Medical and surgical treatments of glaucoma

Medical and surgical treatments of
glaucoma
By mahamutha fahima m
Third mbbs part 1

Contents of the presentation
-----Part 1----
• Treatment of congenital glaucoma
• Treatment of open angle glaucoma
• Anti glaucoma drugs
• Treatment of angle closure glaucoma- general algorithm
• -----Part 2-----
• Surgical procedures for glaucoma-
• Certain terminologies
• Summary
• quiz
• references

Congenital glaucoma treatment
methods
• Medical:The treatment of congenital or infantile glaucoma is
always surgical.
• Preoperative drugs:
• Systemic acetazolamide and mannitol IV along with local beta
blockers, e.g. timolol maleate controlthe intraocular pressure
preoperatively.
• Surgical:1. goniotomy-(type of internal filtration
operation)
• 2.trabeculotomy(type of internal fil operation)
• 3.trabeculectomy(type of external filteration
operation)

Congenital glaucoma treatment
• Goniotomy- toc if cornea is clear.
• •A specially constructed knife is passed at the
limbus.
• •A Barkan goniotomy knife is swept across the angle
of the anterior chamber in the opposite segment
under direct gonioscopic observation.
• •It opens up the blockage of the corneoiridic angle
by the persistent embryonic tissue.

• iii.Trabeculectomy—If all forms of
trabeculotomy fail then a trabeculectomy, a
type of filtering operation may be considered
• Partial thickness fistula is created(.explained in
the later slide no--)
• iv.trabeculotomy with trabeculectomy with
antimetabolites(mitomycin c) gives best best
surgical outcome.
• surgery of choice for congenital glaucoma.

Open angle glaucoma treatment
• PrincipleT:he main aim of treatment is to prevent visual loss and
visual field defect which result from highintraocular pressure.
Regular supervision by tonometry and fundus photography if
possible is advisedto assess the progress of disease
• .Methods:
• 1.Medical—It is always the treatment of choice in the early stages.
• 2.Surgical—It is considered to be the last resort.
• 3.Argon or diode laser trabeculoplasty (ALT or DLT)—It is the most
advanced technique
• .4.Recent advanced procedures—These include laser filtration,
seton valves, deep sclerotomy and viscocanalostomy.

• Medical treatment is always the treatment of
choice.
• Basic rules of drug treatment are
• :i.Initial therapy is usually medical
• .ii. Use the lowest concentration of the drug.
• iii.Use the minimum frequency of the drug per
day.
• iv. Choose the drug with least side effects.
• .v. Combined drug therapy is more effective
and convenient.

Beta receptors are present in the non pigmented epithelial
cells in the ciliary process—located on pars plicata—anterior
rough part of ciliary body

Beta blockers-most commonly used drugs ,not the
drug of choice,most popular drugs
drug MOA OCULAR SIDE EFFECT HIGH YIELD POINTS
Timolol-non
selective,most
popular drug
used.05. %
Decreases the
aquoeous production
1.Allergic blepharo
conjunctivitis
,asthma
2.bradycardia,blurr
ed vision.
3.Copd ,congestive
heart failure.
4.dryness,depressi
on,diabetes
mellitus&superficia
l punctate keratitis
Contraindicated in
asthma,
cardiopulmanary
diases patients.
CHF, Diabetes
Betaxolol,
selective
beta 1 drug
same Can be used in
bronchial
asthma patients
Advantage:increases
blood flow to optic
disc

Prostaglandin analogues-drug of
choice
drug moa Side effects
5 PTS
HIGH YIELD POIINTS
LANTANOPR
OST
INCREASES THE
UVEOSCLERAL
OUTFLOW
1.HYPERPIGMENTATI
ON-OF THE IRIS AND
PERI OCULAR SKIN
PIGMENTATION
It can be used in
ashmatics with
caution
TRAVOPROST 2.HYPERTRICHIASIS&
trichomegaly.
3.uveitis,intraocular
inflammation
BIMATOPROS
T
4.Reactivation of
herpes simplex
5.Cystoid macular
edema in DR

III.ALPHA adrenegic agonists-DOUBLE
MOA
They are not the DOC ,BCOZ LOT
OF ALLERGIC
REAX&TACHYPHYLAXSIS
ALPHA1
SELECTIVE
A-
APRACLONIDINE
B-BRIMONIDINE
NEUROPROTECIV
E,CNS
DEPRESSANT,SLL
EP APNEA IN
CHILDRENC/I IN
INFANTS AND
CHILDREN
C-CLONIDINE
NON SELECTIVE
D-
DIPIVEFRIN
C/I-
SYSTEMIC
HTN,PRODR
UG
E-
EPINEPHRINE
BLACKISH
PIGMENTATIO
N IN
CONJUNCTIVA
–A/E

IV.CA inhibitors-
Moa-
decreases
aqueous
formation
topical
Dorzolamide 2%
Brinzolamide 1%bd
systemic
Acetazolamide,dimox
methazolamide

V.HYPEROSMOTIC AGENTS
• EG:ORAL ROUTE-glycerol-ci-dm patients
• Iv mannitol 20%
• Moa:dec the viterous volume,shifting fluid
from viterous to plasma
• Used in emergency conditions,
• Acute congestive glaucoma
• c/i—chf,ARFpatients

VI.Drugs which increase trabecular
outflow
• Pilocarpine-eg
• it was previously drug of choice for acute
congestive glaucoma
• Nowadays adjunctive therapy.
• Moa-Miotics
• side effects:
• Accomadation spasm –induced myopia
• Retinal detachment-contraindicated in high
myopes

.VI.rhokinase inhibitors
Eg: netasurdil
Moa:
1. Decrease the aq formation
2. Inc the aq outflow
3. Dec episceral venous pressure
ADR:
Vortex keratopathy

Approach to treatment of poag
• Record and grade severity of glaucoma
• Idetify target iop
• Intiate and monitor medical therapy..
• what isStep no 2 if medical therapy fails/non
compliance

Step no 2:Laser trabeculoplasty
• :A trabeculoplasty is a modification of the trabecular
meshwork.
• Laser trabeculoplasty (LTP) is the application of a laser
beam to burn areas of the trabecular meshwork,
located near the base of the iris, to increase fluid
outflow.
• indications
• It should be considered in patients where IOP is
uncontrolled despite maximal tolerated medical
therapy.
• It can also be considered as primary therapy
where there is non-compliance to medical therapy.

• LTP is used in the treatment of various open-angle
glaucomas.[1]
• The two types of laser trabeculoplasty are
argon laser trabeculoplasty (ALT) and
selective laser trabeculoplasty (SLT)-Nd YAG
laser

Technique and procedure
• https://www.youtube.com/watch?v=i3Zm3zJ6
fNU.
• Link for d/b slt and ALT
• ln SLT, 50 burns (50 micron spot size) are
applied over 180 of Trabecular meshwork

Step 3 if every thing fails
• Go and do..external filteration operations such
as trabeculectomy
• ….3 STEPS FOR POAG………TREATMENT..
• THE END

management algorithm for ACG
• Acg-ocular emergency
• ANGLE CLOSURE GLAUCOMA:3 step procedural Tx
• Step 1.decrease IOP-DOC-manitol/azetazolamide/glycerol.
• Step 2.prophylactic peripheral iridectomy/laser iridotomy of
the second eye.preferably slt-Ndyag laser
• Step 3.laser iridotomy of the attacked eyye

Key differeces in presentation of OAG
AND ACG
ACG OAG
FEMALE NO GENDER PREDISPOSITION
50 YRS OLDER
HYPERMETROPIA MYOPIA
SUDDEN PAINFUL SLOW PAINLESS
COLOURED HALOS NO SYMPTOMS
PUPILLARY BLOCK TRABECULAR FIBROSIS

PART 2-OF MANAGEMENT OF
GLAUCOMA

Surgical procedures for glaucoma
• Classification
• 1.peripheral iridectomy.,LASER IRIDOTOMY
• 2.filtering surgeries
Internal
External
• 3.glaucoma drainage devices
• 4.cyclodestructive procedures

• Technique of peripheral iridectomy:
• A, anterior limbal incision to open the anterior
chamber;
• B, prolapse of peripheral iris by pressure at the
posterior lip of the incision;
• C, excision of the prolapsed knuckle of the iris
by de Wecker’s scissors;
• D, suturing the wound

LASER IRIDOTOMY
• CREATION of a hole in peripheral iris(its like making a bypass for
arterial blockage a hole to allow the aqeous to pass from PC to AC)
• MOST COMMONLY PULSED Nd YAG laser is used,laser beams are
usually placed b/w the middle and the peripheral one third of
iris,usually at 11 o clock or 1 o clock position.
• Complications of laser procedures
• Corneal endothelial burns
• Iris hemorrhage
• Corneal endothelial decompensation
• Formation of cataract
• Iop spike

External filterating
surgeries
Guided filtering
surgeries-partial
thickness fistula--
TRABECULECTOMY
SUTURE SUTURELESS
Free filtering
operations –
obsolete now—full
thickness fistula
NON PENETRATING
FILTERATION
SURGERIES
1.SCELEROTOMY
2.VISCO
CANALOSTOMY

• Technique of trabeculectomy: A, fornix-based
• conjunctival flap;
• B & C, partial thickness scleral flap and
excision of trabecular tissue;
• D, peripheral iridectomy anD closure of sclera)
flap;
• E, closure of conjunctival) flap

Trabeculectomy-a new channel created around
tha margin of scleral flap,now aquoeus flows from AC --sub
Conjunctival space

NON PENETRATING SURGERIES
• Viscocanalostomy is a major ocular procedure
in which Schlemm's canal is surgically exposed
by making a large and very deep scleral flap.
• In the VC procedure, Schlemm's canal is
cannulated and viscoelastic substance
injected (which dilates Schlemm's canal and
the aqueous collector channels)

Internal filteration
surgeries
Angle based
procedures
1.Goniotomy 2.trabeculotomy
Schlems canal
based procedures
1.Canaloplaty
2.Trabecular
microbypass stent
3.I stent
4.Express
glaucoma shunt

EXPRESS MINI SHUNT-SCHLEMS
CANAL BASED PROCEDURE

3 d model of gdd placed on a eye

Artificial drainage shunt operation
using Molteno implant

Cyclodestrutive procedures
• Cyclo-destructive procedures lower IOP by destroying part of
the secretory ciliary epithelium thereby reducing aqueous
secretion.
• Indications. These procedures are used mainly in
• absolute glaucomas.
• Cyclo-destructive procedures in current use are:
• • Cyclocryotherapy,
• • Nd: Yag laser cyclodestruction, and
• • Diode laser cyclophotocoagulation.

• Technique of cyclocryotherapy
• 1. Anaesthesia. Topical and peribulbar
blockanaesthesia is given.
• 2. Lids separation is done with eye speculum.
• 3. Cryoapplications.
• Mechanism. IOP is lowered due to destruction of
the
• secretory ciliary epithelium. The cells are destroyed
• By intracellular freezing

Another way of classification
• 1 Procedures that facilitate outflow of aqueous
humor
• 1.1 Laser trabeculoplasty
• 1.2 Iridotomy
• 1.3 Iridectomy
• 1.4 Filtering procedures: penetrating vs. non-
penetrating
• 1.5 Other surgical procedures-Goniotomy and
trabeculotomy
• 1.6 Canaloplasty
• 2 Procedures That Decrease Production Of
Aqueous Humor-*Cyclocryotherapy, or
cyclocryopexy, Cyclophotocoagulation

KEY TECHNICAL TERMS
• 1.Laser trabeculoplasty
• A trabeculoplasty is a modification of the trabecular
meshwork. Laser trabeculoplasty (LTP) is the application of a
laser beam to burn areas of the trabecular meshwork,
• 2. Iridotomy
• An iridotomy involves making puncture-like openings through
the iris without the removal of iris tissue. Performed either
with standard surgical instruments or a laser.
• 3.Iridectomy
• An iridectomy, also known as a corectomy or surgical
iridectomy, involves the removal of a portion of iris tissue

• 4.PERIPHERAL IRIDECTOMY:
• peripheral iridectomy is the removal of iris tissue at the
periphery; and a sector iridectomy is the removal of a wedge-
shaped section of iris that extends from the pupil margin to
the iris root, leaving a keyhole-shaped pupil.
• 5.Deep sclerectomy, also known as nonpenetrating
deep sclerectomy (PDS) or nonpenetrating
trabeculectomy is a filtering surgery where the
internal wall of Schlemm's canal is excised, allowing
subconjunctival filtration without actually entering
the anterior chamber.
• 6.Canaloplasty is a nonpenetrating procedure
utilizing microcatheter technology.

SUMMARY
• Treatment procedure for congenital glaucoma
• Tx algorithm for OAG
• Tx algorithm for ACG
• Commonly used surgical procedures
classification.
• Internal,external filteration
surgeries,GDD,Cyclodestructive procedures.

University qns
• 10 mrk
• classify glaucoma and discuss abt c/f and management of congenital
glaucoma?
• Poag/chronic simple glaucoma etiology risk factors pathogenesis,c/f,field
defects,diagnosis and management?
• Acute primar angle closure glaucoma-ETIOLOGY,risk factors,c/f, treatment
of acute attack?
• 4 mrks
• Topical drugs in glaucoma?
• Iridectomy- indications and complication?
• Trabeculectomy-indications and mention 2 agents used to prevent its
failure.?

REFERENCE
• https://www2.slideshare.net/rameshkrishnan99/6966
901
• Basic ophthalmogy by renu jogi
• Comprehensive ophthalmology by ak khurana.
• https://en.wikipedia.org/wiki/Glaucoma_surgery
• https://www.youtube.com/watch?v=x-d3Ceh26rw
• https://www.youtube.com/watch?v=gHwVINPRyJU
• Simplified ophthalmology conceptual handbook-utsav
bansal

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