Surgery Glaucoma

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my seminar on surgical management of glaucoma

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Surgery Glaucoma

  1. 1. SURGICAL MANAGEMENT OF GLAUCOMA<br />Abinaya.k.a<br />Roll no:1<br />
  2. 2. Surgical management<br />Laser surgeries<br />Trabeculotomy and goniotomy<br />Penetrating filtering surgeries-trabeculectomy<br />Non penetrating filtering surgeries<br />Cyclo destructive procedures<br />Artificial drainage implants<br />
  3. 3. LASER SURGERIES<br />Trabeculoplasty<br />Peripheral iridotomy-Nd:Yag laser<br />Cyclo ablation-diode laser<br />LASER filtration procedures<br />Argon laser<br />selective laser<br />
  4. 4. Trabeculoplasty<br />Laser energy to trabecular meshwork<br />Cellular changes in angle<br />Increases the drainage<br />Patient selection:<br /><ul><li>Patients non-compliant with med therapy.
  5. 5. Elderly
  6. 6. Type of glaucoma-open angle
  7. 7. Pigmentation-pseudo exfoliation type;</li></ul>-pigmentary<br />
  8. 8. Pre-operatively:<br />The eye should be free from inflammation<br />Iop should not be too high<br />It should not be end stage glaucoma<br />
  9. 9. ARGON LASER TRABECULOPLASTY<br />Involves application of laser burns to the trabeculum at blue-green wavelengths<br />It enhances aqueous flow<br />Alt is ineffective in pediatric glaucoma and most of sec glaucoma except pigmentary and pseudo exfoliatory types<br />
  10. 10. Application of laser beam:at the junction of pigmented and non pigmented trabeculum.<br />Ideal reaction:minute gas bubble or blanching<br />
  11. 11. Mechanism of action<br />Mechanical effect:<br />Tightening of TM<br />Opening of intervening spaces<br />Opening of collapsed schlemm’s canal<br />Biological response:<br />Release of cytokines-signals the macrophages to clear material that has accumulated in meshwork<br />
  12. 12. procedure<br />Pre-op:brimonidine eye drops 15 mins before<br />Local anaesthetic<br />Gonioscopic contact lens to visualise the angle<br />180 or 360 treated per session<br />Post-op:glaucoma eye drops,anti-glaucoma medication ot be continued,short course of topical steroids<br />Follow up-6 wks later<br />
  13. 13. Complications:<br /><ul><li>Peripheral anterior synechiae
  14. 14. Small hemorrhages
  15. 15. Elevation of IOP
  16. 16. uveitis
  17. 17. Adverse effect on subsequent filtering surgery
  18. 18. Success rate:POAG-75-80%</li></li></ul><li>selective LASER TRABECULOPLASTY<br />Nd:yag laser <br />Laser targets only the pigmented cells in TM<br />Advantage over ALT-the surgeon can repeat the surgery over the same angle<br />
  19. 19. peripheral iridotomy<br />Definition: <br /> -creating a full thickness hole in the peripheral iris in order to alleviate the pupillary block.<br />
  20. 20. Indications:<br /><ul><li>PACG
  21. 21. Fellow eye of a patient with acute glaucoma
  22. 22. Narrow occludable angles
  23. 23. Secondary angle closure with pupil block
  24. 24. Narrow angle in POAG
  25. 25. Combined mech glaucoma</li></li></ul><li>Peripheral iridotomy<br />
  26. 26. TECHNIQUE OF IRIDOTOMY<br />PUPIL IS MIOSED PRE-OP<br />SITE:PERIPHERY OF IRIS,SUPERIOR IRIS<br />11-1 o clock position TO PREVENT THE IRRADIATION OF FOVEA.<br />SUCCESSFUL IRIDOTOMY:GUSH OF PIGMENT DEBRIS<br />
  27. 27. COMPLICATIONS:<br />Bleeding<br />Iritis<br />Glare and diplopia<br />Corneal burns<br />
  28. 28. Surgery for congenital glaucoma<br />Goniotomy<br />Trabeculotomy<br />trabeculectomy<br />
  29. 29. goniotomy<br />Done when cornea is clear or the angle can be visualised.<br />Mech:<br />Incision of obstructing trabecular meshwork<br />Direct conduit between AC & schlemm canal<br />Barkangoniotomy knife<br />
  30. 30.
  31. 31. Pre-op care:<br />Acetazolamide:one week before to clear corneal opacity<br />ARI & NLD obstruction – treated<br />Complications:<br />Post-op hyphema<br />Injury to iris & lens<br />DM detachment<br />
  32. 32. TRABECULOTOMY<br />Harm’s trabeculotome<br />
  33. 33. Filtering proceduretrabeculectomy<br />Patient selection:<br />
  34. 34. Pre-op considerations:<br />Any type of glaucoma<br />Intact,non-scarred conjunctiva<br />Surgical technique:<br /><ul><li>Incision through the conjunctica
  35. 35. Partial thickness scleral flap
  36. 36. A small hole in AC
  37. 37. Iridectomy at this point
  38. 38. Scleral flap closed with stitches
  39. 39. Conjunctival tissue closed with stitches to allow formation of bleb</li></li></ul><li>trabeculectomy<br />
  40. 40. I.LIMBAL BASED CONJUNCTIVAL FLAP<br />II.OUTLINE OF SUPERFICIAL SCLERAL FLAP<br />
  41. 41. III.DISSECTION OF SUP.SCLERAL FLAP<br />IV.INCISION FOR DEEP SCLERECTOMY<br />
  42. 42. V.EXCISION OF DEEP SCLERAL BLOCK<br />VI.PERIPHERAL IRIDECTOMY<br />
  43. 43.
  44. 44. Bleb is situated in superior aspect of eye covered by the upper eyelid<br />Anti-metabolites:<br />5 FU and mitomycin(0.02%) used.<br />It prevents scarring of tissue<br />Frequent use will lead to hypotony<br />Anaesthesia:<br />~retro bulbar / topical<br /><ul><li>Post-op :
  45. 45. Success rate:65-70%</li></li></ul><li>SHALLOW, DIFFUSE FILTERING BLEB<br />THIN, POLYCYSTIC BLEB<br />
  46. 46. VASCULARISED, NON-PENTRATING BLEB<br />LEAKING BLEB<br />
  47. 47. Post-op complications<br />Shallow anterior chamber<br /><ul><li>Pupillary block
  48. 48. Over filtration
  49. 49. Malignant glaucoma</li></ul>Failure of filtration<br />Bleb related complications<br /><ul><li>Bleb leakage
  50. 50. Blebitis
  51. 51. Bacterial infection</li></li></ul><li>Non-penetrating filtering surgeries<br />Intro:<br /><ul><li>AC is not entered , so post-op hypotony does not occur.
  52. 52. Dis adv:
  53. 53. Two types:
  54. 54. Deep sclerectomy
  55. 55. Visco-canalostomy</li></li></ul><li>Artificial drainage devices<br />Intro:<br /><ul><li>Plastic devices which create a communication between AC and sub tenon space.</li></ul>Indications:<br /><ul><li>Uncontrolled glaucoma
  56. 56. Sec. glaucoma-neo vascular glaucoma,aniridia
  57. 57. Severe conjunctival scarring</li></li></ul><li>Implant types<br />With a valve:<br />~ahmed and krupin<br />Without a valve:<br />~molteno and baerveldt<br />SETON’S OPERATION<br />
  58. 58. Complications:<br />Excessive drainage<br />Corneal decompensation<br />Cataract<br />Diplopia<br />Late endophthalmitis<br />Success rate:75%<br />
  59. 59. Cyclo destructive procedures<br />Surgical and laser procedures that ablate the ciliary body to lower the iop<br />surgery:-cyclocryotherapy<br />Laser-cyclophotocoagulation<br />Feared complication:hypotony<br />
  60. 60. Thank you!<br />

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