Surgical management of glaucoma pgs

Surgical Management of Glaucoma

Delivered by:

Cesar A. Perez, Jr. MD, DPBOPrepared by

Philippine Glaucoma SocietyThursday, April 7, 2011

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Outline

• Overview• Trabeculectomy

– Indications, technique & post-operative care

• Laser iridotomy– Indications, technique & post-op care

Thursday, April 7, 2011

TRABECULECTOMY


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Indications for glaucoma surgery


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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous

progression in spite of maximum tolerated medical therapy


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• Poor compliance with medical therapy– Relative indication. Maximize compliance 1st


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• Pupillary block angle closure glaucoma– Laser iridotomy 1st, then give medications if there is residual elevated IOP


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• Synechial angle closure for @ 360 degrees– May go straight to trabeculectomy


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• Synechial angle closure for @ 360 degrees– May go straight to trabeculectomy

• Congenital glaucoma– Definitive treatment is surgery



POAG


POAG


POAG

Medical Tx


POAG PACG

Medical Tx


POAG PACG

Medical Tx


POAG PACG

Medical Tx

LaserIridotomy


POAG PACG

Medical Tx

LaserIridotomy


POAG PACGSecondary glaucoma

Medical Tx

LaserIridotomy



Medical Tx

LaserIridotomy



Medical Tx

LaserIridotomyTreat primary

cause, if possible



Medical Tx


cause, if possible



Congenital glaucoma

Medical Tx


cause, if possible



Congenital glaucoma

Medical Tx


cause, if possible



Congenital glaucoma

Medical Tx

LaserIridotomy

Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy

Treat primary cause, if possible



Congenital glaucoma

Medical Tx

LaserIridotomy





Congenital glaucoma

Medical Tx

LaserIridotomy





Congenital glaucoma

Medical Tx

LaserIridotomy



No superior conjunctival scarring, relatively “quiet eye “; > 2y/o



Congenital glaucoma

Medical Tx

LaserIridotomy






Congenital glaucoma

Medical Tx

LaserIridotomy




Trabeculectomy + mitomycin-C



Congenital glaucoma

Medical Tx

LaserIridotomy







Congenital glaucoma

Medical Tx

LaserIridotomy




•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies




Congenital glaucoma

Medical Tx

LaserIridotomy








Congenital glaucoma

Medical Tx

LaserIridotomy








Congenital glaucoma

Medical Tx

LaserIridotomy






Glaucoma drainage device, preferably by a GL specialist



Congenital glaucoma

Medical Tx

LaserIridotomy





Poor visual Potential

(LP-NLP)





Congenital glaucoma

Medical Tx

LaserIridotomy






(LP-NLP)





Congenital glaucoma

Medical Tx

LaserIridotomy






(LP-NLP)



Consider transcleral cyclophoto-

coagulation if w/ pain



Congenital glaucoma

Medical Tx

LaserIridotomy






(LP-NLP)







Congenital glaucoma

Medical Tx

LaserIridotomy






(LP-NLP)







Congenital glaucoma

Medical Tx

LaserIridotomy






(LP-NLP)




coagulation if w/ painLegend:

Uncontrolled IOP


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Traction suture


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Traction suture

Peripheral cornea


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Traction suture

Peripheral cornea Superior rectus


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Traction suture

• For good exposure of the surgical site

– Peripheral cornea• Concerns:

– Perforation of the cornea

– Superior rectus• Concerns:

– Greater potential for bleeding– Risk of ptosis post-op


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Conjunctival Peritomy: Fornix based


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Conjunctival Peritomy: Fornix based

• Easier to create

• Easier exposure & dissection of the sclera

• Creates a more posterior diffuse bleb

• May be more prone to leaks if not closed properly


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Conjunctival Peritomy: Limbal based


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Conjunctival Peritomy: Limbal based

• More difficult dissection & exposure

• Better water-tight closure


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Cauterization of episcleral vessels


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Removal of residual episcleral tissues

JA Tumbocon, MD


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Application of Anti-metabolites


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Application of Anti-metabolites• Mitomycin-C 2mg/ vial

– Concentration: 0.25 to 0.5 mg/ml– Duration: 1 to 5 minutes– Concentration & duration is dependent on the

appearance of the conjunctiva & presence of risk factors for failure


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Application of Anti-metabolites• Mitomycin-C 2mg/ vial

– Concentration: 0.25 to 0.5 mg/ml– Duration: 1 to 5 minutes– Concentration & duration is dependent on the

appearance of the conjunctiva & presence of risk factors for failure

• 5-Fluorouracil 250mg/ml– Intra-op: 0.5ml (25mg) to 1ml (50mg) for 5 mins– Post-op: 0.1ml (5mg) subconjunctival injection

daily for 7-14 days (Total dose not to exceed 50mg or 1ml.)


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Application of Anti-metabolites


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Irrigate copiously


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Scleral Flap Dissection

• 1/3 to 1/2 scleral thickness– Thinner flap = more

aqueous flow

• Shapes: – square, rectangular,

trapezoidal, triangular


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Scleral Flap Dissection


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Paracentesis


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Limbal Fistula


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Limbal FistulaDescemet’s punch


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Limbal Fistula Knife & Vannas scissors


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Limbal Fistula Knife & Vannas scissors


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Peripheral Iridectomy


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• Iris usually prolapses through after creation of the the limbal fistula

• Iridectomy should be wider than the limbal fistula/ internal sclerectomy

• Better too wide than too small


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Scleral Flap closure


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Scleral Flap closure

• 10-0 Nylon suture

• May use 2 to 6 interrupted sutures

• Burry all suture knots


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Scleral Flap closure• No standard number or tightness

of sutures

• Should be able to visualize minimal aqueous flow through the borders of the scleral flap after AC reformation

– Add more sutures if there is excessive aqueous flow

– Loosen or remove sutures if there is no flow

• Better to err on the “tight side”


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Conjunctival Closure Limbal based peritomy

JA Tumbocon, MD


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Conjunctival Closure Fornix based peritomy


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Reform AC, note for elevation of the bleb & check for leaks


JA Tumbocon, MD


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Trabeculectomy: Post-op care


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Trabeculectomy: Post-op care• Follow-up closely

– Success = 50% surgery + 50% post-op care


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– Success = 50% surgery + 50% post-op care• Keep aqueous flowing

– Massage, laser suture lysis &/ or removal of releasable scleral flap sutures


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• Topical steroids (usually for 6-12 weeks)


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• Prophylactic topical antibiotic


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• Prophylactic topical antibiotic• + Cycloplegic agent (e.g. Atropine)

– Stabilizes blood-aqueous barrier– Pulls lens-iris diaphragm posteriorly


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JA Tumbocon, MD

http://www.glaucomatoday.com/art/0305/0305sp.pdf




Thank you


Laser I r idotomy


Laser Iridotomy• Mechanism

– Creates a bypass route for the aqueous to flow from the posterior to the anterior chamber & thus relieve relative or absolute pupillary block

• Lasers– Nd:YAG Laser– Argon Laser– Diode Laser


Interruption of Pupillary block• Creation of a hole in the outer

half of the iris (iridotomy / iridectomy

– allows fluid from the PC to enter to the AC, bypassing the pupillary block

– equalization of pressure in both chambers

– peripheral iris falls posteriorly

– opens the appositionally closed angle


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Laser Iridotomy

• Indications:

– Relative pupillary block / primary angle closure

– Occludable angles– Occlusio pupillae– Fellow eye of patients w/ unilateral

angle closure (prophylactic L.I.)


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Laser Iridotomy• Other Indications:

– Nanophthalmos/ crowded “middle segment”

– Prevent pseudophakic or aphakic pupillary block

– With the use of post-vitrectomy silicone oil (inferior iridectomy)

– Can be used as initial therapy in:• Phacomorphic glaucoma

• Plateau iris


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Laser IridotomyPre-op evaluation: Gonioscopy

Closed angles Opens on indentation gonioscopy


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Laser Iridotomy

• Pre-laser medications– Brimonidine – Proparacaine– Pilocarpine (optional)


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Abraham lens

Magnifies view & has 4x laser beam minification (increases power concentration)


Laser Iridotomy site

• Supero-temporal or supero-nasal peripheral iris

• Choose an iris crypt, if available

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Laser Iridotomy site


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Laser Iridotomy

• Nd: Yag (1064nm wavelength)

• Argon

• Frequency doubled CW Nd: YAG (532 nm wavelength / “Green Laser”)

• Diode

“ThermalLasers”


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Nd: YAG Laser Iridotomy

• Suggested Settings: – 2-6 mJ– 1-4 pulses / burst

• Less bursts for phakic eyes

– 2-4 bursts


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Nd: YAG Laser Iridotomy

• Advantages:– Fewer applications needed for

perforation– Less inflammation– Greater tendency to remain

patent

• Disadvantages:– Possibility of bleeding from the

treatment site


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Argon Laser Iridotomy Techniques


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Argon Laser Iridotomy Techniques“Chipping Technique”

• Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs– Short pulse duration: 1000-1500mW, 50 um,

0.02-0.05 secs


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Argon Laser Iridotomy Techniques“Chipping Technique”

• Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs– Short pulse duration: 1000-1500mW, 50 um,

0.02-0.05 secs


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Argon Laser Iridotomy Techniques“Hump technique”

– Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only• Perforation: 1000mW, 50um, 0.2sec


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Argon Laser Iridotomy Techniques“Hump technique”

– Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only• Perforation: 1000mW, 50um, 0.2sec


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Argon Laser Iridotomy Techniques“Drumhead technique”

– Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns• Perforation: 500mW, 50um, 0.2sec


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Argon Laser Iridotomy Techniques“Drumhead technique”

– Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns• Perforation: 500mW, 50um, 0.2sec


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Argon Laser Iridotomy

• Advantage:– Less potential for bleeding

• Disadvantage:– Requires more energy and more prone to

closure than Nd:YAG iridotomy


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Combined Argon & Nd: YAG Laser Iridotomy

• Suggested Settings:– Argon: Use “chipping, drumhead or hump” technique

settings to thin out the iris. – Nd:YAG for perforation: 1.5 - 5mJ, 1-2 pulses/burst,

1-2 burstsThursday, April 7, 2011

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Combined Argon & Nd: YAG Laser Iridotomy

• Suggested Settings:– Argon: Use “chipping, drumhead or hump” technique

settings to thin out the iris. – Nd:YAG for perforation: 1.5 - 5mJ, 1-2 pulses/burst,

1-2 burstsThursday, April 7, 2011

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Laser Iridotomy

• Endpoint

– Rush of pigment bearing aqueous through the iridectomy

– Deepening of the AC

– Presence of a retro-illuminated red reflex (not definite sign of a patent iridotomy)

– Visualization of anterior lens capsule through the iridectomy


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Laser Iridotomy


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Pre-L.I. Post-L.I.

Laser Iridotomy


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Laser Iridotomy

• Immediate post-laser – Check IOP hourly for at least 3 hours

(check for IOP spike)

– Topical steroids x 3-7 days


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Laser Iridotomy

• Potential Complications– IOP elevation– Persistent iritis– Corneal burns– Corectopia– Localized lenticular opacities– Posterior synechiae formation– Iris atrophy– Possibility of retinal burns (argon)– Late iridotomy closure


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Laser Iridotomy

• Post L.I. follow up– Patency of iridotomy– IOP – Gonioscopy: Monitor the irido-corneal angle.

May still close in spite of a patent iridotomy (possibly by other non-pupillary block mechanisms)

Long-term follow up is essential


Thank you


Documents

Surgical management of glaucoma pgs