportive treatment in selected patients.

Microinvasive glaucoma surgeries — MIGS

Microinvasive glaucoma surgeries are modern surgical methods that can be performed through smaller incisions and aim to support the eye’s natural drainage pathways. MIGS procedures may generally be performed in suitable selected patients with mild to moderate glaucoma and, in some cases, together with cataract surgery.

The aim of these surgeries is to facilitate aqueous outflow, reduce intraocular pressure and help reduce the need for medication. Although MIGS surgeries are less invasive than conventional glaucoma surgeries, they may not be suitable for every patient. Therefore, the treatment decision is made after a detailed eye examination and individualized assessment.
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The most important point for patients to know before glaucoma surgery is that the main purpose of these operations is not to improve vision, but to reduce intraocular pressure and slow or stop the progression of optic nerve damage. Vision loss caused by glaucoma-related optic nerve damage is often irreversible.

Surgical success may vary depending on glaucoma type, disease stage, eye structure and wound-healing response. In some patients, the target intraocular pressure may not be achieved or additional treatments may be needed over time. Therefore, a second operation, laser procedure, medication or minor postoperative corrective interventions may become necessary. Regular follow-up is very important for maintaining surgical success.

The possible risks of glaucoma surgery vary according to the type of operation and the patient’s eye structure. In general, the risk of complications may be higher in conventional glaucoma surgeries than in microinvasive glaucoma surgeries.

Temporary blurred vision or decreased vision, excessively low intraocular pressure, intraocular bleeding, infection, inflammation, swelling in the back of the eye or renewed elevation of eye pressure may occur after surgery. Some of these problems may be temporary; however, regular postoperative follow-up is essential for early detection and proper management.

Recovery after glaucoma surgery varies depending on the type of surgery and the patient’s eye structure. More frequent check-ups may be needed, especially after conventional glaucoma surgeries, to monitor intraocular pressure and wound healing closely. After surgery, patients usually need to use eye drops for several weeks and, in some cases, for up to one to three months. Temporary blurred vision or decreased vision may occur during this period. Regular examinations, correct use of drops and contacting the physician in case of unexpected complaints are important for a safe recovery process.

Minimally invasive glaucoma surgery, abbreviated as MIGS, is a general term used to describe modern glaucoma surgeries performed through smaller incisions compared with classic glaucoma operations. The aim of these methods is to facilitate the outflow of intraocular fluid and reduce intraocular pressure. MIGS procedures may be directed at the eye’s natural fluid outflow area, called the angle. This group may include small incisions made from inside or outside the eye, procedures designed to widen the drainage pathway, microimplants and shunt applications. The method is selected according to glaucoma type, disease stage, target pressure and eye structure.

MIGS surgeries are generally preferred in patients with open-angle glaucoma. Open-angle glaucoma may include different subgroups such as primary open-angle glaucoma, pseudoexfoliative glaucoma and pigmentary glaucoma. In these diseases, resistance to aqueous outflow increases, which can lead to elevated intraocular pressure. In suitable patients, MIGS methods aim to reduce this outflow resistance and help achieve better pressure control. However, not every glaucoma patient is suitable for MIGS; the decision is made after a detailed eye examination.

One of the most important advantages of MIGS surgeries is that they can be performed through smaller incisions than conventional glaucoma surgeries. Therefore, in suitable patients, recovery may be more comfortable and postoperative follow-up may be less intensive compared with classic surgeries. In addition, because some MIGS methods support the eye’s natural drainage pathways, they may provide effective results in selected patient groups. For example, angle-based MIGS surgeries such as GATT have reported successful outcomes in certain open-angle glaucoma types, especially pseudoexfoliative glaucoma. However, the effectiveness of MIGS surgeries may vary according to glaucoma type, disease stage and target intraocular pressure.
Although recovery after MIGS surgery varies according to the method used and the patient’s eye structure, it is generally shorter and more comfortable than recovery after conventional glaucoma surgery. Patients can often return to daily life earlier. In the postoperative period, monitoring intraocular pressure, using drops regularly and attending control examinations are important. In some patients, the number of glaucoma drops may be reduced or medication needs may be reorganized after surgery; however, this decision is made by the physician according to intraocular pressure follow-up.
In classic glaucoma surgeries such as trabeculectomy, long-term success rates may decrease over time and vary according to the patient group in five-year follow-up. In microinvasive glaucoma surgeries known as MIGS, high success rates have been reported in appropriately selected patients, especially in short- and medium-term follow-up. The most important long-term limitation of MIGS surgeries is that the pressure-lowering effect may become insufficient over time in some patients or the target pressure may not be reached. In such cases, the disease stage, target pressure and clinical characteristics are reassessed, and more classic glaucoma surgeries such as trabeculectomy or glaucoma drainage implant surgery may be considered. Especially in conjunctiva-sparing ab interno MIGS methods, a previously performed MIGS surgery is generally not expected to negatively affect the success of a future classic glaucoma surgery, should it become necessary.
Childhood glaucomas are most commonly encountered in two main forms: primary congenital glaucoma, which is present from birth and related to developmental abnormalities of the eye, and aphakic or pseudophakic glaucoma, which can develop after childhood cataract surgery. Primary congenital glaucoma usually presents within the first two years of life, whereas glaucoma after cataract surgery may develop months or years later and requires regular follow-up. Although medication may help control intraocular pressure in some patients, surgical methods are considered especially when adequate response to treatment cannot be achieved. The surgical option is individualized according to glaucoma type, disease severity, the child’s age, corneal status and previous surgeries.
The most typical symptoms of childhood glaucoma include excessive tearing, sensitivity to light and squeezing the eyelids shut. These findings may appear especially during infancy due to increased intraocular pressure. In some children, the eyes may appear larger than normal; cloudiness or edema may develop in the cornea, the transparent layer of the eye. Therefore, when enlargement of the eye, light sensitivity, persistent tearing or corneal haziness is noticed, a detailed eye examination for childhood glaucoma is important.
The diagnosis of childhood glaucoma is made through detailed eye examination and intraocular pressure measurement. In young children or suspected cases in which sufficient cooperation cannot be achieved, examination under general anesthesia may be required for more comprehensive assessment. During this evaluation, eye pressure is measured, the cornea and eye dimensions are examined, and the optic nerve is assessed in detail. If the diagnosis is confirmed and surgical treatment is considered necessary, surgery may be planned in the same session in suitable patients.
In primary congenital glaucoma, the main treatment approach is usually surgical. Because increased intraocular pressure in these patients is mostly caused by a developmental abnormality of the eye’s drainage angle, the first surgical options often consist of angle-based procedures. During the treatment process, eye-pressure-lowering drops may be used temporarily to control pressure; however, many cases require surgical intervention for lasting pressure control. Goniotomy, trabeculotomy and GATT surgery, which has been included among microinvasive glaucoma surgeries in recent years, are among the surgical options that may be used in suitable cases of primary congenital glaucoma. In aphakic or pseudophakic glaucoma that develops after cataract surgery, the treatment approach is determined according to disease severity and response to medication. In cases where adequate pressure control cannot be achieved with medical treatment, micropulse diode laser and glaucoma drainage implant, or tube surgery, may be considered. The choice of surgery is planned individually by taking into account the child’s age, eye structure, corneal status, previous surgeries and target intraocular pressure.
Childhood glaucoma requires lifelong regular follow-up even after treatment. In these patients, intraocular pressure may rise again over time and optic nerve damage may progress silently. Regular examinations are very important because the eyeball may be larger than normal, the cornea may become thin or cloudy, and the optic nerve may be sensitive to pressure. These children should also be closely monitored for amblyopia, refractive errors, corneal problems and cataract development.

Cataract and Premium Intraocular Lens Surgery

What is cataract?
A cataract is the loss of transparency of the eye’s natural lens, which is normally clear. This lens can be compared in shape to a small lentil and helps focus light clearly on the retina. When the lens becomes cloudy, visual quality decreases; the patient may begin to see blurred, hazy or dull images.
Cataract most commonly develops due to aging. As age advances, the structure of the lens changes and it may gradually lose its transparency. More rarely, cataract may be seen in newborn babies. Diabetes, intraocular inflammations known as uveitis, long-term corticosteroid use, eye trauma, previous eye surgeries and some systemic diseases may also lead to cataract development.
The most common symptom of cataract is blurred vision and decreased visual quality. Both distance and near vision may be affected; in some patients, deterioration in distance vision is more prominent. Glare, light scattering or halos around car headlights or streetlights at night are commonly described by cataract patients. Faded color perception, frequent changes in glasses prescription and difficulty reading may accompany these complaints. In advanced cataract cases, swelling of the lens may increase intraocular pressure and, rarely, cause eye pain.
Cataract is diagnosed by an ophthalmologist through a detailed eye examination. Visual acuity is evaluated and the lens is examined using a slit-lamp biomicroscope. During the examination, the type and density of cataract, the extent to which it affects vision and whether surgery is needed are evaluated. Other ocular structures such as the retina, cornea and eye pressure are also checked.
Cataract is most common in older age groups and usually develops due to aging. However, it is not only a disease of old age. Cataract may also develop earlier in babies from birth, during childhood, after trauma, in people with diabetes, in patients using corticosteroids or in those with certain eye diseases.
Cataract development cannot be completely stopped; however, reducing certain risk factors may help reduce the likelihood of cataract appearing at an earlier age. Protection from prolonged ultraviolet exposure, wearing sunglasses, avoiding smoking, maintaining good diabetes control and avoiding unnecessary corticosteroid use are important in this regard. However, when cataract causes significant visual impairment, the effective treatment is surgery.
Modern cataract surgery is usually performed using phacoemulsification, or the phaco technique. In this method, a small incision is created at the edge of the cornea and a controlled opening is prepared in the front capsule of the natural lens. Then, using a phaco device that applies ultrasound energy, the cloudy inner part of the lens is fragmented and removed. The outer shell of the lens, called the capsule, is preserved, and at the end of the operation an artificial intraocular lens is placed into this capsule. The implanted lens may be a standard monofocal lens or, in suitable patients, one of the specially designed lenses commonly known as smart lenses. The operation is often completed without sutures.
During the first few days after cataract surgery, blurred vision, stinging, tearing or sensitivity to light may occur. Vision usually improves and becomes clearer within days. During recovery, regular use of prescribed drops, avoiding eye rubbing, maintaining hygiene and attending follow-up examinations are important. The speed of recovery may vary depending on the patient’s eye structure, the hardness of the cataract and the presence of additional eye disease.
The need for glasses after cataract surgery depends on the type of lens implanted and the refractive planning performed before surgery. When a standard monofocal lens is used, distance vision is usually targeted and patients may need glasses for near reading. In patients with astigmatism, near vision needs or specific visual expectations, toric, multifocal, trifocal or EDOF lens options may be considered.
If left untreated, cataract may progress over time and lead to significant deterioration in visual quality. In advanced cataracts, surgery may become technically more difficult and the recovery period may be prolonged. In some cases, cataract progression may cause intraocular pressure to rise. Therefore, in cataracts that significantly affect vision or pose a risk to eye health, surgical treatment should be planned at the appropriate time.

Premium Intraocular Lens / Smart Lens

What is a smart lens?
“Smart lens” is a commonly used term in Türkiye for specially designed intraocular lenses used during cataract surgery, in which the patient’s clouded natural lens is removed and replaced with an artificial lens. Depending on the selected lens type, these lenses aim to support distance, near and intermediate vision such as computer-screen distance. The goal is to reduce the patient’s need for glasses in daily life and provide more comfortable vision at different distances.
Smart lenses may primarily be considered in suitable patients who have cataract and aim for greater independence at different visual distances after surgery. In addition, intraocular lens surgery may be an option in some patients who do not have cataract but use glasses because of myopia, hyperopia, astigmatism or age-related near vision problems. However, this decision should be made by evaluating the patient’s age, eye structure, corneal and retinal status, intraocular pressure, occupation and visual expectations together.
Standard intraocular lenses are usually monofocal. With these lenses, distance vision is often targeted and patients may need glasses for near vision after surgery. With multifocal, trifocal or EDOF lenses commonly referred to as smart lenses, the aim is to support not only distance vision but also intermediate and near vision. However, not every lens type is suitable for every patient; lens selection should be based on a detailed eye examination and individualized assessment.
Smart lens surgery is essentially performed according to the principles of standard cataract surgery. Using the modern cataract surgery method called phacoemulsification, the patient’s natural lens is removed and a special intraocular lens selected according to the patient’s eye structure is implanted. If a toric lens is planned in patients with astigmatism, special marking and measurement methods may be required before or during surgery. The operation is generally performed under local anesthesia, meaning that only the eye is anesthetized.
The duration of smart lens surgery may vary depending on whether the patient has cataract, the hardness of the cataract, the eye structure and the lens type to be used. Although it is generally a short surgical procedure, the average operation time is approximately 20 to 30 minutes. The duration may be longer in more complex eyes or advanced cataract cases.
In the first few days after surgery, blurred vision, light sensitivity or mild stinging may occur. Vision usually becomes clearer within days; however, full adaptation may vary according to the lens type used and the patient’s eye structure. During this period, regular use of prescribed drops, avoiding eye rubbing and attending follow-up examinations are important.
Smart lenses consist of groups of lenses with different designs. Trifocal lenses aim to support distance, intermediate and near vision, whereas EDOF lenses aim to provide high visual quality especially at distance and intermediate ranges by increasing depth of focus.
Because smart lenses are implanted through phaco surgery, known as cataract surgery, the general risks of this surgery may rarely occur. These may include infection, changes in intraocular pressure, inflammation, corneal edema, retinal problems or lens-position-related issues. Today, modern cataract surgery is performed with advanced technology and high safety standards; however, as with every surgical procedure, risk is not zero. In addition, some patients may experience glare, halos, light scattering or changes in contrast sensitivity at night due to the optical structure of the lens.
The aim of smart lenses is to reduce the patient’s dependence on glasses in daily life as much as possible. With appropriate patient selection and correct lens choice, many patients may experience a significant reduction in the need for glasses at distance, intermediate and near ranges. However, it would not be correct to guarantee that glasses will never be needed. Some patients may require low-power near glasses for reading very small print, seeing near objects in low light or performing prolonged detailed work.
Age-related near vision loss, or presbyopia, usually occurs after the age of 40 as the natural lens loses its focusing ability. Smart lenses may be considered as a surgical option for this near vision need in suitable patients. Especially in patients with cataract or those found suitable for intraocular lens surgery, the selected lens type may aim to support near and intermediate vision. Suitability should be decided after a detailed eye examination.

After surgery, patients should use the prescribed drops as recommended and attend follow-up examinations regularly. During the first days, the eye should not be rubbed, hygiene should be maintained and heavy activities should be avoided for the period recommended by the physician. Patients can often return to daily life within a short time; however, the recovery process may vary from person to person. In case of sudden vision loss, severe pain, marked redness or intense discharge, the physician should be contacted without delay.

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