Basic principles of glaucoma

1. Glaucoma basic principles part 2
Samhaa Mohammed Abd El Moneim
Zagazig Ophthalmic Hospital

2. Different patterns of visual field
defects

3. Tips in perimetry (VF defect)
Central
scotoma
Enlarged
blind spot
Respect
horizontal
line
Respect
vertical
line
Superotemporal
not respect
vertical line
• Demyelinating
• Toxic,
nutritional
• LHON
• compressive
• Papillodema
• Congenital
anomalies
• Glaucoma
• AION
• Drusen
• BRVO,
BRAO
• Chiasm
& post
chiasm
lesion
• Tilted
disc

6. Bitemporal heminaopia
(chiasm lesion)

7. Enlarged blind spot
• Papillodema
• congenital disc anomaly

8. Lt homonymous haeminopia
Rt retrochiasm lesion
• Optic tract lesion
• Optic radiation lesion (pie
in the sky) … rt temporal
lobe lesion.

9. Lt homonymous haeminopia
Rt retrochiasm lesion
• Optic radiation lesion (pie
in the floor) … rt parietal
lobe lesion.

10. Rt inf altitudinal VF defect
• Glauucoma
• AION
• Drusen
• Sup BRVO, BRAO

11. Lt optic atrophy & Rt supero-
temporal hemifeild defect
• Lesion compress ant chiasm
(pituitary tumour, intracranial
meningioma junctional scotoma )
• Glaucoma (respect HL)

12. Ccentral, centrocecal scotoma
• Demyelinating
• Glaucoma
• Toxic, nutritional ON
• Compressive

13. Rt homonymous haeminopia
• Lt retrochiasm lesion
• Optic tract lesion
• Optic radiation (pie in the sky)
temporal lobe lesion.

14. Bitemporal haeminopia
• Chiasmatic lesion

15. Lt absolute temporal defect respect
VL
• Chiasm, retrochiasm lesion
• Glaucoma ( respect HL)

16. Bilateral sup altitudinal defect
• Glaucoma
• AION
• Inf BRVO, BRAO
• Drusen

17. Rt sup arcuate defect
• Glaucoma
• AION
• Drusen
• Inf BRAO, BRVO

18. Bilateral inferrior arcuate defect
• Glaucoma

19. Antiglaucomatous drugs

20. Drug Mechanis
m
Route of
adm.
Side effect Agents Contraindication
PG ↑ US
outflow
(25-
30%)
Once
daily
Ocular:
• Conj hyperemia
• Lash lenghthening,
thickening,
hyperpigmentation.
• Iris pigmentation
• Loss of periorbital fat
• Inter-individual
response,
Tachyphlasis within
days
• ↑CME
Systemic:
• Headache, skin rash,
myalgia, URT
symptoms
• Travaprost
• Latanoprost
(less SE)
• Bimatoprost
(greater
↓IOP)
• Preop….
(CME)
• Ant uveitis
• Herpetic
keratitis
• Rubeosis
iridis
• Pregnancy

21. Drug Mechanis
m
Route of
adm.
Side effect Agents Contraindication
BB ↓
aqeous
secretio
n
(25-
30%)
Twice
daily
(not at
bed
time)
Ocular:
• Allergy, punctate
keratitis
• Tachyphlaxis
Systemic:
• Bronchospasm
• Bradycardia,
hypotension, heart
block, peripheral
vasoconstriction (B/P,
not instill at bedtime)
• Depression, Loss of
lipido
• Timolol
• Betaxolol
(less↓IOP
than timolol
but increase
blood flow to
ON),cardiosel
ective, less
bronchospas
m
• Levobunolol(c
ardioselective)
• Carteolol (less
systmic SE)
• Asthma
• Heart failure
• Eldery with
vascular
insuffeciency
(raynaud̛s
phenomeno
m)
ɑ2
agonist
↓
aqeous
secretio
n
↑ US
outflow
(20-
Twice
daily
Ocular:
• Allergic conj.
Systemic:
• Xerostomia
• Fatigue
• Brimonidine
• Apraclonidine
(post laser
surgery, loss
of effect over
wks) short
term ttt
• Infant < 2y
(CNS &
respiratory
depression)

22. Drug Mechanis
m
Route of
adm.
Side effect Agents Contraindication
Topical
CAI
↓
aqeous
secretio
n
(20%)
Twice
daily
Systemic:
• Allergy to sulfa
• SJS
• BM suppresion
Ocular:
• Allergic conj.
• ↑corneal
decompensation
• Dorzolamide
• Brinzolamide
(lower ocular
SE)
• Allergy to
sulfonamide
• Renal or liver
dis
• Sickle cell dis
• Pregnancy
Systemic
CAI
↓
aqeous
secretio
n
(20%)
Once to
4
times/d
Systemic:
• Tingling, fatigue, wt
loss
• Bitter taste, GIT
• Renal stones, ↓K
• SJS
• BM suppresion
• Teratogenic
Ocular:
• Choroidal effusion
Short term ttt for
high risk of VA
loss (SE)
• Acetazolamid
e 250mg (tab),
500mg (vial)
• Methazolami
de (long
duration)
• Allergy to
sulfonamide
• Renal or liver
dis
• Sickle cell dis
• Pregnancy

23. Drug Mechanis
m
Route of
adm.
Side effect Agents Contraindication
Osmotic
agents
Drawn
out
water
from
vitrous
Systemic:
• Volume overload
• Urnie retention
• Headache, nausea,
confusion
Short term in v
high IOP (ACG,
preop.)
• Mannitol 20%
(1g/kg or
5ml/kg over
30-60min)
• Glycerol oral
50% (1g/kg or
2ml/kg with
lemon juice
• Inflamatory
conditions
(compromise
d BAB)
• Renal failure
• CVS
problems
• DM
Miotic Opening
angle, ↑
TM
outflow
(20-
25%)
Ocular:
• Miosis, myopic shift,
cataract, VF denser
Systemic:
• Confusion,
bronchospasm,brady
chardia, urine
frequency
• Pilocarpine
• carbachol

24. General rules of medical ttt
• Close eye, occlude over lacrimal sac for 3 min →
↓systemic absorption.
• Clean & wipe skin with dry tissue after instillation.
• Pregnancy ---- avoid systemic CAI (teratogenic), PG
(abortion).
• Start single drug (PG) --- stop and shift to another --- two
drugs --- two bottles (maximum)
• Neuroprotective drugs (ɑ agonist, CAI)

25. • Combined agents:
Cosopt®: timolol and dorzolamide, administered twice daily.
Xalacom®: timolol and latanoprost once daily.
DuoTrav®: timolol and travoprost once daily.
Combigan®: timolol and brimonidine twice daily.
Azarga®: timolol and brinzolamide twice daily.

26. How to manage a glaucoma case
‫نفسك‬ ‫اسأل‬
Type
Risk factors
Appropriate & avoided ttt
acquired

27. Glaucoma Laser ttt
1. Laser trabeculoplasty:
• (ALT) Argon Laser Trabeculoplasty
• (SLT) Selective Laser Trabeculoplasty
• (MLT) Micropulse diode Laser Trabeculoplasty
2. Peripheral Laser iridotomy
3. Diode laser cyclophotocoagulation
4. Peripheral Laser iridoplasty

28. Glaucoma Laser ttt
Type (mode of action ???)
Argon, YAG, Diode
Technique & settings
Spot size
Power
Duration
Indications & contraindications (type of glaucoma as 1ry
ttt??, medical ttt failure, incompliance & intolerance)
Complication (bleeding , inflamation, IOP spikes, failure)
TTT (topical steroids, antiglaucoma ttt, FU)

29. Glaucoma laser ttt
1. Laser trabeculoplasty
Lasertrabeculoplasty
ALT (Argon Laser Trabeculoplasty)
Long established
Selective laser trabeculoplasty (SLT)
Target pigmented TM
Repeatable
Less tissue destruction (no thermal damage) than ALT
Micropulse Laser trabeculoplasty (MLT)
Hermal ablation with no visible tissue reaction

30. Glaucoma Laser ttt
1. Laser trabeculoplasty:
SLT
• 0.6 MJ YAG, spot size 400 mic for 0.3ns, no thermal damage
• Over inf 180° target pigmented TM ---- 50 spots, bubbles.
ALT
• 400 mw, spot size 50 mic., 0.1 second, 50 spots
• More tissue destruction, blanching.
MLT
• Thermal energy without damage
• Short duration pulses, spot size 100 mic, 0.1 second, 800mw
Indications & contraindications (type of glaucoma as 1ry ttt??,
medical ttt failure, incompliance & intolerance)
Complication (bleeding , inflamation, IOP spikes, failure)
TTT (topical steroids, antiglaucoma ttt pre & post op??, FU)

31. Glaucoma Laser ttt
Laser trabeculoplasty (SLT selective laser trabeculoplasty)

32. Glaucoma Laser ttt
2. Peripheral Laser iridotomy PLI
PLI
• YAG 4-5 MJ targeting iris crypts--- iris pigments gush & red reflex.
• Between 11 & 1 o’clock.
• Need miosis.
Indications & contraindications (type of glaucoma as 1ry
ttt??, medical ttt failure, incompliance & intolerance)
Complication (corneal burns, glare, bleeding , inflamation, IOP
spikes, failure)
TTT (topical steroids, antiglaucoma ttt pre & post op??, FU)
ACG, Pupillary block glaucoma

33. Glaucoma Laser ttt
Peripheral Laser Iridotomy

34. Glaucoma Laser ttt
3. Diode Laser cyclophotocoagulation
TS CPC (Trans Scleral)
• 1500mw, 2mm from limbus till POP sound
• 270°, 6 shots in each quadrant, 2mm from limbus
Indications & contraindications (type of glaucoma as 1ry
ttt??, medical ttt failure, low vision)
Complication (hypotony, scleral thinning & perforation, lens
sublaxation, bleeding , inflamation, IOP spikes, failure)
TTT (topical steroids, antiglaucoma ttt pre & post op??, FU)
Refractory glaucomas

35. Glaucoma Laser ttt
Diode laser cyclophotocoagulation

36. Glaucoma Laser ttt
4. Peripheral laser iridoplasty
Setting & technique
• 200mw, spot size 400 mic., 0.2 second.
• 20-40 burns over 360°
Indications & contraindications (type of glaucoma as 1ry
ttt??, medical ttt failure)
Complication (altered accomodation, bleeding , inflamation, IOP
spikes, failure)
TTT (topical steroids, antiglaucoma ttt pre & post op??, FU)
Plataeu iris syndrome

37. Glaucoma surgical ttt
1. Trabeculectomy (MMC)
2. Non penetrating glaucoma surgery:
• Deep sclerotomy
• Viscocanalostomy
• Canaloplasty
• Trabectome (ab interno)
3. Drainage episcleral shunts:
• Malteno, Braveldt
• Ahmed (with valve)
4. Mini shunts:
• Express (ab externo, stent under scleral flap with trab)
• iStent (ab interno through TM to schlemm canal)

38. Glaucoma surgical ttt
Trabeculectomy (MMC)

39. Glaucoma surgical ttt
IStent glaucoma surgery

40. Glaucoma surgical ttt
Express glaucoma surgery (video)