Surgical Management                    of Glaucoma                                   Delivered by:                        ...
Outline         • Overview         • Trabeculectomy                – Indications, technique & post-operative              ...
TRABECULECTOMYThursday, April 7, 2011
Indications for glaucoma surgery                                        4Thursday, April 7, 2011
Indications for glaucoma surgery  • Uncontrolled IOP or documented glaucomatous    progression in spite of maximum tolerat...
Indications for glaucoma surgery  • Uncontrolled IOP or documented glaucomatous    progression in spite of maximum tolerat...
Indications for glaucoma surgery  • Uncontrolled IOP or documented glaucomatous    progression in spite of maximum tolerat...
Indications for glaucoma surgery  • Uncontrolled IOP or documented glaucomatous    progression in spite of maximum tolerat...
Indications for glaucoma surgery  • Uncontrolled IOP or documented glaucomatous    progression in spite of maximum tolerat...
Thursday, April 7, 2011
POAGThursday, April 7, 2011
POAGThursday, April 7, 2011
POAG                          Medical TxThursday, April 7, 2011
POAG        PACG                          Medical TxThursday, April 7, 2011
POAG        PACG                          Medical TxThursday, April 7, 2011
POAG         PACG                                          Laser                                       Iridotomy          ...
POAG         PACG                                          Laser                                       Iridotomy          ...
Secondary                           POAG         PACG       glaucoma                                          Laser       ...
Secondary                           POAG         PACG       glaucoma                                          Laser       ...
Secondary                           POAG         PACG       glaucoma                                          Laser     Tr...
Secondary                           POAG         PACG       glaucoma                                          Laser     Tr...
Secondary                                   Congenital                           POAG         PACG       glaucoma       gl...
Secondary                                   Congenital                           POAG         PACG       glaucoma       gl...
Secondary                                           Congenital                           POAG         PACG               g...
Secondary                                           Congenital                           POAG         PACG               g...
Secondary                                           Congenital                           POAG         PACG               g...
Secondary                                                Congenital                                POAG         PACG      ...
Secondary                                                Congenital                                POAG         PACG      ...
Secondary                                                Congenital                                POAG         PACG      ...
Secondary                                                Congenital                                POAG         PACG      ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Secondary                                                                Congenital                                POAG   ...
Traction suture                                            6Thursday, April 7, 2011
Traction suture            Peripheral cornea                                            6Thursday, April 7, 2011
Traction suture            Peripheral cornea         Superior rectus                                              6Thursda...
Traction suture         • For good exposure of the surgical site                – Peripheral cornea                       ...
Conjunctival Peritomy:                              Fornix based                                               8Thursday, ...
Conjunctival Peritomy:                              Fornix based         • Easier to create         • Easier exposure & di...
Conjunctival Peritomy:                              Limbal based                                               10Thursday,...
Conjunctival Peritomy:                              Limbal based         • More difficult dissection & exposure         • ...
Cauterization of                          episcleral vessels                                               12Thursday, Apr...
Removal of residual                           episcleral tissues                            JA Tumbocon, MD               ...
Application of Anti-metabolites                                    14Thursday, April 7, 2011
Application of Anti-metabolites         • Mitomycin-C 2mg/ vial                – Concentration: 0.25 to 0.5 mg/ml         ...
Application of Anti-metabolites         • Mitomycin-C 2mg/ vial                – Concentration: 0.25 to 0.5 mg/ml         ...
Application of Anti-metabolites                                    15Thursday, April 7, 2011
Irrigate copiously                                               16Thursday, April 7, 2011
Scleral Flap Dissection         • 1/3 to 1/2 scleral           thickness                – Thinner flap = more             ...
Scleral Flap Dissection                                                18Thursday, April 7, 2011
Paracentesis                                         19Thursday, April 7, 2011
Limbal Fistula                                           20Thursday, April 7, 2011
Limbal Fistula                          Descemet’s punch                                             21Thursday, April 7, ...
Limbal Fistula                          Knife & Vannas scissors                                                    22Thurs...
Limbal Fistula                          Knife & Vannas scissors                                                    23Thurs...
Peripheral Iridectomy                                              24Thursday, April 7, 2011
Peripheral Iridectomy                                              25Thursday, April 7, 2011
Peripheral Iridectomy         • Iris usually prolapses through after           creation of the the limbal fistula         ...
Scleral Flap closure                                                 27Thursday, April 7, 2011
Scleral Flap closure         • 10-0 Nylon suture         • May use 2 to 6           interrupted sutures         • Burry al...
Scleral Flap closure        • No standard number or tightness          of sutures        • Should be able to visualize    ...
Conjunctival Closure                             Limbal based peritomy                            JA Tumbocon, MD         ...
Conjunctival Closure                             Fornix based peritomy                                                    ...
Reform AC, note for elevation of the                  bleb & check for leaks                                          32Th...
JA Tumbocon, MDThursday, April 7, 2011
Trabeculectomy: Post-op care                                       34Thursday, April 7, 2011
Trabeculectomy: Post-op care    • Follow-up closely           – Success = 50% surgery + 50% post-op care                  ...
Trabeculectomy: Post-op care    • Follow-up closely           – Success = 50% surgery + 50% post-op care    • Keep aqueous...
Trabeculectomy: Post-op care    • Follow-up closely           – Success = 50% surgery + 50% post-op care    • Keep aqueous...
Trabeculectomy: Post-op care    • Follow-up closely           – Success = 50% surgery + 50% post-op care    • Keep aqueous...
Trabeculectomy: Post-op care    • Follow-up closely           – Success = 50% surgery + 50% post-op care    • Keep aqueous...
35Thursday, April 7, 2011
http://www.glaucomatoday.com/art/0305/0305sp.pdf                             JA Tumbocon, MDThursday, April 7, 2011
Thank youThursday, April 7, 2011
L a s e r Ir i d o to myThursday, April 7, 2011
Laser Iridotomy         • Mechanism                – Creates a bypass route for the aqueous to                  flow from ...
Interruption of Pupillary block       • Creation of a hole in the outer         half of the iris (iridotomy /         irid...
Laser Iridotomy         • Indications:                – Relative pupillary block /                  primary angle closure ...
Laser Iridotomy         • Other Indications:                – Nanophthalmos/ crowded “middle                  segment”    ...
Laser Iridotomy                   Pre-op evaluation: Gonioscopy               Closed angles         Opens on indentation  ...
Laser Iridotomy         • Pre-laser medications                – Brimonidine                – Proparacaine                ...
Abraham lens           Magnifies view & has 4x laser beam minification                     (increases power concentration)...
Laser Iridotomy site         • Supero-temporal or supero-nasal           peripheral iris         • Choose an iris crypt, i...
Laser Iridotomy site                                                 47Thursday, April 7, 2011
Laser Iridotomy         • Nd: Yag (1064nm wavelength)         • Argon         • Frequency doubled CW Nd: YAG              ...
Nd: YAG Laser Iridotomy         • Suggested Settings:                – 2-6 mJ                – 1-4 pulses / burst         ...
Nd: YAG Laser Iridotomy         • Advantages:                – Fewer applications needed for                  perforation ...
Argon Laser Iridotomy Techniques                             51Thursday, April 7, 2011
Argon Laser Iridotomy Techniques                          “Chipping Technique”       • Suggested Settings:          – Long...
Argon Laser Iridotomy Techniques                          “Chipping Technique”       • Suggested Settings:          – Long...
Argon Laser Iridotomy Techniques                          “Hump technique”              – Suggested Settings:             ...
Argon Laser Iridotomy Techniques                          “Hump technique”              – Suggested Settings:             ...
Argon Laser Iridotomy Techniques                          “Drumhead technique”              – Suggested Settings:         ...
Argon Laser Iridotomy Techniques                          “Drumhead technique”              – Suggested Settings:         ...
Argon Laser Iridotomy         • Advantage:                – Less potential for bleeding         • Disadvantage:           ...
Combined Argon & Nd: YAG Laser            Iridotomy  • Suggested Settings:     – Argon: Use “chipping, drumhead or hump” t...
Combined Argon & Nd: YAG Laser            Iridotomy  • Suggested Settings:     – Argon: Use “chipping, drumhead or hump” t...
Laser Iridotomy         • Endpoint                – Rush of pigment bearing aqueous through                  the iridectom...
Laser Iridotomy                                            58Thursday, April 7, 2011
Laser Iridotomy                          Pre-L.I.            Post-L.I.                                                    ...
Laser Iridotomy         • Immediate post-laser                – Check IOP hourly for at least 3 hours                    (...
Laser Iridotomy         • Potential Complications                – IOP elevation                – Persistent iritis       ...
Laser Iridotomy         • Post L.I. follow up                – Patency of iridotomy                – IOP                – ...
Thank youThursday, April 7, 2011
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Surgical management of glaucoma pgs

  1. 1. Surgical Management of Glaucoma Delivered by: Cesar A. Perez, Jr. MD, DPBO Prepared by Philippine Glaucoma SocietyThursday, April 7, 2011
  2. 2. Outline • Overview • Trabeculectomy – Indications, technique & post-operative care • Laser iridotomy – Indications, technique & post-op care 2Thursday, April 7, 2011
  3. 3. TRABECULECTOMYThursday, April 7, 2011
  4. 4. Indications for glaucoma surgery 4Thursday, April 7, 2011
  5. 5. Indications for glaucoma surgery • Uncontrolled IOP or documented glaucomatous progression in spite of maximum tolerated medical therapy 4Thursday, April 7, 2011
  6. 6. Indications for glaucoma surgery • Uncontrolled IOP or documented glaucomatous progression in spite of maximum tolerated medical therapy • Poor compliance with medical therapy – Relative indication. Maximize compliance 1st 4Thursday, April 7, 2011
  7. 7. Indications for glaucoma surgery • Uncontrolled IOP or documented glaucomatous progression in spite of maximum tolerated medical therapy • Poor compliance with medical therapy – Relative indication. Maximize compliance 1st • Pupillary block angle closure glaucoma – Laser iridotomy 1st, then give medications if there is residual elevated IOP 4Thursday, April 7, 2011
  8. 8. Indications for glaucoma surgery • Uncontrolled IOP or documented glaucomatous progression in spite of maximum tolerated medical therapy • Poor compliance with medical therapy – Relative indication. Maximize compliance 1st • Pupillary block angle closure glaucoma – Laser iridotomy 1st, then give medications if there is residual elevated IOP • Synechial angle closure for @ 360 degrees – May go straight to trabeculectomy 4Thursday, April 7, 2011
  9. 9. Indications for glaucoma surgery • Uncontrolled IOP or documented glaucomatous progression in spite of maximum tolerated medical therapy • Poor compliance with medical therapy – Relative indication. Maximize compliance 1st • Pupillary block angle closure glaucoma – Laser iridotomy 1st, then give medications if there is residual elevated IOP • Synechial angle closure for @ 360 degrees – May go straight to trabeculectomy • Congenital glaucoma – Definitive treatment is surgery 4Thursday, April 7, 2011
  10. 10. Thursday, April 7, 2011
  11. 11. POAGThursday, April 7, 2011
  12. 12. POAGThursday, April 7, 2011
  13. 13. POAG Medical TxThursday, April 7, 2011
  14. 14. POAG PACG Medical TxThursday, April 7, 2011
  15. 15. POAG PACG Medical TxThursday, April 7, 2011
  16. 16. POAG PACG Laser Iridotomy Medical TxThursday, April 7, 2011
  17. 17. POAG PACG Laser Iridotomy Medical TxThursday, April 7, 2011
  18. 18. Secondary POAG PACG glaucoma Laser Iridotomy Medical TxThursday, April 7, 2011
  19. 19. Secondary POAG PACG glaucoma Laser Iridotomy Medical TxThursday, April 7, 2011
  20. 20. Secondary POAG PACG glaucoma Laser Treat primary Iridotomy cause, if possible Medical TxThursday, April 7, 2011
  21. 21. Secondary POAG PACG glaucoma Laser Treat primary Iridotomy cause, if possible Medical TxThursday, April 7, 2011
  22. 22. Secondary Congenital POAG PACG glaucoma glaucoma Laser Treat primary Iridotomy cause, if possible Medical TxThursday, April 7, 2011
  23. 23. Secondary Congenital POAG PACG glaucoma glaucoma Laser Treat primary Iridotomy cause, if possible Medical TxThursday, April 7, 2011
  24. 24. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical TxThursday, April 7, 2011
  25. 25. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical TxThursday, April 7, 2011
  26. 26. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical TxThursday, April 7, 2011
  27. 27. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical Tx No superior conjunctival scarring, relatively “quiet eye “; > 2y/oThursday, April 7, 2011
  28. 28. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical Tx No superior conjunctival scarring, relatively “quiet eye “; > 2y/oThursday, April 7, 2011
  29. 29. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical Tx No superior conjunctival scarring, relatively “quiet eye “; > 2y/o Trabeculectomy + mitomycin-CThursday, April 7, 2011
  30. 30. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + trabeculectomy Medical Tx No superior conjunctival scarring, relatively “quiet eye “; > 2y/o Trabeculectomy + mitomycin-CThursday, April 7, 2011
  31. 31. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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-CThursday, April 7, 2011
  32. 32. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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-CThursday, April 7, 2011
  33. 33. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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-CThursday, April 7, 2011
  34. 34. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Glaucoma drainage device, preferably by a GL specialistThursday, April 7, 2011
  35. 35. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy + mitomycin-C Glaucoma drainage device, preferably by a GL specialistThursday, April 7, 2011
  36. 36. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy + mitomycin-C Glaucoma drainage device, preferably by a GL specialistThursday, April 7, 2011
  37. 37. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy Consider + mitomycin-C transcleral Glaucoma drainage device, cyclophoto- coagulation if preferably by a GL specialist w/ painThursday, April 7, 2011
  38. 38. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy Consider + mitomycin-C transcleral Glaucoma drainage device, cyclophoto- coagulation if preferably by a GL specialist w/ painThursday, April 7, 2011
  39. 39. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy Consider + mitomycin-C transcleral Glaucoma drainage device, cyclophoto- coagulation if preferably by a GL specialist w/ painThursday, April 7, 2011
  40. 40. Secondary Congenital POAG PACG glaucoma glaucoma Laser Refer to GL specialist: Treat primary Iridotomy •Goniotomy, trabeculotomy, cause, if possible or combined trabeculotomy + 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 Poor visual - active proliferative membrane Potential in the AC (e.g. epithelial ingrowth, NV) (LP-NLP) - active AC inflammation - multiple failed trabeculectomies Trabeculectomy Consider + mitomycin-C transcleral Glaucoma drainage device, cyclophoto- coagulation if Legend: preferably by a GL specialist w/ pain Uncontrolled IOPThursday, April 7, 2011
  41. 41. Traction suture 6Thursday, April 7, 2011
  42. 42. Traction suture Peripheral cornea 6Thursday, April 7, 2011
  43. 43. Traction suture Peripheral cornea Superior rectus 6Thursday, April 7, 2011
  44. 44. 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 7Thursday, April 7, 2011
  45. 45. Conjunctival Peritomy: Fornix based 8Thursday, April 7, 2011
  46. 46. Conjunctival Peritomy: 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 9Thursday, April 7, 2011
  47. 47. Conjunctival Peritomy: Limbal based 10Thursday, April 7, 2011
  48. 48. Conjunctival Peritomy: Limbal based • More difficult dissection & exposure • Better water-tight closure 11Thursday, April 7, 2011
  49. 49. Cauterization of episcleral vessels 12Thursday, April 7, 2011
  50. 50. Removal of residual episcleral tissues JA Tumbocon, MD 13Thursday, April 7, 2011
  51. 51. Application of Anti-metabolites 14Thursday, April 7, 2011
  52. 52. Application of Anti-metabolites • 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 14Thursday, April 7, 2011
  53. 53. Application of Anti-metabolites • 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.) 14Thursday, April 7, 2011
  54. 54. Application of Anti-metabolites 15Thursday, April 7, 2011
  55. 55. Irrigate copiously 16Thursday, April 7, 2011
  56. 56. Scleral Flap Dissection • 1/3 to 1/2 scleral thickness – Thinner flap = more aqueous flow • Shapes: – square, rectangular, trapezoidal, triangular 17Thursday, April 7, 2011
  57. 57. Scleral Flap Dissection 18Thursday, April 7, 2011
  58. 58. Paracentesis 19Thursday, April 7, 2011
  59. 59. Limbal Fistula 20Thursday, April 7, 2011
  60. 60. Limbal Fistula Descemet’s punch 21Thursday, April 7, 2011
  61. 61. Limbal Fistula Knife & Vannas scissors 22Thursday, April 7, 2011
  62. 62. Limbal Fistula Knife & Vannas scissors 23Thursday, April 7, 2011
  63. 63. Peripheral Iridectomy 24Thursday, April 7, 2011
  64. 64. Peripheral Iridectomy 25Thursday, April 7, 2011
  65. 65. Peripheral Iridectomy • 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 26Thursday, April 7, 2011
  66. 66. Scleral Flap closure 27Thursday, April 7, 2011
  67. 67. Scleral Flap closure • 10-0 Nylon suture • May use 2 to 6 interrupted sutures • Burry all suture knots 28Thursday, April 7, 2011
  68. 68. Scleral Flap closure • 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” 29Thursday, April 7, 2011
  69. 69. Conjunctival Closure Limbal based peritomy JA Tumbocon, MD 30Thursday, April 7, 2011
  70. 70. Conjunctival Closure Fornix based peritomy 31Thursday, April 7, 2011
  71. 71. Reform AC, note for elevation of the bleb & check for leaks 32Thursday, April 7, 2011
  72. 72. JA Tumbocon, MDThursday, April 7, 2011
  73. 73. Trabeculectomy: Post-op care 34Thursday, April 7, 2011
  74. 74. Trabeculectomy: Post-op care • Follow-up closely – Success = 50% surgery + 50% post-op care 34Thursday, April 7, 2011
  75. 75. Trabeculectomy: Post-op care • Follow-up closely – Success = 50% surgery + 50% post-op care • Keep aqueous flowing – Massage, laser suture lysis &/ or removal of releasable scleral flap sutures 34Thursday, April 7, 2011
  76. 76. Trabeculectomy: Post-op care • Follow-up closely – Success = 50% surgery + 50% post-op care • Keep aqueous flowing – Massage, laser suture lysis &/ or removal of releasable scleral flap sutures • Topical steroids (usually for 6-12 weeks) 34Thursday, April 7, 2011
  77. 77. Trabeculectomy: Post-op care • Follow-up closely – Success = 50% surgery + 50% post-op care • Keep aqueous flowing – Massage, laser suture lysis &/ or removal of releasable scleral flap sutures • Topical steroids (usually for 6-12 weeks) • Prophylactic topical antibiotic 34Thursday, April 7, 2011
  78. 78. Trabeculectomy: Post-op care • Follow-up closely – Success = 50% surgery + 50% post-op care • Keep aqueous flowing – Massage, laser suture lysis &/ or removal of releasable scleral flap sutures • Topical steroids (usually for 6-12 weeks) • Prophylactic topical antibiotic • + Cycloplegic agent (e.g. Atropine) – Stabilizes blood-aqueous barrier – Pulls lens-iris diaphragm posteriorly 34Thursday, April 7, 2011
  79. 79. 35Thursday, April 7, 2011
  80. 80. http://www.glaucomatoday.com/art/0305/0305sp.pdf JA Tumbocon, MDThursday, April 7, 2011
  81. 81. Thank youThursday, April 7, 2011
  82. 82. L a s e r Ir i d o to myThursday, April 7, 2011
  83. 83. 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 LaserThursday, April 7, 2011
  84. 84. 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 angleThursday, April 7, 2011
  85. 85. Laser Iridotomy • Indications: – Relative pupillary block / primary angle closure – Occludable angles – Occlusio pupillae – Fellow eye of patients w/ unilateral angle closure (prophylactic L.I.) 41Thursday, April 7, 2011
  86. 86. 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 42Thursday, April 7, 2011
  87. 87. Laser Iridotomy Pre-op evaluation: Gonioscopy Closed angles Opens on indentation gonioscopy 43Thursday, April 7, 2011
  88. 88. Laser Iridotomy • Pre-laser medications – Brimonidine – Proparacaine – Pilocarpine (optional) 44Thursday, April 7, 2011
  89. 89. Abraham lens Magnifies view & has 4x laser beam minification (increases power concentration) 45Thursday, April 7, 2011
  90. 90. Laser Iridotomy site • Supero-temporal or supero-nasal peripheral iris • Choose an iris crypt, if available 46Thursday, April 7, 2011
  91. 91. Laser Iridotomy site 47Thursday, April 7, 2011
  92. 92. Laser Iridotomy • Nd: Yag (1064nm wavelength) • Argon • Frequency doubled CW Nd: YAG “Thermal (532 nm wavelength / “Green Laser”) Lasers” • Diode 48Thursday, April 7, 2011
  93. 93. Nd: YAG Laser Iridotomy • Suggested Settings: – 2-6 mJ – 1-4 pulses / burst • Less bursts for phakic eyes – 2-4 bursts 49Thursday, April 7, 2011
  94. 94. 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 50Thursday, April 7, 2011
  95. 95. Argon Laser Iridotomy Techniques 51Thursday, April 7, 2011
  96. 96. Argon Laser Iridotomy Techniques “Chipping Technique” • Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs – Short pulse duration: 1000-1500mW, 50 um, 0.02-0.05 secs 52Thursday, April 7, 2011
  97. 97. Argon Laser Iridotomy Techniques “Chipping Technique” • Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs – Short pulse duration: 1000-1500mW, 50 um, 0.02-0.05 secs 52Thursday, April 7, 2011
  98. 98. Argon Laser Iridotomy Techniques “Hump technique” – Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only • Perforation: 1000mW, 50um, 0.2sec 53Thursday, April 7, 2011
  99. 99. Argon Laser Iridotomy Techniques “Hump technique” – Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only • Perforation: 1000mW, 50um, 0.2sec 53Thursday, April 7, 2011
  100. 100. Argon Laser Iridotomy Techniques “Drumhead technique” – Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns • Perforation: 500mW, 50um, 0.2sec 54Thursday, April 7, 2011
  101. 101. Argon Laser Iridotomy Techniques “Drumhead technique” – Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns • Perforation: 500mW, 50um, 0.2sec 54Thursday, April 7, 2011
  102. 102. Argon Laser Iridotomy • Advantage: – Less potential for bleeding • Disadvantage: – Requires more energy and more prone to closure than Nd:YAG iridotomy 55Thursday, April 7, 2011
  103. 103. Combined Argon & Nd: YAG Laser Iridotomy • Suggested Settings: – 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 56Thursday, April 7, 2011
  104. 104. Combined Argon & Nd: YAG Laser Iridotomy • Suggested Settings: – 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 56Thursday, April 7, 2011
  105. 105. 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 57Thursday, April 7, 2011
  106. 106. Laser Iridotomy 58Thursday, April 7, 2011
  107. 107. Laser Iridotomy Pre-L.I. Post-L.I. 59Thursday, April 7, 2011
  108. 108. Laser Iridotomy • Immediate post-laser – Check IOP hourly for at least 3 hours (check for IOP spike) – Topical steroids x 3-7 days 60Thursday, April 7, 2011
  109. 109. 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 61Thursday, April 7, 2011
  110. 110. 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 62Thursday, April 7, 2011
  111. 111. Thank youThursday, April 7, 2011
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