Surgical management of glaucoma pgs

Surgical Management
of Glaucoma

Delivered by:

Cesar A. Perez, Jr. MD, DPBO
Prepared by

Philippine Glaucoma Society
Thursday, April 7, 2011

Outline
• Overview
• Trabeculectomy
– Indications, technique & post-operative
care
• Laser iridotomy
– Indications, technique & post-op care

2


TRABECULECTOMY


Indications for glaucoma surgery

4


• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical
therapy

4


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

4


therapy

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

4


therapy


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

4


therapy


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

• Congenital glaucoma
– Definitive treatment is surgery

4


POAG


POAG

Medical Tx


POAG PACG

Medical Tx


POAG PACG

Laser
Iridotomy

Medical Tx


Secondary
POAG PACG
glaucoma

Laser
Iridotomy

Medical Tx


Secondary
POAG PACG
glaucoma

Laser
Treat primary Iridotomy
cause, if possible

Medical Tx


Secondary Congenital
POAG PACG glaucoma
glaucoma

Laser
Treat primary Iridotomy
cause, if possible

Medical Tx


POAG PACG glaucoma
glaucoma

Laser Refer to GL specialist:
Treat primary Iridotomy •Goniotomy, trabeculotomy,
cause, if possible
or combined trabeculotomy
+ trabeculectomy
Medical Tx


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

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


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

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

Trabeculectomy
+ mitomycin-C


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

No superior conjunctival •Any condition that has a high risk for
scarring, relatively failure for Trab w/ MMC
“quiet eye “; > 2y/o - scarred superior conjunctivae
- active proliferative membrane
in the AC (e.g. epithelial ingrowth, NV)
- active AC inflammation
- multiple failed trabeculectomies
Trabeculectomy
+ mitomycin-C


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

“quiet eye “; > 2y/o - scarred superior conjunctivae
- active proliferative membrane
in the AC (e.g. epithelial ingrowth, NV)
Trabeculectomy
+ mitomycin-C
Glaucoma drainage device,
preferably by a GL specialist


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

“quiet eye “; > 2y/o - scarred superior conjunctivae Poor visual
- active proliferative membrane Potential
in the AC (e.g. epithelial ingrowth, NV) (LP-NLP)
Trabeculectomy
+ mitomycin-C
Glaucoma drainage device,
preferably by a GL specialist


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

Trabeculectomy Consider
+ mitomycin-C transcleral
Glaucoma drainage device, cyclophoto-
coagulation if
preferably by a GL specialist w/ pain


POAG PACG glaucoma
glaucoma

cause, if possible
+ trabeculectomy
Medical Tx

Trabeculectomy Consider
+ mitomycin-C transcleral
Glaucoma drainage device, cyclophoto-
coagulation if
Legend: preferably by a GL specialist w/ pain
Uncontrolled IOP

Traction suture

6


Traction suture

Peripheral cornea

6


Traction suture

Peripheral cornea Superior rectus

6


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

7


Conjunctival Peritomy:
Fornix based

8


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

9


Limbal based

10


Limbal based

• More difficult dissection & exposure

• Better water-tight closure

11


Cauterization of
episcleral vessels

12


Removal of residual
episcleral tissues

JA Tumbocon, MD

13


Application of Anti-metabolites

14


• 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

14


• 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.)

14



15


Irrigate copiously

16


Scleral Flap Dissection
• 1/3 to 1/2 scleral
thickness
– Thinner flap = more
aqueous flow

• Shapes:
– square, rectangular,
trapezoidal,
triangular

17


Scleral Flap Dissection

18


Paracentesis

19


Limbal Fistula

20


Limbal Fistula
Descemet’s punch

21


Limbal Fistula
Knife & Vannas scissors

22


Limbal Fistula
Knife & Vannas scissors

23


Peripheral Iridectomy

24



25


• 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

26


Scleral Flap closure

27


• 10-0 Nylon suture

• May use 2 to 6
interrupted sutures

• Burry all suture
knots

28


• 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”
29


Conjunctival Closure
Limbal based peritomy

JA Tumbocon, MD

30


Conjunctival Closure
Fornix based peritomy

31


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

32


JA Tumbocon, MD


Trabeculectomy: Post-op care

34


• Follow-up closely
– Success = 50% surgery + 50% post-op care

34


• Keep aqueous flowing
– Massage, laser suture lysis &/ or removal of
releasable scleral flap sutures

34


• Topical steroids (usually for 6-12 weeks)

34


• Prophylactic topical antibiotic

34


• Prophylactic topical antibiotic
• + Cycloplegic agent (e.g. Atropine)
– Stabilizes blood-aqueous barrier
– Pulls lens-iris diaphragm posteriorly
34


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

JA Tumbocon, MD


Thank you


L a s e r Ir i d o to my


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

Laser Iridotomy
• Indications:
– Relative pupillary block /
primary angle closure
– Occludable angles
– Occlusio pupillae
– Fellow eye of patients w/ unilateral
angle closure (prophylactic L.I.)

41


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
42


Laser Iridotomy
Pre-op evaluation: Gonioscopy

Closed angles Opens on indentation
gonioscopy

43


Laser Iridotomy

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

44


Abraham lens

Magnifies view & has 4x laser beam minification
(increases power concentration)
45


Laser Iridotomy site

• Supero-temporal or supero-nasal
peripheral iris

• Choose an iris crypt, if available

46


Laser Iridotomy site

47


Laser Iridotomy
• Nd: Yag (1064nm wavelength)

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

• Diode

48


Nd: YAG Laser Iridotomy
• Suggested Settings:
– 2-6 mJ
– 1-4 pulses / burst
• Less bursts for phakic eyes
– 2-4 bursts

49


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
50


Argon Laser Iridotomy Techniques

51


“Chipping Technique”

– Long pulse duration: 700-1500mW, 50 um, 0.2 secs
– Short pulse duration: 1000-1500mW, 50 um,
0.02-0.05 secs
52


“Hump technique”

– Suggested Settings:
• “Hump”: 500mW, 500um, 0.5sec 1 burn only
• Perforation: 1000mW, 50um, 0.2sec
53


“Drumhead technique”

– Suggested Settings:
• Drumhead: 200mW, 200um, 0.2 sec, 4 burns
• Perforation: 500mW, 50um, 0.2sec
54


Argon Laser Iridotomy
• Advantage:
– Less potential for bleeding

• Disadvantage:
– Requires more energy and more prone to
closure than Nd:YAG iridotomy

55


Combined Argon & Nd: YAG Laser
Iridotomy

– 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 bursts 56


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

57


Laser Iridotomy

58


Laser Iridotomy

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

59


Laser Iridotomy

• Immediate post-laser
– Check IOP hourly for at least 3 hours
(check for IOP spike)
– Topical steroids x 3-7 days

60


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
61


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
62


Surgical management of glaucoma pgs

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