when our glaucoma meds fail us: what’s next? · 1 when our glaucoma meds fail us: what’s next?...
TRANSCRIPT
1
WHEN OUR GLAUCOMA
MEDS FAIL US:
WHAT’S NEXT?
CHRIS CAKANAC, OD, FAAO
• NO DISCLOSURES
GLAUCOMA TREATMENT
IN THE UNITED STATES
• MEDICAL THERAPY
• LASER THERAPY
• SURGICAL THERAPY
WHAT IS MAXIMAL
MEDICAL THERAPY?
• 2 BOTTLES?
• 3 BOTTLES?
• MORE?
HOW LOW DO YOU GO ?
THE LOWER THE BETTER!
2
TARGET IOP
• AGIS (ADVANCED GLAUCOMA
INTERVENTION STUDY)
• IOP < 18 MM = NO VF PROGRESSION
TARGET IOP
• OHTS (OCULAR HYPERTENSION
STUDY)
• PXS WITH IOP 24-32 MM
RANDOMIZED TO TX OR NO TX
• TX ( 20% IOP REDUCTION )
TARGET IOP
• OHTS (OCULAR HYPERTENSION
STUDY)
• TX ( 20% IOP↓) = 4.4% GO ON TO VF LOSS
• NO TX = 9.5% GO ON TO VF LOSS
HOW LOW DO YOU GO?
(PRACTICALLY)
• AGE DEPENDENT
• DISC DEPENDENT
• VISUAL FIELD DEPENDENT
TODAY’S TOPICS
• LASER
• SELECTIVE LASER TRABECULOPASTY
• MINIMALLY INVASIVE GLAUCOMA
PROCEDURES (MIGS)
• SURGERY
• TRABECULECTOMY
• TUBE SHUNTS
LASER THERAPY
• ARGON LASER TRABECULOPLASTY
(ALT)
• SELECTIVE LASER
TRABECULOPLASTY (SLT)
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ALT
• HIGH ENERGY,
SMALL SPOT
• AIM ABOVE TBM
• TREAT 180
• THE OTHER 180 IF
NECESSARY
• CAN NOT
RETREAT
ALT
HOW DOES IT WORK?
• DESTROYS TBM
• STRETCHES TBM
• STIMULATES
MACROPHAGES
ALT
• USUALLY REDUCES IOP BY 20%
• 5 YR WINDOW
• CAN NOT BE REPEATED
SELECTIVE LASER
TRABECULPLASTY
• LARGE SPOT, LOW
ENERGY
• AIM AT TBM
• TREAT 180 OR
360
• REPEATABLE!
SLT
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HOW DOES IT WORK?
• STIMULATES
MACROPHAGES
• NO TISSUE
DAMAGE
SLT - ADVANTAGES
• USUALLY 20% REDUCTION IN
IOP
• REPEATABLE WHEN EFFECT
WEARS OFF
• PRIMARY THERAPY?
• REDUCES COMPLIANCE ISSUES
SLT - DISADVANTAGES
• IS 20% ENOUGH?
• WORKS IN 80% OF PATIENTS
• WEARS OFF 2-5 YEARS
COMANAGEMENT OF SLT
• TOPICAL ANESTHESIA
• IOPIDINE PREOP
• EXPECT IOP SPIKE DAY1
• EXPECT AC INFLAMMATION WEEK 1
• ADJUST MEDS?
Selective Laser Trabeculoplasty:
NSAIDs vs Steroids in Post-Operative Management
Jennifer Calafati MD, Donna Williams-
Lyn PhD,
Iqbal Ike K. Ahmed MD, FRCSCAuthors have no financial interest
Results
IOP Control
0
5
10
15
20
25
30
Pre-Op 1 hr 0.25 mo 1 mo 3 mo 6 mo 12 mo
Time
IOP
(m
mH
g)
NSAID (V)
Steroid (PF)
5
ResultsGTTS (Between Groups)
Steroid NSAID p value
Preop gtts 0.89 0.80 0.776
6 mo gtts 0.88 0.68 0.460
1 yr gtts 0.78 0.74 0.967
Pain (Between Groups)
Steroid NSAID p value
Preop gtts 0 0 1
6 mo gtts 0 0 1
1 yr gtts 0 0 1 *Pain grading: Patient reported; 0=none, 10=most severe ever felt
Conclusion
•Both steroids and NSAIDs can be considered equally successful treatment options for IOP control following selective laser trabeculoplasty.
• Both steroids and NSAIDs can be considered equally successful treatment options for the management of inflammation following selective laser trabeculoplasty.
• Patient comfort (as reflected by patient-reported pain scores) is satisfactory with both therapies.
TODAY’S TOPICS
• LASER
• SELECTIVE LASER TRABECULOPASTY
• MINIMALLY INVASIVE GLAUCOMA
PROCEDURES
• SURGERY
• TRABECULECTOMY
• TUBE SHUNTS
MIGS
• DONE THROUGH CLEAR
CORNEAL INCISION
• PRESERVES CONJUNCTIVA
• MINIMAL COMPLICATIONS
• FOR MODERATE GLAUCOMA
• LOWER IOP TO MID-TEENS
MIGS – MINIMALLY
INVASIVE GLAUCOMA
PROCEDURES
• ISTENT
• TRABECTOME
• ENDOCYCLOPHOTOCOAGULATION
ISTENT (GLAUKOS)
• TITANIUM STENT
• IMPLANTED IN SCHLEMS CANAL
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INITIAL APPROVAL 2012
• INDICATED FOR USE IN
CONJUNCTION WITH
CATARACT SURGERY FOR MILD
TO MODERATE GLAUCOMA
CURRENTLY TREATED WITH
MEDICATION
ISTENT RESULTS
• IOP REDUCED BY 16 – 30%
• 1.2 MEAN REDUCTION IN MEDS
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RESULTS
(SAMUELSON ET AL)
• 72% OF IMPLANTED EYES HAD
IOP<21MM (VS 50% FOR NO
IMPLANT)
ADVANTAGES
• DONE DURING CATARACT
SURGERY
• LEAST INVASIVE
• MINIMAL TRAUMA
• REVERSIBLE
DISADVANTAGES
• LEAST IOP LOWERING OF MIGS
• RESTRICTIVE INDICATION AND
REIMBURSEMENT
• MAY REQUIRE MORE MULTIPLE
STENTS
DISADVANTAGES
• LEAST IOP LOWERING OF MIGS
• RESTRICTIVE INDICATION AND
REIMBURSEMENT
• MAY REQUIRE MORE MULTIPLE
STENTS
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RESTRICTIVE
• NOT A STAND ALONE PROCEDURE
• MULTIPLE STENTS NOT APPROVED
• PART OF THE FACILITY FEE
DISADVANTAGES
• LEAST IOP LOWERING OF MIGS
• RESTRICTIVE INDICATION AND
REIMBURSEMENT
• MAY REQUIRE MULTIPLE
STENTS
TWO OR THREE STENTS
(BELOVAY ET AL)
• 70% IMPLANTED EYES HAD IOP
OF 15 MM OR LESS
• 2.4 REDUCTION IN NUMBER OF
MEDS
COMPLICATIONS
• TOUCHING ADJACENT TISSUES
• IRIS – 7%
• ENDOTHELIUM – 1%
FAILURE TO IMPLANT – 2%
STENT MALPOSTION – 1%
ISTENT
COMANAGEMENT
• SAME PROTOCOL AS CATARACT
SURGERY
• GONIO IF NEEDED
MIGS – MINIMALLY
INVASIVE GLAUCOMA
PROCEDURES
• ISTENT
• TRABECTOME
• ENDOCYCLOPHOTOCOAGULATION
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TRABECTOME (NEOMEDIX)
• ELECTRO CAUTERY PROBE
• VAPORIZES TBM, SCHLEMM’S INNER WALL
• 60-120 DEGREES TREATED NASALLY
INDICATIONS
• INITIAL- OPEN ANGLE GLAUCOMA
WITH UNCONTROLLED IOP
• NEWER
• PSEUDOEXFOLIATION
• PIGMENT DISPERSION
• UVEITIC
• NEOVASCULAR
• INFANTILE
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ADVANTAGES DISADVANTAGES
• REQUIRES CLEAR ANGLE VIEW
• DESTRUCTIVE
• IOP IN MID TEENS
COMPLICATIONS
• 1 DAY POST OP INCREASE
• EARLY HYPHEMA
• LATE HYPHEMA
POST PROCEDURE CARE
ENDOCYCLOPHOTCOAGULATION
(ENDO OPTIKS)
ENDOLASER
CYCLOPHOTOCOAGULATION
(ECP)
• 810 NM DIODE LASER
• TREAT TIPS OF CILIARY PROCESSES
• DECREASES AQUEOUS PRODUCTION
• USEFUL FOR ALL TYPES OF GLAUCOMA
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ECP: HOW ITS DONE ECP – HOW ITS DONE
OLDER TYPES OF
CYCLODESTRUCTION
• CYCLOCRYODESTRUCTION
• TRANS-SCLERAL
CYCLOPHOTOABLATION
• 24% RISK OF COMPLICATIONS
ECP – ADVANTAGES
• USES ENDOSCOPY TO
DIRECTLY VIEW CILIARY TIPS
• MORE CONTROL
• LESS COMPLICATIONS
12
ECP VS OTHER PROCEDURES ECP RESULTS
• DECREASE IOP 18 - 34%
• MINIMAL RISK OF HYPOTONY
• 6% RISK OF VA LOSS OF > 2
LINES (CME)
ECP ADVANTAGES
• COMMONLY DONE WITH
CATARACT SURGERY
• CAN ELIMINATE OR REDUCE
MEDS
• ONLY MIG TO DECREASE
AQUEOUS PRODUCTION
ECP DISADVANTAGES
• CAUSES INFLAMMATION
• DESTRUCTIVE
• HOW LONG DOES IT LAST?
COMANAGEMENT OF ECP
• DAY 1 • MORE INFLAMMATION
• HIGHER IOP
• STEROID IS Q2H
• MAINTAIN GLAUCOMA MEDS
• WEEK 1• MINIMAL INFLAMMATION
• IOP TAKES 1-4 WEEKS TO REDUCE
• TAPER STEROID
• 1 MONTH• RE-EVALUATE NEED FOR GLAUCOMA MEDS
TODAY’S TOPICS
• LASER
• SELECTIVE LASER TRABECULOPASTY
• MINIMALLY INVASIVE GLAUCOMA
PROCEDURES
• SURGERY
• TRABECULECTOMY
• TUBE SHUNTS
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SURGICAL THERAPY
TRABECULECTOMY
DRAINAGE DEVICES
TRABECULECTOMY
• ALLOWS AQUEOUS TO BYPASS TBM
• FLOWS INTO SUBCONJ SPACE
• ABSORBED BY EPIVENOUS SYSTEM
“Establishment of trans-scleral
aqueous outflow sufficient to
maintain a steady state pressure
gradient of just the right amount
represents a highly abnormal
state and can only be achieved
by causing a partial failure of the
normal wound healing process” –
Healey and Troupe
TBC INDICATIONS
• LOSS OF FUNCTION DESPITE
MAXIMAL MEDICAL THERAPY
• TARGET PRESSURE NOT
ACHEIVED
HOW LOW DO YOU GO ?
6-12 MM
ADVANTAGES OF TBC
• MORE EFFICIENT AT LOWERING
IOP THAN:• MEDICAL THERAPY
• LASER
• MIGS
• LESS RELIANCE ON PATIENT
COMPLIANCE
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DISADVANTAGES OF TBC
• COMPLICATIONS!!!
• “IN TRABECULECTOMY, LIKE
NO OTHER OCULAR SURGERY,
THE BATTLE IS WON OR LOST
AFTER THE SURGERY IS DONE”
– A. IWACH
CIGTS
• (COLLABORATIVE INITIAL
GLAUCOMA TREATMENT STUDY)
• RANDOMIZED PTS TO MEDICAL
OR SURGICAL MGMT
CIGTS
• SURGICAL
• LOWER AVG IOP
• SAME VF
PROGRESSION
• MEDICAL
• LESS LIKELY TO
HAVE MAJOR
VISION LOSS
EVENT
• BETTER
QUALITY OF
LIFE SCORE
THE PROCEDURE
NEXT… FINALLY…
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ANTIMETABOLITES
• DECREASE WOUND HEALING
RESPONSE
• IMPROVE BLEB SURVIVAL
RATES
• INCREASE COMPLICATIONS
ANTIMETABOLITES
• 5 FLUOROURACIL
• TEMPORARILY
INHIBITS DNA
REPLICATION
• REVERSIBLE
• USES
• DURING SURGERY
• POSTOP INJECTION
• MITOMYCIN-C
• PERMANENTLY
BINDS DNA
• 100X MORE POTENT
• NONREVERSIBLE
• USES
• DURING SURGERY
POST OP MEDS
• TOPICAL ANTIBIOTIC
• PRED FORTE QIH WHILE AWAKE
• ATROPINE QID
RESTRICTIONS
• NO PHYSICAL ACTIVITY
• NO BENDING OR LIFTING
• NO READING
• SHIELD DURING SLEEP
1 DAY POST OP
• IOP – USUALLY LOW
• ANTERIOR CHAMBER - FORMED
• BLEB STATUS – DIFFUSE AND
AVASCULAR
• FUNDUS - NORMAL
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1 WEEK POST OP
• IOP – INCREASING
• ANTERIOR CHAMBER
• FUNDUS
• BLEB STATUS
BLEB STATUS –
GOOD SIGNS
• DIFFUSE
• LARGE AREA
• THIN WALL
• RELATIVELY
AVASCULAR
• POLYCYSTIC
BLEB STATUS –
GOOD SIGNS
BLEB STATUS –
BAD SIGNS
• SMALL AREA
• THICK WALL
• VASCULARIZED
• CORKSCREW
VESSELS
BLEB STATUS BLEB STATUS
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COMPLICATIONS
• IOP
• ANTERIOR CHAMBER
COMPLICATIONS
• HIGH IOP – FORMED AC
• HIGH IOP – SHALLOW AC
• LOW IOP – FORMED AC
• LOW IOP – SHALLOW AC
COMPLICATIONS
• HIGH IOP – FORMED AC• BLEB PROBLEM
• HIGH IOP – SHALLOW AC• IRIS PROBLEM
• LOW IOP – FORMED AC• OVERFILTRATION
• LOW IOP – SHALLOW AC• LEAK
HIGH IOP – FORMED ACBLEB PROBLEM
• SCLEROSTOMY BLOCKED• DO GONIO
• SCLERAL FLAP TOO TIGHT• OCULAR MASSAGE
• RELEASE SUTURES
MASSAGE
• DAY 1 – 6 MO
• FOCAL STEADY
PRESSURE
• 10 SECONDS/QID
• CHECK IOP BEFORE
AND AFTER
• THEORETICAL
WORSENING?• IOP > 100 MM
• ↓ BLOODFLOW TO ONH
HIGH IOP – FORMED AC
• SCLEROSTOMY BLOCKED• DO GONIO
• SCLERAL FLAP TOO TIGHT• OCULAR MASSAGE
• RELEASE SUTURES
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RELEASE SUTURES
ADJUSTABLE SUTURES
RELEASE SUTURES
ARGON LASER SUTURE LYSIS
• DONE DAY 3 TO
WEEK 3
• START CLOSEST
TO LIMBUS
• CUT ONE
SUTURE AT A
TIME
• DO OCULAR
MASSAGE
• MEASURE IOP
HIGH IOP – SHALLOW ACIRIS PROBLEM
• SHALLOW AC
• NARROWING OF
THE ANGLE
• PERIPHERAL
IRIS CORNEA
TOUCH
• FLAT CHAMBER
• LENTICULAR
CORNEAL
TOUCH
HIGH IOP – SHALLOW AC
• PUPILLARY BLOCK
• LESS COMMON
• SUPRACHOROIDAL HEM
• AQUEOUS MISDIRECTION
PUPILLARY BLOCK• CYCLOPLEGICS
• RELAXES IRIS
DIAPHRAM
• PREVENTS
FORWARD
MOVEMENT
• DISCOURAGES
AC SHALLOWING
• SUPRESS
AQUEOUS PROD.
COMPLICATIONS
• HIGH IOP – FORMED AC
• HIGH IOP – SHALLOW AC
• LOW IOP – FORMED AC
• LOW IOP – SHALLOW AC
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LOW IOP – FORMED ACOVERFILTRATION
• IOP < 5MM
• OVERFILTRATION• TOO MUCH 5FU OR MMC
• TOO LARGE SCLEROSTOMY
CAN IOP BE TOO LOW?
• HYPOTONY = IOP < 5 MM
• FLUCTUATING VISION, ESPECIALLY
WITH BLINK
• CHOROIDAL EFFUSIONS
• HYPOTONY MACULOPATHY
CHOROIDAL EFFUSIONS
• FLUID COLLECTS
IN
SUPRACHOROIDAL
SPACE
• D/C STEROIDS,
GLAUCOMA MEDS
• DRAIN IF
“KISSING”
HYPOTONY
MACULOPATHY
• LINES RADIATING
FROM FOVEA
• ENGORGED
VESSELS
• NO FA LEAKAGE
• MISALIGNED
PHOTORECEPTORS
OVERFILTRATION
TREATMENT
• D/C STEROIDS AND GLAUCOMA
MEDS
• ADD FLAP SUTURES
• AUTOLOGOUS BLOOD?
COMPLICATIONS
• HIGH IOP – FORMED AC
• HIGH IOP – SHALLOW AC
• LOW IOP – FORMED AC
• LOW IOP – SHALLOW AC
• LEAK
20
BLEB LEAK
• TEARY EYE,
FLUCTUATING
VA
• FLAT BLEB
• POSITIVE
SEIDEL SIGN
BLEB LEAK TREATMENT
• D/C STEROIDS
• GIVE AQUEOUS SUPPRESSANTS
• BANDAGE CL
• GLUE
• AUTOLOGOUS BLOOD?
• SURGICAL PATCH
COMPLICATIONS
• HIGH IOP – FORMED AC• BLEB PROBLEM
• HIGH IOP – SHALLOW AC• IRIS PROBLEM
• LOW IOP – FORMED AC• OVERFILTRATION
• LOW IOP – SHALLOW AC• LEAK
POST OP INFECTIONS
• BLEBITIS
• ENDOPHTHALMITIS
BLEBITIS
• PAIN,
DISCHARGE
• INJECTION
• “WHITE ON
RED”
• INFILTRATE
• CELLS IN AC
• NO VIT CELLS
BLEBITIS RISK FACTORS
• BLEPHARITIS
• DRY EYE
• CL WEAR
• BLEB LEAK
• INCIDENCE 5% PER YR
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BLEBITIS BUGS
• EARLY POST OP PERIOD
• STAPH EPIDERMIDIS
• LATER
• STREPTOCOCCUS
BLEBITIS TREATMENT
• FLUOROQUINILONE QIH
• POLYTRIM QIH
• ORAL FLUOROQUINOLONE
BLEB RELATED
ENDOPHTHALMITIS
• BLEBITIS
• HYPOPYON
• VIT CELLS
ENDOP TREATMENT
• VITREOUS TAP
• INTRAVITREAL ANTIBIOTICS
• FORTIFIED ANTBIOTICS
• VANCOMYCIN 50 MG/ML QIH
• CEFTAZ 50 MG/ ML QIH
• ORAL FLUOROQUINOLONE
GLAUCOMA DRAINAGE
DEVICES
GLAUCOMA DRAINAGE
DEVICES (GDD)
• AQUEOUS SHUNT
• TUBE
• TUBE SHUNT
• SETON
22
GDD TYPES OF GDD’S
• NONVALVE
• BAERVELDT
• MOLTENO
• VALVE
• AHMED
• KRUPEN
INDICATIONS FOR
GDD’S
• WHEN TBC HAS FAILED
• TWO SITES
• WHEN TBC IS LIKELY TO FAIL
• NEOVASCULAR GLAUCOMA
• CHRONIC UVEITIS OR INFLAMM
ADVANTAGES OF GDD’S
• LESS INVASIVE
• NO WOUND HEALING EFFECTS
• LESS EARLY HYPOTONY
• LESS LONG TERM SIDE EFFECTS
DISADVANTAGES OF
GDD’S
• IOP MAY NOT BE LOW ENOUGH
TUBE VS TRABECULECTOMY
STUDY
23
RESULTS
(IOP> 21 MM WITH NO MEDS)
• FAILURES AT 3 YRS
• TUBE – 15%
• TRAB – 30%
• FAILURES AT 5 YRS
• TUBE – 30%
• TRAB – 47%
POST OP CARE –
1 DAY
• EXPECT LOW IOP
• TOPICAL ANTIBIOTIC
• PRED ACETATE 1% QID
• NO CYCLOPLEGICS NEEDED
1 WEEK
• IOP SHOULD BE
HIGHER
• REMOVE SUTURE
(IF PREVIOUSLY
PLACED)
1 MONTH
• IOP SHOULD BE EQUALIZING
• D/C POST OP MEDS
COMPLICATIONS
• DIPLOPIA
• BLOCKED TUBE
• TUBE MIGRATION
• ENDOTHELIAL DECOMPENSATION
• TUBE EROSION