Lecture on Principles of Medical & Surgical Management of Glaucoma For 4th Year MBBS Undergraduate Students By Prof. Dr. Hussain Ahmad Khaqan

1. Principles of Medical & Surgical
Management of Glaucoma
Prof. Dr. Hussain Ahmad Khaqan
 MD
 FRCS(Glasgow)
 FCPS(Ophth.)
 FCPS(Vitreo Retina)
 MHPE (KMU)
 CICO(UK)
 CMT(UOL)
 Fellowship in Medical Retina (LMU, Munich)
 Fellowship in Vitreo Retinal Surgery (LMU, Munich)
 Consultant Ophthalmologist & Retinal Surgeon
Professor of Ophthalmology
Lahore General Hospital, Lahore
Ameer Ud Din Medical College, Lahore
Post Graduate Medical Institute, Lahore
Shaukat Khanum Memorial Cancer Hospital & Research Centre ,Lahore

2. PRIMARY OPEN ANGLE GLAUCOMA

3. TREATMENT
• Rigorous IOP-lowering commonly achieved with:
1. Medications
2. Laser: Argon laser trabeculoplasty (ALT) and selective
laser trabeculoplasty [SLT]
3. Glaucoma surgery.

4. MEDICATION
• Prostaglandin agonists (e.g. , latanoprost 0.005% q.h.s. , bimatoprost
0.01% or 0.03% q.h.s. , travoprost 0.004% q.h.s. , tafluprost 0.0015%
q.h.s.
• Beta-blockers (e.g., levobunolol or timolol 0.25% to 0.5% daily or b.i.d.)
• Selective α2-receptor agonists (brimonidine 0.1%, 0.15%, or 0.2% b.i.d. to
t.i.d.)
• Apraclonidine 0.5% or 1% may be used for short-term therapy (3 months)
• Topical carbonic anhydrase inhibitors (CAIs) (e.g. , dorzolamide 2% or
brinzolamide 1% b.i.d. to t.i.d.)
• Miotics (e.g. , pilocarpine q.i.d.)
• Sympathomimetic (dipivefrin 0.1% b.i.d. or epinephrine 0.5% to 2.0%
b.i.d.)
• Systemic carbonic anhydrase inhibitors (CAIs) (e.g. , methazolamide 25 to
50 mg p.o. b.i.d. to t.i.d. , acetazolamide 125 to 250 mg p.o. b.i.d. to
q.i.d. , or acetazolamide 500 mg sequel p.o. b.i.d.).

5. PRIMARY CLOSED ANGLE GLAUCOMA

6. MEDICAL TREATMENT
• Topical therapy with β-blocker
• Topical pilocarpine (2% or 4%) can also be used
• Intravenous/oral acetazolamide 5–10 mg/kg
• Topical steroid
• Compression gonioscopy is essential to determine if the
trabecular blockage is reversible and may break an acute
attack.
• Mydriatic and a cycloplegic agent (e.g. , cyclopentolate 1% to
2%, and phenylephrine 2.5% every 15 minutes for four doses)
• Systemic steroids may be required to treat serous choroidal
detachments secondary to inflammation.

7. SURGICAL TREATMENT
• ND-YAG peripheral iridotomy
• Iris procedures (surgical iridectomy), angle
procedures (goniotomy, trabeculotomy)
• Trabeculectomy with/without augmentation.
• Deep sclerectomy, minimally invasive glaucoma
surgery (MIGS) and Setons (tube drainage surgery).

8. PHACOLYTIC GLAUCOMA

9. TREATMENT
• The immediate goal of therapy is to reduce the IOP and to reduce the
inflammation. The cataract should be removed promptly (within several days).
1. Medical therapy options include:
• Topical β-blocker (e.g. , timolol 0.5% daily or b.i.d.), α-2 agonist (e.g., brimonidine
0.1% to 0.2% b.i.d. to t.i.d.) and/or topical carbonic anhydrase inhibitors (CAIs)
(e.g. , dorzolamide 2% t.i.d.).
• Systemic carbonic anhydrase inhibitors (CAIs) (e.g., acetazolamide 500 mg sequel
p.o. b.i.d.).
• Topical cycloplegic (e.g., cyclopentolate 1% t.i.d.).
• Topical steroid (e.g., prednisolone acetate 1% every 15 minutes for four doses then
q1h).
• Hyperosmotic agent if necessary and no contraindications are present (e.g.,
mannitol, 1 to 2 g/kg i.v. over 45 minutes).
2. Surgical therapy: Cataract extraction

10. PHACOMORPHIC GLAUCOMA

11. TREATMENT
• Medical (topical and systemic): as for primary angle
closure glaucoma
• ND-YAG peripheral iridotomy to reverse pupil block
component.
• Early cataract extraction is the definitive treatment.

12. GLAUCOMA SECONDARY TO LENS
SUBLUXATION/DISLOCATION

13. TREATMENT
• Positional: dilate and lie patient supine (to encourage
posterior movement of lens), and constrict (to keep
lens safely behind pupil); long-term miotic therapy
may be needed, unless the lens dislocates safely into
the vitreous.
• Early lens extraction: if positional measures fail, if
complete dislocation into the anterior chamber, if
cataract, or if recurrent problem. Often best dealt
with by a vitreoretinal approach.