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FULL PANRETINAL PHOTOCOAGULATION IMPROVES THE OUTCOME OF
TRABECULECTOMY IN NEOVASCULAR GLAUCOMA
Saleh alobeidan MD
Essam osman FRCS
Saleh alamro FRCS
Ahmed Abuelasrar MD PhD
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Neovascular Glaucoma is one of the mostChallenging forms of secondary glaucomas. It
occurs when the fibrovascular tissue proliferates onto the chamber angle, obstructs the trabecular
meshwork, and produces peripheral anterior synechiae and progressive angle closure. The
elevated intraocular pressure is often difficult to control and frequently results in loss of vision.
FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
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TUBE SURGERY IN NVG“ 60 eyes long term results ”
_______________________________________
Success rate : 62.1% at 1 year 10.5% at 5 years
Complications : 48 % lost light perception 18% phthysis bulbi
Mermoud A. et alOphthalmology, June 1993
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5 FU FILTERING SURGERY IN NVG“ 34 eyes long term results ”
_______________________________________
Success rate : 71% at 1 year 28% at 5 years
Complications : 35 % lost light perception 24% phthysis bulbi
Tsai J.C. et alOphthalmology, June 1995
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
“If the neovascular element can be removed and further neovascularisation
prevented, then we are left with an uncomplicated angle-closure problem
which should be amenable to classical drainage surgery.”
Flanagan D.W. & Blach R.K. Br J. Ophtamol 1983;67,526-8
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
• Steps of management• Admission.• Topical steroids.• Atropine drops.• Antiglaucoma RX.• Full PRP.• MMC Trab.• Close follow up.• Prolonged tapering of steriods.
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
PATIENT DEMOGRAPHICS(23 eyes, 21 patients)
Patients and methods
Gender: M 15 F 8
Age: (yrs.) Mean 53.1+ 10.4 Range 32-72
Etiology of NVG : DR 19 CRVO 4
Lens Status: Phakic 20 Pseudophakic 3
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVGPATIENT DEMOGRAPHICS
(23 eyes; 21 patients)Patients and methods
Initial IOP mmHg: Mean 53.1+10.7 Range 20-55 mmHg Gonioscopy: Open - 4 Closed - 14 NA - 5 Initial V/A: Range HM - 20/40 PRP:
No. of shots mean 1293.7+337.7Rubeosis at surgery: 3 Cases
No. of medications: Mean 3.0+0.3 Range 2-4
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
Surgical Technique__________________________________________
Procedure - Standard Trabeculectomy - Mitomycin “C” 0.2mg/ml/2mins.
Precautions - Gradual decompression of the eye
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VIDEO
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
_______________________________________
Short Term Complications: Transient hypotony - 14/23 (61%) Hyphema - 8/23 (35%) Choroidal Detachment - 2/23 (9%) Leaking Bleb - 1/23 (4%)
Long Term Complications: Cataract prog. – 2/23 (9%) NLP Hypotony Maculopathy Non Phthisis Bulbi
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CRITERIA FOR SUCCESS _______________________________________
Complete success IOP < 22 mmHg without medications
Qualified success IOP < 22 mmHg with medications
Complete failure Eyes required further surgery to control IOP
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
Results
F/U: 24.3+25.1 (3-94 mos.)Preop IOP: 53+10.7 Final IOP: 14.0+4.9 (6-22 mmHg)
(P<0.001; Wilcoxon Test)
Final V/A: HM – 20/40 9/23 measurable improvement 5/23 no change 9/23 VA
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
Results
No. of Preop med : 3.0+3 (2-4)
No. of Postop med : 0.2+0.5 (0-2) (P<0.001; Wilcoxon Test)
Bleb: Present in all cases at the last follow-up.
continuation
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
SUCCESS RATE_______________________________________
Complete Success 20/23 (87%)
Qualified Success 3/23 (13%)
continuation
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PRP FOLLOWED BY TRABECULECTOMY IN NVG
__________________________________________Table 1.1
Previous Studies(16 eyes)
Current Study(23 eyes)
Age
Mean
Range
56.44+7.8
19-80
53.1+10.4 years
32.72
Etiology
DR
CRVO
7 (43.7%)
9 (56.2%)
19 (82.61%)
4 (17.39%)
Presenting IOP
Mean
Range
48.8+10.4
32-68
53.1+10.7
20-55Allen et al. Ophthalmology 1982;89:1181-7D.W. Flanagan & R.K. Blach. Br JO 1983;67:526-8
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PRP FOLLOWED BY TRABECULECTOMY IN NVG
__________________________________________Table 1.2
Previous Studies(16 eyes)
Current Study(23 eyes)
Final IOP
Mean
Range
20.3+8.5
11-42
14.0+4.9
6-22
F/U (months)
Mean
Range
12.00+7.1
1-33
24.3+25.1
3-94
Success
Complete
Qualified
Failure
8(50%)
5(31.2%)
3(18.7%)
20 (86.96%)
3 (13.04%)
Allen et al. Ophthalmology 1982;89:1181-7D.W. Flanagan & R.K. Blach. Br JO 1983;67:526-8
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• FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
• “If the neovascular element can be removed and further neovascularisation prevented, then we are left with an uncomplicated angle-closure problem which should be amenable to classical drainage surgery.”
Flanagan D.W. & Blach R.K. Br J. Ophtamol 1983;67,526-8
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FULL PRP IMPROVES THE OUTCOME OF TRABECULECTOMY IN NVG
• It is our impression that patients whose retinal disease is well treated before filteration surgery do much better surgically than those who are not.
• It is also our impression that mitomycin C produces better results, at least for the first year, than does 5 FU. After only another 10 years will we know if these additional medications will further enhance the long term results of filteration surgery in eyes with NVG.
Rich.R Ophthalmology 1995
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5CONCLUSION
Neovascular glaucoma is a treatable condition
•Full PRP improves the outcome of trabeculectomy with MMC.
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