SURGICAL MANAGEME

NT OF GLAUCOMA

ABINAYA.K.AROLL NO:1

SURGICAL MANAGEMENT Laser surgeries Trabeculotomy and goniotomy Penetrating filtering surgeries-

trabeculectomy Non penetrating filtering surgeries Cyclo destructive procedures Artificial drainage implants

LASER SURGERIES

Trabeculoplasty

Peripheral iridotomy-Nd:Yag laser

Cyclo ablation-diode laser

LASER filtration procedures

Argon laser

selective laser

TRABECULOPLASTY Laser energy to trabecular meshwork

Cellular changes in angle

Increases the drainage Patient selection: Patients non-compliant with med therapy. Elderly Type of glaucoma-open angle Pigmentation-pseudo exfoliation type;

-pigmentary

PRE-OPERATIVELY: The eye should be free from

inflammation Iop should not be too high It should not be end stage glaucoma

ARGON LASER TRABECULOPLASTY Involves application of laser burns to the

trabeculum at blue-green wavelengths It enhances aqueous flow

Alt is ineffective in pediatric glaucoma and most of sec glaucoma except pigmentary and pseudo exfoliatory types

Application of laser beam:at the junction of pigmented and non pigmented trabeculum.

Ideal reaction:minute gas bubble or blanching

MECHANISM OF ACTION Mechanical effect: Tightening of TM Opening of intervening spaces Opening of collapsed schlemm’s canal

Biological response: Release of cytokines-signals the

macrophages to clear material that has accumulated in meshwork

PROCEDURE Pre-op:brimonidine eye drops 15 mins

before Local anaesthetic Gonioscopic contact lens to visualise the

angle 180 or 360 treated per session Post-op:glaucoma eye drops,anti-

glaucoma medication ot be continued,short course of topical steroids

Follow up-6 wks later

Complications: Peripheral anterior synechiae Small hemorrhages Elevation of IOP uveitis Adverse effect on subsequent filtering

surgery Success rate:POAG-75-80%

SELECTIVE LASER TRABECULOPLASTY Nd:yag laser Laser targets only the pigmented cells

in TM Advantage over ALT-the surgeon can

repeat the surgery over the same angle

PERIPHERAL IRIDOTOMY Definition:

-creating a full thickness hole in the peripheral iris in order to alleviate the pupillary block.

Indications: PACG Fellow eye of a patient with acute

glaucoma Narrow occludable angles Secondary angle closure with pupil block Narrow angle in POAG Combined mech glaucoma

PERIPHERAL IRIDOTOMY

TECHNIQUE OF IRIDOTOMY PUPIL IS MIOSED PRE-OP SITE:PERIPHERY OF IRIS,SUPERIOR IRIS 11-1 o clock position TO PREVENT THE

IRRADIATION OF FOVEA. SUCCESSFUL IRIDOTOMY:GUSH OF PIGMENT

DEBRIS

COMPLICATIONS: Bleeding Iritis Glare and diplopia Corneal burns

SURGERY FOR CONGENITAL GLAUCOMA

1. Goniotomy2. Trabeculotomy3. trabeculectomy

GONIOTOMY Done when cornea is clear or the angle

can be visualised. Mech:Incision of obstructing trabecular

meshwork

Direct conduit between AC & schlemm canal

Barkan goniotomy knife

Pre-op care: Acetazolamide:one week before to clear

corneal opacity ARI & NLD obstruction – treated Complications: Post-op hyphema Injury to iris & lens DM detachment

TRABECULOTOMY

Harm’s trabeculotome

FILTERING PROCEDURETRABECULECTOMY

Patient selection:

Pre-op considerations: Any type of glaucoma Intact,non-scarred conjunctivaSurgical technique: Incision through the conjunctica Partial thickness scleral flap A small hole in AC Iridectomy at this point Scleral flap closed with stitches Conjunctival tissue closed with stitches

to allow formation of bleb

TRABECULECTOMY

I.LIMBAL BASED CONJUNCTIVAL FLAP

II.OUTLINE OF SUPERFICIAL SCLERAL FLAP

III.DISSECTION OF SUP.SCLERAL FLAP

IV.INCISION FOR DEEP SCLERECTOMY

V.EXCISION OF DEEP SCLERAL BLOCK

VI.PERIPHERAL IRIDECTOMY

Bleb is situated in superior aspect of eye covered by the upper eyelid

Anti-metabolites: 5 FU and mitomycin(0.02%) used. It prevents scarring of tissue Frequent use will lead to hypotony Anaesthesia:~retro bulbar / topicalo Post-op :o Success rate:65-70%

THIN, POLYCYSTIC BLEB

SHALLOW, DIFFUSE FILTERING BLEB

VASCULARISED, NON-PENTRATING BLEB

LEAKING BLEB

POST-OP COMPLICATIONS Shallow anterior chamber Pupillary block Over filtration Malignant glaucoma Failure of filtration Bleb related complications Bleb leakage Blebitis Bacterial infection

NON-PENETRATING FILTERING SURGERIES Intro: AC is not entered , so post-op hypotony

does not occur. Dis adv: Two types: Deep sclerectomy Visco-canalostomy

ARTIFICIAL DRAINAGE DEVICES Intro: Plastic devices which create a

communication between AC and sub tenon space.

Indications: Uncontrolled glaucoma Sec. glaucoma-neo vascular

glaucoma,aniridia Severe conjunctival scarring

IMPLANT TYPES With a valve:~ahmed and krupin Without a valve:~molteno and baerveldtSETON’S OPERATION

Complications: Excessive drainage Corneal decompensation Cataract Diplopia Late endophthalmitis

Success rate:75%

CYCLO DESTRUCTIVE PROCEDURES Surgical and laser procedures that

ablate the ciliary body to lower the iop surgery:-cyclo cryotherapy Laser-cyclophotocoagulation Feared complication:hypotony

Thank

you!