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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.