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Efficacy of Punch Trabeculectomy in different types of Glaucoma
Dr. Anand Sudhalkar
Baroda.
Acknowledgements:
Dr. Sandhya
Dr. Shubhangi
Ms. Dhruti
Mr. Mayank Rao
Introduction:
IOP the only Modifiable Risk Factor in glaucoma management
Maintaining IOP below the Target reduces field loss and improves optic nerve circulation.
R. Vogel et al. Association between intraocular pressure and loss of visual field in chronic simple glaucoma
BJO 1983; vol 67, 220-227, G. Gazzard Intraocular pressure and visual
field loss in primary angle closure and primary open angle glaucomas BJO 2003; 87:720-725
Popovi. Target intraocular pressure in the
management of glaucoma. Coll Antropol 2005; 29 Suppl 1:149-51.
Anders Heijl. Reduction of Intraocular
Pressure and Glaucoma Progression, Arch Ophthalmol. 2002; 120:1268-1279.
AIM:To compare the IOP lowering efficacy
Medical treatment v/s Standardized Punch trabeculectomy
surgery without anti-metabolites.
Vernon: Medium to long term intraocular pressure control following small flap trabeculectomy (microtrabeculectomy) BJO 1998;82:1383-1386
Stalmans, Gillis: Safe trabeculectomy technique: long term outcome. BJO 2006; 90(1):44-7
Material:
46 eyes of 41 patients subjected to Punch Trab. after Trial of medical treatment.
POAG – 22 PNAG – 19 ACUTE CONGESTIVE – 5.
Methods:
Complete eye examination Gonioscopy Autoperimetry (Octopus) Mean Baseline IOP: with Non Contact
Applanation tonometry at 8 am, 3 pm and 8 pm
Mean Baseline IOP and Age group
Report
22.00 38.00
50.00 78.00
31.36 63.7273
22 22
25.00 45.00
45.00 82.00
31.11 62.3158
19 19
28.00 42.00
51.00 89.00
41.60 62.0000
5 5
22.00 38.00
51.00 89.00
32.37 62.9565
46 46
Minimum
Maximum
Mean
N
Minimum
Maximum
Mean
N
Minimum
Maximum
Mean
N
Minimum
Maximum
Mean
N
TYPE OF GLAUCOMAPOAG
PNAG
ACUTE NAG
Total
BASELINEIOP AGE
Target IOP calculations
Initial Target IOP: 20 to 40% reduction from Baseline IOP
•Sonal Wadhwa, Comprehensive ophthalmological update volume 6, in November 2005.
Dynamic Resetting Target by quantifying Fields
The VF score is calculated as follows: First, neighboring points are defined as those adjacent to a given point, whether on a side or a corner. Each of the 52 points in the field is individually graded. A point is called defective if its probability is 0.05 or less, and it has at least two neighboring points with probabilities of 0.05 or less in the same vertical hemifield (superior or inferior). A weight is assigned depending on the minimum depth of the defect at the given point and the two most defective neighboring points. A minimum defect of 0.05, 0.02, 0.01, and 0.005 is given a weight of 1, 2, 3, and 4, respectively. A point without two neighboring points all depressed to at least P ≤ 0.05 is given a weight of zero. For example, a point at P ≤ 0.01 with only two neighboring points of defect, both at P ≤ 0.05, would receive a weight of 1. The weights for all 52 points in the field are summed, resulting in a value between 0 and 208 (52 x 4). The sum is then scaled to a range of 0 to 20 (dividing the sum by 10.4), to yield values in the same range as the VF score previously developed by the Advanced Glaucoma Intervention Study (AGIS).1 The resultant score is a nearly continuous measure of VF loss.
Further reduced by deducting the mean deviation from the field report.(Dr. Curt Hartleben)
Brenda W. Gillespie (Investigative Ophthalmology and Visual Science. 2003; 44:2613-2620.)
Final Target IOP
Report
31.3636 11.1818 62.804022 22 22
7.0139 3.0022 12.5870
22.00 5.00 40.00
50.00 16.00 85.71
31.1053 12.9474 57.196519 19 19
5.4964 3.1530 12.5673
25.00 6.00 40.00
45.00 17.00 82.86
41.6000 16.0000 60.40625 5 5
8.4439 2.4495 9.0189
28.00 13.00 46.43
51.00 19.00 69.05
32.3696 12.4348 60.227246 46 46
7.2122 3.3176 12.3072
22.00 5.00 40.00
51.00 19.00 85.71
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
TYPE OF GLAUCOMA1 POAG
2 PNAG
4 ACUTE NAG
Total
BASELINE IOP TARGETED IOP % fall Targeted
Medical Management Protocol:
Monotherapy: Baseline IOP < 30mm Hg (28 eyes): Beta Blockers or Alpha 2 agonist
Combination therapy: IOP > 30 mm Hg (18 eyes):+ Latanoprost in POAG and + Pilocar 2% or Dorzolamide in PNAG.
Maximum Medical Therapy (all cases):+ Oral tab. Acetazolamide and + I.V. Inj Mannitol 20%
Duration of Medical Treatment Trial
POAG: 3 months to 2 Years PNAG: 2 months to 1 year Acute Glaucoma: 2 to 7 days
Surgical Technique: Trab+Phaco
Upper nasal site(A. K. Negi and Vernon)
Fornix based conj. Flap Triangular scleral flap upto
clear cornea Temporal Phaco incision Complete Phaco surgery Extend the tunnel into clear
cornea Kelly’s Punch Iridectomy Closure
Surgery: post op follow up: (Mean 13 months)
Bleb Enhancement by Pressure on globe
Post OP Complications
Bleb Related: NIL Endophthalmitis: NIL Hyphema: 1. in POAG Group Choroidal Effusion: 2, one each in POAG and
Acute narrow angle glaucoma patients. All resolved after conservative management. Post Trab. Cataract formation NIL in 9 eyes
followed up 12 months.
RESULTS: % fall in IOP
Report
31.3636 11.1818 62.8040 20.4406 33.3008 45.850 54.650722 22 22 13 22 22 22
7.0139 3.0022 12.5870 5.5533 8.9548 9.1722 13.5614
22.00 5.00 40.00 11.54 12.00 29.03 26.92
50.00 16.00 85.71 31.03 51.28 61.54 78.00
31.1053 12.9474 57.1965 15.5996 28.4540 43.135 60.925919 19 19 13 19 19 19
5.4964 3.1530 12.5673 7.3971 13.0915 12.9324 12.2529
25.00 6.00 40.00 6.67 7.69 23.33 40.74
45.00 17.00 82.86 28.00 66.67 73.33 87.50
41.6000 16.0000 60.4062 7.1429 28.0626 40.733 63.53695 5 5 1 5 5 5
8.4439 2.4495 9.0189 . 10.9979 11.4755 12.8050
28.00 13.00 46.43 7.14 13.73 25.49 42.86
51.00 19.00 69.05 7.14 44.44 55.56 74.51
32.3696 12.4348 60.2272 17.6173 30.7295 44.172 58.208546 46 46 27 46 46 46
7.2122 3.3176 12.3072 7.0518 11.0877 11.0004 13.1497
22.00 5.00 40.00 6.67 7.69 23.33 26.92
51.00 19.00 85.71 31.03 66.67 73.33 87.50
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
TYPE OF GLAUCOMA1 POAG
2 PNAG
4 ACUTE NAG
Total
BASELINE IOP TARGETED IOP % fall Targeted% fall with
Monotherapy
% fall withcombination
Therapy
% reductionwith MAX.
MEDTREATMENT
ications% reductionwith surgery
Comparison between Trab and Trab with Phaco at separate sites
Ref. Lochhead J BJO 2003;87(7)850-2
Report
38.44 14.444 60.51 41.590 66.1329 9 9 9 9
9.5931 2.6034 11.1551 13.1573 13.1955
23.00 10.00 43.33 23.33 43.48
51.00 19.00 75.00 61.54 87.50
30.89 11.946 60.16 44.801 56.28137 37 37 37 37
5.7532 3.3162 12.7144 10.5223 12.5673
22.00 5.00 40.00 29.03 26.92
45.00 18.00 85.71 73.33 76.92
32.37 12.435 60.23 44.172 58.20946 46 46 46 46
7.2122 3.3176 12.3072 11.0004 13.1497
22.00 5.00 40.00 23.33 26.92
51.00 19.00 85.71 73.33 87.50
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
Mean
N
Std. Deviation
Minimum
Maximum
SINGLE OR COMBINEDONLY TRAB
COMBINED PHACO
Total
BASELINEIOP
TARGETEDIOP
% fallTargeted
% reductionwith MAX.
MEDTREATMENTi
cations% reductionwith surgery
Relax Target by 1Std. Dev.
Report
62.8040 51.7566 54.6507
40.00 25.82 26.92
85.71 76.23 78.00
12.5870 14.1401 13.5614
22 22 22
57.1965 46.2435 60.9259
40.00 26.72 40.74
82.86 73.37 87.50
12.5673 13.5832 12.2529
19 19 19
60.4062 52.0953 63.5369
46.43 34.57 42.86
69.05 61.14 74.51
9.0189 10.7935 12.8050
5 5 5
60.2272 49.5162 58.208540.00 25.82 26.92
85.71 76.23 87.50
12.3072 13.6080 13.1497
46 46 46
Mean
Minimum
Maximum
Std. Deviation
N
Mean
Minimum
Maximum
Std. Deviation
N
Mean
Minimum
Maximum
Std. Deviation
N
Mean
Minimum
Maximum
Std. Deviation
N
TYPE OF GLAUCOMA1 POAG
2 PNAG
4 ACUTE NAG
Total
% fall Targeted% reductionTarget + 1SD
% reductionwith surgery
Post Op Success Analysis:
Complete: 35/46 eyes (76.08%) Qualified: 7/46 eyes (15.2%) Failure: 4/46 eyes (8.62%).
91.28%
Paired Sample “t” Test to compare Target IOP with the IOP reduction in various groups:
Paired Samples Statistics
32.3696 46 7.2122 1.0634
12.4348 46 3.3176 .4892
22.5481 27 2.7127 .5221
12.2593 27 2.9167 .5613
22.1739 46 5.4255 .7999
12.4348 46 3.3176 .4892
17.8891 46 4.9716 .7330
12.4348 46 3.3176 .4892
13.0000 46 3.2931 .4855
12.4348 46 3.3176 .4892
BASELINE IOP
TARGETED IOP
Pair 1
Monotherapy
TARGETED IOP
Pair 2
Combination Therapy
TARGETED IOP
Pair 3
MAX. MED. TREATMENT
TARGETED IOP
Pair 4
POST OP IOP WITHOUTMEDICINE
TARGETED IOP
Pair 5
Mean N Std. DeviationStd. Error
Mean
Paired Samples Correlations
46 .221 .141
27 .131 .515
46 .276 .063
46 .357 .015
46 .053 .727
BASELINE IOP &TARGETED IOP
Pair 1
Monotherapy &TARGETED IOP
Pair 2
Combination Therapy &TARGETED IOP
Pair 3
MAX. MED. TREATMENT& TARGETED IOP
Pair 4
POST OP IOP WITHOUTMEDICINE & TARGETEDIOP
Pair 5
N Correlation Sig.
Paired Samples Test
19.9348 7.2431 1.0679 17.7839 22.0857 18.667 45 .000
10.2889 3.7137 .7147 8.8198 11.7580 14.396 26 .000
9.7391 5.5234 .8144 8.0989 11.3794 11.959 45 .000
5.4543 4.8938 .7216 4.0011 6.9076 7.559 45 .000
.5652 4.5492 .6707 -.7857 1.9162 .843 45 .404
BASELINE IOP -TARGETED IOP
Pair 1
Monotherapy - TARGETEDIOP
Pair 2
Combination Therapy -TARGETED IOP
Pair 3
MAX. MED. TREATMENT -TARGETED IOP
Pair 4
POST OP IOP WITHOUTMEDICINE - TARGETED IOP
Pair 5
Mean Std. DeviationStd. Error
Mean Lower Upper
95% ConfidenceInterval of the
Difference
Paired Differences
t df Sig. (2-tailed)
Conclusion:
Consistent & substantial (>50%) lowering of IOP is obtained only after surgical intervention.
A standardized surgical technique assures the safety and consistency.
The cost of life-long medication and compliance needs special consideration when prescribing topical medications.
