glaucoma

2. MEDICAL MANAGEMENT:-

3. 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.

4. SURGICAL ANATOMY:-
INTERNAL ANATOMY
• IRIS
• CILIARY BODY BAND
• SCLERAL SPUR
• TRABECULAR MESHWORK
• SCHWALBE LINE

5. SURGICAL ANATOMY:-
EXTERNAL ANATOMY
• ANTERIOR LIMBUS
• CONJUNCTIVA & TENON CAPSULE
• POSTERIOR LIMBUS

6. 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

7. 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)

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. FILTERING SURGERY:
• DRAINAGE FISTULA
• FILTERING BLEB
• ROUTES OF AQUEOUS DRAINAGE

14. 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

15. FILTERING BLEB:
• CHARACTERISED BY ELEVATION OF CONJUNCTIVA AT THE SURGICAL SITE .
• THE CLINICAL APPEARANCE & FUNCTION OF BLEB VARIES IN:
REGARD TO EXTENT , ELEVATION & VASCULARITY.

16. 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.

17. LIMBAL STAB INCISION:
• PARACENTESIS SITE: SELF HEALING, BEVELED INCISION AT THE LIMBUS
• SITE:TEMPORALLY AT THE HORIZONTAL MERIDIAN OR IN THE INFERIOR –TEMPORAL QUADRANT.

18. PREPARATION OF FLAP:
LIMBUS BASED FORNIX BASED

19. 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.

20. 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.

21. Cauterization of area intended for margins
of scleral flaps.

22. Margins of scleral flap outlined
by partial thickness incisions.
C- triangular scleral flap as an
alternative technique.

23. Anterior chamber entered just behind the hinge
of the scleral flap.

24. E – completion of anterior & lateral
margins of deep limbal incision
with scissors.

25. F – flap of deep limbal tissue excised using
kelly punch.

26. COMPLICATIONS:
• INTRAOPERATIVE COMPLICATIONS
• EARLY POSTOPERATIVE COMPLICATIONS
• POSTOPERATIVE COMPLICATIONS

27. INTRAOPERATIVE
• TEARING /BUTTONHOLING OF THE CONJUNCTIVAL FLAP
• HEMORRHAGE
• CHOROIDAL EFFUSION

28. EARLY POSTOPERATIVE :
• HYPOTONY & FLAT CHAMBER
• CONJUNCTIVAL DEFECT
• EXCESSIVE FILTRATION
• SEROUS CHOROIDAL DETACHMENT

29. LATE POSTOPERATIVE :
• LATE FAILURE OF FILTERATION
• A LEAKING FILTERING BLEB
• BLEBITIS
• BLEB RELATED ENDOPHTHALMITIS

30. ANTIFIBROTIC AGENTS
• CORTICOSTEROIDS
• 5-FLUOROURACIL
• MITOMYCIN C
• OTHERS

31. 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

32. 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 .

33. 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

34. LASER IRIDOTOMY
• INDICATION:-PRESENCE OF PUPILLARY BLOCK
Therapeutic
TO PREVENT
PUPILLARY BLOCK
Diagnostic
PATENT IRIDOTOMY
FAILS TO CHANGE THE
PERIPHERALIRIS
CONFIGURATION

35. 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.

37. 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

38. 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

39. 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.

40. A B C

41. 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.

42. TECHNIQUE:
SPOT SIZE POWER TIME
200-500µM 200-500MW 0.1-0.5 SEC

44. 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.

45. DEVICES:
VALVED
• AHMED (NEW WORLD MEDICAL)
NON VALVED
• MOLTENO (MOLTENO
OPHTHALMIC,DUNEDIN,NEWZEALAND)
• BAERVELDT (ABBOTT MEDICAL OPTICS)

48. INDICATIONS:
• FAILED TRABECULECTOMY WITH ANTIFIBROTICS
• ACTIVE UVEITIS
• NEOVASCULAR GLAUCOMA
• INADEQUATE CONJUNCTIVA
• APHAKIA
• CONTACT LENS USE.

49. CONTRAINDICATIONS
• BORDERLINE CORNEAL ENDOTHELIAL FUNCTION.
PREOPERATIVE EVALUATION
• MOTILITY
• STATUS OF CONJUNCTIVA
• SCLERA
• PREVIOUSLY PLACED SCLERAL BUCKLE.

50. 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

51. COMPLICATIONS:-
• TUBE CORNEA TOUCH
• FLAT CHAMBER & HYPOTONY
• TUBE OCCLUSION
• PLATE MIGRATION
• VALVE MIGRATION
• TUBE /PLATE EXPOSURE OR EROSION

52. CYCLODESTRUCTIVE PROCEDURES:
• TRANS SCLERA CYCLOPHOTOCOAGULATION
• ENDOSCOPIC CYCLOPHOTOCOAGULATION

53. 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

54. 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

59. COMPLICATIONS:-
EARLY:
• UVEITIS & HYPHEMA
• DELLEN
• LOSS OF CENTRAL VISION
• OCULAR DECOMPRESSION RETINOPATHY
LATE:
• LATE FAILURE OF FILTRATION
• A LEAKING FILTERING BLEB

60. THANK YOU