MEDICAL MANAGEMENT:-

INDICATIONS:

• WHEN MEDICAL THERAPY FAILS TO ARREST VISUAL FIELD LOSS

• A NON COMPLIANT PATIENT

• PATIENT WHO CAN'T COME FOR REPEATED REVIEW

• IF MEDICATION ALONE CAN'T CONTROL IT.

SURGICAL ANATOMY:-

INTERNAL ANATOMY

• IRIS

• CILIARY BODY BAND

• SCLERAL SPUR

• TRABECULAR MESHWORK

• SCHWALBE LINE

SURGICAL ANATOMY:-

EXTERNAL ANATOMY

• ANTERIOR LIMBUS

• CONJUNCTIVA & TENON CAPSULE

• POSTERIOR LIMBUS

CHOICE OF SURGERY:-

OPEN ANGLE GLAUCOMA

LASER TRABECUOPLASTY

INCISIONAL THERAPY

CLOSE ANGLE GLAUCOMA

LASER IRIDOTOMY

LASER GONIOPLASTY /PERIPHERAL

IRIDOPLASTY

PERIPHERAL IRIDECTOMY

OTHER

GLAUCOMA DRAINAGE DEVICES

CILIARY BODY ABLATION PROCEDURESS

LASER TRABECULOPLASTY

• LTP IS A TECHNIQUE WHERE LASER ENERGY IS APPLIED TO THE T.M IN DISCRETE

SPOTS,USUALLY COVERING 180’ TO 360’ / TREATMENT

VARIOUS MODALITIES:

ARGON LASER TRABECULOPLASTY(ALT)

DIODE LASER TRABECULOPLASTY

SELECTIVE LASER TRABECULOPLASTY(SLT)

MECHANISMS:

• TREATED AREA OF TM –MAY SHRINK—CAUSING STRETCHING OF ADJACENT

AREAS-

• TM- RELEASES IL1 ß& TNF A INCREASING OUTFLOW FACILITY THROUGH

INDUCTION OF SPECIFIC MATRIX METALLOPROTEINASES.

INDICATIONS:

• POAG

• PIGMENTARY GLAUCOMA

• EXFOLIATION SYNDROME

• STEROID INDUCED GLAUCOMA

LESS RESPONSIVE TO

APHAKIC & PSEUDOPHAKIC

EYES THAN PHAKIC EYES

IT LOWERS DOWN IOP BY 20-25 %

IT IS NOT EFFECTIVE FOR TREATING UVEITIC

GLAUCOMA.

TECHNIQUE:

ALT

• 50ΜM –0.1 SEC

• THROUGH A GONIOLENS AT THE ANT.

NONPIGMENTED & POST. PIGMENTED EDGE OF

THE TM.

• (300-1000MW)

• APPLIED 360’ BUT EFFECTIVE 180’(40-50

APPLICATIONS)

SLT

• FDA APPROVED ---LASER TARGETS

INTRACELLULAR MELANIN.

• A FREQUENCY DOUBLED Q SWITCHED ND:YAG

LASER WITH-- 400ΜM SPOT SIZE TO DELIVER

0.4-1.0 MJ OF ENERGY FOR 0.3 NS.

A DIODE LASER: A 75µm WITH A POWER SETTING 600-

1000MW FOR 0.1 SEC.

COMPLICATIONS:

• TRANSIENT RISE OF IOP

• IT HAS REPORTED TO INCREASE 50-60 MMHG

• LOW GRADE IRITIS

• PREVENTION:

• IF TREATED AT 180 ‘/SESSION

• TOPICAL ANTI INFLAMMATORY DRUGS FOR 4-7

DAYS

INCISIONAL SURGERY:

• TRADITIONALLY REFERRED AS FILTERS.

• MORE ACCURATE TO CALL IT AS FISTULIZING PROCEDURES.

• GOAL:- TO CREATE A NEW PATHWAY (FISTULA) THAT ALLOWS AQUEOUS HUMOR TO FLOW OUT OF THE

ANTERIOR CHAMBER THROUGH THE SURGICAL OPENING IN THE SCLERA & INTO THE SUBCONJUNCTIVAL

& SUB TENON SPACES.

FILTERING SURGERY:

• DRAINAGE FISTULA

• FILTERING BLEB

• ROUTES OF AQUEOUS DRAINAGE

MECHANISM OF ACTION:

• DRAINAGE FISTULA:- MECHANISM IS TO CREATE AN OPENING OR FISTULA AT THE LIMBUS .

• IT ALLOWS A DIRECT COMMUNICATION BETWEEN THE ANTERIOR CHAMBER & SUBCONJUC SPACE.

• IT BYPASSES THE TRABECULAR MESH WORK , SCHLEM CANAL & COLLECTING CHANNELS .

• AQUEOUS GET ABSORBED BY SURROUNDING TISSUES & DRAINS WITH TEARS THROUGH NLD

FILTERING BLEB:

• CHARACTERISED BY ELEVATION OF CONJUNCTIVA AT THE SURGICAL SITE .

• THE CLINICAL APPEARANCE & FUNCTION OF BLEB VARIES IN:

REGARD TO EXTENT , ELEVATION & VASCULARITY.

TECHNIQUE:

TRACTION SUTURES

•Clear cornea technique:7-0 polyglactin

or silk suture is passed apprx 3/4th

thickness 1 mm from the limbus with a

bite width of 4-5 mm.

LIMBAL STAB INCISION:

• PARACENTESIS SITE: SELF HEALING, BEVELED INCISION AT THE LIMBUS

• SITE:TEMPORALLY AT THE HORIZONTAL MERIDIAN OR IN THE INFERIOR –TEMPORAL QUADRANT.

PREPARATION OF FLAP:

LIMBUS BASED FORNIX BASED

FISTULIZING TECHNIQUES:

FULL THICKNESS:

• COMPLICATED BY EXCESSIVE AQ FILTERATION.

• PROLONGED FLAT AC , CORNEAL

DECOMPENSATION,SYNECHIAE

FORMATION,CATARACTS.

• ENDOPHTHALMITIS .

PARTIAL THICKNESS:

• SUGGESTED BY SUGAR (1961)

• WAS POPULARIZED BY CAIRNS (1968)

• THIS TECHNIQUE WAS KNOWN AS

TRABECULECTOMY.

1- Aqueous flow incut ends of

schlemm canals

2-cyclodialysis

3-through the scleral flaps

4-through the CT subst of

scleral flap

5-around the margins of

scleral flap.

Cauterization of area intended for margins

of scleral flaps.

Margins of scleral flap outlined

by partial thickness incisions.

C- triangular scleral flap as an

alternative technique.

Anterior chamber entered just behind the hinge

of the scleral flap.

E – completion of anterior & lateral

margins of deep limbal incision

with scissors.

F – flap of deep limbal tissue excised using

kelly punch.

COMPLICATIONS:

• INTRAOPERATIVE COMPLICATIONS

• EARLY POSTOPERATIVE COMPLICATIONS

• POSTOPERATIVE COMPLICATIONS

INTRAOPERATIVE

• TEARING /BUTTONHOLING OF THE CONJUNCTIVAL FLAP

• HEMORRHAGE

• CHOROIDAL EFFUSION

EARLY POSTOPERATIVE :

• HYPOTONY & FLAT CHAMBER

• CONJUNCTIVAL DEFECT

• EXCESSIVE FILTRATION

• SEROUS CHOROIDAL DETACHMENT

LATE POSTOPERATIVE :

• LATE FAILURE OF FILTERATION

• A LEAKING FILTERING BLEB

• BLEBITIS

• BLEB RELATED ENDOPHTHALMITIS

ANTIFIBROTIC AGENTS

• CORTICOSTEROIDS

• 5-FLUOROURACIL

• MITOMYCIN C

• OTHERS

CORTICOSTEROIDS

• PREVENT BLEB FAILURE

• IT MODULATE WOUND HEALING PROCESS

• INHIBITS CELL ATTACHMENT & PROLIFERATION.

• STILL THE INCIDENCE OF BLEB FAILURE IS HIGH

IN: GLAUCOMA IN APHAKIA & PSEUDOPHAKIA&

NEOVASCULAR. GLAUCOMA

5-FLUOROURACIL

• PYRIMIDINE ANALOG ANTIMETABOLITE WHICH

BLOCK DNA SYNTHESISTHROUGH THE

INHIBITION OF THYMIDYLATE SYNTHESIS

SHOWN TO INHIBIT FIBROBLAST

PROLIFERATION IN CELL CULTURE.

• PROTOCOL- SUB CONJ INJECTION.. 5 MG TWICE

DAILY FOR 7 DAYS & THEN ONCE FOR 7 DAYS.

• COMPLICATIONS-CONJUNCTIVAL WOUND

LEAKS,CORNEAL EPITHELIAL DEFECTS.

• SUCCESS REPORTED IN -5 MG 5 FU FOR 7-14

DAYS.

MITOMYCIN C

• ANTINEOPLASTIC ANTIBIOTIC FROM

STREPTOMYCIN CAESPITOSUS.

• A SPONGE SOAKED IN 0.5 MG/ML TO THE

SUBCONJUNCTIVAL TISSUES FOR 5 MINUTES

• RETROSPECTIVE STUDIES 0.2 MG /ML APPLIED FOR

2 MINS .

COMPLICATIONS:

EARLY• INFECTION

• HYPOTONY

• SHALLOW/FLAT AC

• HYPHEMA

• CME

• TRANSIENT IOP RISE

• CHOROIDAL EFFUSION

• SUPRACHOROIDAL HAEMMORHAGE

• PERSISTENT UVEITIS

LATE

• LEAKAGE OR FAILURE OF THE FILTERING BLEB

• CATARACT

• BLEBITIS

• BLEB MIGRATION

• HYPOTONY

• PTOSIS

• EYELID RETARACTION

LASER IRIDOTOMY

• INDICATION:-PRESENCE OF PUPILLARY BLOCK

Therapeutic

TO PREVENT PUPILLARY BLOCK

Diagnostic

PATENT IRIDOTOMY FAILS TO CHANGE THE

PERIPHERAL IRIS CONFIGURATION

CONTRAINDICATIONS:

• RUBEOSIS IRIDIS

• PATIENTS ON ANTI COAGULANTS, ASPIRIN

PREOP EVALUATION

• CLOUDY CORNEA TREATMENT

• SHALLOW CHAMBER

• ENGORGED IRIS

• PRETREATMENT WITH PILOCARPINE

• APRACLONIDINE/BRIMONIDINE TO BLUNT IOP

SPIKES.

TECHNIQUE:

ARGON LASER

• COLOUR OF THE IRIS

ND:YAG LASER

• Q SWTCHED LASER

• REQUIRES FEWER PULSES

• NOT EFFECTED BY IRIS COLOUR

• INITIAL SETTINGS 2-8MJ

Spot size Power time

50um 800-

1000mw

0.1 sec

COMPLICATIONS:

ARGON LASER

• LOCALISED LENS OPACITY

• ACUTE RISE IN IOP

• EARLY IRIDOTOMY

• POSTERIOR SYNECHIAE

• CORNEAL/RETINAL BURNS

ND:YAG LASER

• DISRUPTION OF THE ANTERIOR LENS CAPSULE

• CORNEAL ENDOTHELIUM

• BLEEDING

• POST OP IOP SPIKE

• INFLAMMATION

INCISIONAL IRIDECTOMY:

• CHANDLER

• SITE: SUPERIOR QUADRANTS FORNIX/LIMBUS BASE

• A 3MM TO 4MM INCISION IS MADE INTO THE AC & 1 TO 1.5 MM BEHIND THE CL JUNCTION.

A B C

LASER GONIOPLASTY/PERIPHERAL IRIDOPLASTY

• GOALS: IT IS A TECHNIQUE TO DEEPEN THE ANGLE.

• PRIMARILY USED IN ANGLECLOSURE GLAUCOMA RESULTING FROM PLATEAU IRIS.

• STROMAL BURNS ARE CREATED IN THE PERIPHERAL IRIS TO CAUSE CONTRACTION & FLATTENING.

TECHNIQUE:

SPOT SIZE POWER TIME

200-500µM 200-500MW 0.1-0.5 SEC

GLAUCOMA DRAINAGE DEVICE :

• THESE DEVICES HAVE BEEN DEVELOPED THAT AID ANGLE FILTRATION BY SHUNTING AQUEOUS TO A SITE

AWAY FROM THE LIMBUS.

• IT INVOLVES PLACING A TUBE IN THE

ANTERIOR CHAMBER

CILIARY SULCUS

THROUGH THE PARS PLANA INTO THE VITREOUS CAVITY.

DEVICES:

VALVED

• AHMED (NEW WORLD MEDICAL)

NON VALVED

• MOLTENO (MOLTENO

OPHTHALMIC,DUNEDIN,NEWZEALAND)

• BAERVELDT (ABBOTT MEDICAL OPTICS)

INDICATIONS:

• FAILED TRABECULECTOMY WITH ANTIFIBROTICS

• ACTIVE UVEITIS

• NEOVASCULAR GLAUCOMA

• INADEQUATE CONJUNCTIVA

• APHAKIA

• CONTACT LENS USE.

CONTRAINDICATIONS

• BORDERLINE CORNEAL ENDOTHELIAL FUNCTION.

PREOPERATIVE EVALUATION

• MOTILITY

• STATUS OF CONJUNCTIVA

• SCLERA

• PREVIOUSLY PLACED SCLERAL BUCKLE.

TECHNIQUE:-• SITE: SUPEROTEMPORAL QUADRANT IS PREFFERED OVER THE SUPERONASAL QUADRANT.

• VALVED DEVICES MUST BE PRIMED

• EXTRAOCULAR PLATE BETWEEN THE VERTICAL & HORIZONTAL RECTUS MUSCLE.

• TUBE PORTION OF THE DEVICE IS ROUTED 1 OF 3 WAYS

ANTERIOR ENTER THE ANTERIOR CHAMBER

PSEUDOPHAKIC EYES CILIARY SULCUS

VITRECTOMY THROUGH PARS PLANA FOR POSTERIOR

IMPLANTATION

COMPLICATIONS:-

• TUBE CORNEA TOUCH

• FLAT CHAMBER & HYPOTONY

• TUBE OCCLUSION

• PLATE MIGRATION

• VALVE MIGRATION

• TUBE /PLATE EXPOSURE OR EROSION

CYCLODESTRUCTIVE PROCEDURES:

• TRANS SCLERA CYCLOPHOTOCOAGULATION

• ENDOSCOPIC CYCLOPHOTOCOAGULATION

TRANSSCLERAL CP

• IN 1961 WEEKEND & ASSOCIATES- XENON ARC PHOTO COAGULATION OVER THE CILIARY BODY

• IN 1969 VUCICEVIC & ASSOCIATES –USE OF RUBY LASERS

• IN 1984 BECKMANN & WAELTERMANN – RUBY LASER

INSTRUMENTS

ND YAG

• WAVELENGTH OF 1064NM

• TRAVERSE THE SCLERA WITH LOW ABSORPTION &

SCATTER.

• MAY BE OPERATED AS PULSED, FREE RUNNING,

THERMAL MODE ,OR A CONTINUOUS WAVE MODE

• MAY BE DELIVERED NONCONTACT , SLIT LAMP OR A

CONTACT PROBE

SEMICONDUCTOR DIODE LASERS

• RANGE OF 750-850 NMS

• DO NOT TRAVERSE THE SCLERA AS EFFECIENTLY

AS ND :YAG LASER

COMPLICATIONS:-

EARLY:

• UVEITIS & HYPHEMA

• DELLEN

• LOSS OF CENTRAL VISION

• OCULAR DECOMPRESSION RETINOPATHY

LATE:

• LATE FAILURE OF FILTRATION

• A LEAKING FILTERING BLEB

THANK YOU