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An important lesson I learned during my professional life – which also extends to my personal life – is that everyone in this world can teach me something. I spend a majority of my time pursuing excellence in ophthalmology with a focus on glaucoma and cataracts. My dedication to these areas, however, leaves me deficit in knowledge in other sections of life. This drives me to learn as much as I can from others who do have that wisdom. One group I respect and study are plumbers. When we really break it down, we face the same problem everyday: restoring the proper flow of fluid. The only major difference is the location in which we operate (no pun intended). One interesting note is that the best solutions to our problems revolve around re-establishing nature drainage. And it is this approach that provides the optimal results.
Let’s see how this analogy to plumbing can help us strategize when we are thinking about glaucoma. In a normal eye, aqueous is made by the ciliary process and eventually exits the anterior chamber through the trabecular meshwork. The meshwork, like a sieve in your sink, is the area of greatest resistance to flow and represents a major source of obstruction if clogged. Over time due to changes in this and distal structures to it, the outflow system becomes impenetrable. The accumulation of aqueous leads to elevated intraocular pressure with subsequent damage to the optic nerve in the form of glaucoma.
When most people are faced with the challenge of a clogged drain, their primary objective is to divert the fluid out of the kitchen sink. The good news is that there are several ways to address this dilemma. However, some answers are clearly better than others. One method is to leave the kitchen and go outside of the house to locate the external wall that is adjacent to the sink. Then you can make a hole through that wall and just let the fluid run out of the house. That is one way of doing it which works but typically leaves your significant other wondering why you took such an extreme approach. In the world of glaucoma, this would be a trabeculectomy or tube shunt surgery.
Another approach that would be viable and certainly less destructive would be to create an emergency opening through your sink located near the original drain in case the fluid level ever reaches a certain threshold. This method would address the problem, but the flow of water distally would not connect to the rest of the plumbing in your house. What’s the end result? Your kitchen floor would be all wet and your kids would be asking if you couldn’t have come up with another plan. This would be similar to that of suprachoroidal shunting of aqueous.
This leaves us with what a plumber, and most other people, would first try to do: fix the problem at its real root – the clogged drain itself. After all, your home was built specially to have a plumbing system in place to efficiently and effectively utilize the sink as a passage way for water. It represents the most natural way to address the issue and doesn’t create secondary problems with water in uncommon areas. What does all this mean? This solution provides the best benefit-to-risk profile of any available choices.
Restoring the flow of aqueous through the diseased trabecular meshwork and opening up any clogged channels beyond that point is the same approach as addressing the obstructed drain in your kitchen. The exciting news is that you, as the “eye plumber”, have the tools and ability to solve this problem yourself. It can be achieved through a two-pronged approach with SLT and ABiC. The application of SLT will eventually lead to improving flow through the resistant meshwork while ABiC will clean up Schlemm’s Canal and distal collector channels that may be contributing to the obstruction to flow. It is safe, effective, and natural. For most patients with glaucoma, especially those with mild to moderate levels, this approach can successfully address their issues.
The thought process of addressing glaucoma is similar to that of a plumber facing an overflowing sink. The beauty of having technology like SLT and ABiC is that you don’t have to make major changes or utilize solutions that create more problems while being unnatural. Not only will you be able to address the underlying problem but also your finished product will look professional to anyone viewing your work. So, before calling in a general contractor to redo a wall in your house, ask yourself what your friendly plumber would do first.