This document provides an overview of surgeries for glaucoma, including their evolution and mechanisms. It discusses non-filtering surgeries like iridotomy and trabeculotomy, as well as filtering surgeries like trabeculectomy. The document also covers combined cataract extraction and trabeculectomy, cyclo-destructive procedures, and the use of surgery in specific glaucoma subtypes. It aims to educate physicians on the various surgical options available to treat glaucoma.

1. SURGERIES FOR
GLAUCOMA: AN
OVERVIEW
P R E S E N T E R : D R . I D D I N D YA B AW E
M O D U L ATO R : D R . K A L I N A K I A B U B A K A R
M A K E R E R E U N I V E R S I T Y
D E P A R T M E N T O F O P H T H A L M O L O G Y
S E P T E M B E R , 2 0 2 1

2. EVOLUTION OF SURGERIES FOR
GLAUCOMA

3. GLAUCOMA SURGERIES: UNDERLYING
MECHANISM
• Open the angle, establish drainage physiologically
• Create an alternative path (sub-conjunctival space or supra-choroidal space)
• Reduce secretion from ciliary body
• Multiple surgeries
• Advancements and modifications of older surgeries

4. ANGLE COCKPIT OF GLAUCOMA
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7. GLAUCOMA SURGERY EVOLUTION
TIMELINE
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8. GLAUCOMA SURGERY EVOLUTION
TIMELINE
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9. GLAUCOMA SURGERY EVOLUTION
TIMELINE
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10. CLASSIFICATION OF GLAUCOMA
SURGERIES
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11. NON-FILTERING SURGERIES
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12. SURGICAL IRIDECTOMY: CHANDLER’S
TECHNIQUE
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13. SURGICAL STEPS OF IRIDECTOMY
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14. COMPLICATIONS
• Hemorrhage
• Incomplete iridectomy – check for trans-illumination
• Lens injury
• Elevated IOP
• Due to easier laser iridectomies available, role of surgical iridectomy inly for patients
unable to sit on slit-lamp, too hazy cornea, unsuccessful repeat YAG PI esp with
inflammatory glaucoma

15. TRABECULOTOMY: OPEN THE TM TO CREATE A DIRECT
COMMUNICATION BETWEEN ANTERIOR CHAMBER AND SCHLEMM
CANAL: AB EXTERNO/INTERNO (1960 – BURIAN AND SMITH)
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16. SURGICAL STEPS – AB EXTERNO
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17. .
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18. SURGICAL STEPS: AB INTERNO
THREAD A NYLON SUTURE INTO SCHLEMM’S CANAL AND PULL THE TWO
ENDS TO RUPTURE THROUGH THE TM INTO AC
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20. GONIOTOMY: INCISION IN ANGLE TO
REMOVE OBSTRUCTION TO OUTFLOW
(BARKAN, 1965)
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21. SURGICAL STEPS OF GONIOTOMY (USING BARKAN’S
GONIOTOMY LENS 25G NEEDLE AS THE GONIOTOMY
KNIFE)
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23. CYCLODIALYSIS: SEPARATION OF CB FROM SCLERAL
SPUR TO CREATE DIRECT COMMUNICATION BETWEEN
ANTERIOR CHAMBER AND SUPRA-CHOROIDAL SPACE AND
REDUCE AQUEOUS PRODUCTION (HEINE, 1905)
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26. TRABECULECTOMY (SUGAR, 1961
AND CAIRNS, 1968)
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27. TRABECULECTOMY SURGERY
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28. TRABECULECTOMY SURGERY
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29. ROUTES OF AQUEOUS HUMOR
DRAINAGE AFTER TRABECULECTOMY
• Filtration around margins of scleral flap
• Filtration through connective tissue substance of scleral falp
• Filtration through outlet channels in scleral flap
• Aqueous drainage into cut ends of Schlemm’s canal
• Cyclodialysis (if tissue dissected posterior to scleral spur

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31. GLAUCOMA AND CATARACT

32. FACTORS THAT DETERMINE THE
MANAGEMENT OF GLAUCOMA AND
CATARACT
• 1. Severity and progression of glaucoma:
• -IOP level (most important factor)
• -Optic nerve head changes
• -Visual field changes
• 2. Severity and progression of cataract:
• -VA and visual requirements
• -Ocular co-morbidities/visual potential

33. 3. PATIENT FACTORS
• Age
• Race (black higher rate of glaucoma progression)
• Family history of blindness from glaucoma
• Fellow eye blinded from glaucoma
• Concomitant risk factors for glaucoma (DM, HTN, myopia, other vascular diseases)
• Compliance to follow-up and medication use

34. SEVERITY OF GLAUCOMA

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36. .

37. SEVERITY OF CATARACT

38. INDICATIONS FOR COMBINED CATARACT
EXTRACTION AND TRABECULECTOMY
• General principle:
• Indications for trabeculectomy – when IOP is raised to a level that there is evidence of
progressive VF or ON changes despite maximal medical treatment plus indication for
cataract surgery (visual impairment)
• Medical indications of cataract surgery:
• -Phacoantigenic uveitis
• -Phacolytic glaucoma
• -Phacomorphic glaucoma
• -Anterior disclocation of crystalline lens
• -Inability to view the posterior segment

39. WHAT ARE THE COMMON SCENARIOS
FOR TRABECULECTOMY?
• Uncontrolled POAG with maximal medical treatment
-Failure of medial treatment (IOP not controlled with progressive VF or ON damage)
-Side effects of medical treatment
-Non-compliance with medical treatment
• -Additional considerations:
-Young patient with good quality of vision
-One-eyed patient (other eye blind from glaucoma)
-Family history of blindness from glaucoma
-Glaucoma risk factors (HTN, DM)
• Uncontrolled PACG after laser PI and medical treatment
• Secondary OAG or ACG

40. ADVANTAGES OF COMBINED CE AND
TRAB
• One operation
• Faster visual rehabilitation
• Patient may be able to be taken off all glaucoma medications
• Prevents post-op IOP spikes
• HVF monitoring easier with clear media
• No subsequent cataract operation needed (lower risk of bleb failure)

41. DISADVANTAGES OF COMBINED CE
AND TRAB
• Strong evidence that IOP control with trab alone is better than combined surgery
• More manipulation during the combined operation (higher risk of bleb failure)
• Vitreous loss during cataract surgery (higher risk of bleb failure)
• Larger wounds created (higher risk of wound leakage and shallow AC)

42. WAYS TO PERFORM THE COMBINED OP
. CORNEAL SECTION ECCE + TRAB
• ADVANTAGES:
• -More control
• -Less conjunctival manipulation
• -Smaller wound (lower risk of leakage
and shallow AC)
• DISADVANTAGES:
• -Longer
• -Higher corneal astigmatism

43. LIMBAL SECTION ECCE + TRAB
• ADVANTAGES:
• -Faster
• -Less astigmatism
• DISADVANTAGES:
• -Larger wound
• -More conjunctival manipulation
• -Increased risk of flat AC

44. PHACOEMULSIFICATION + TRAB
• ADVANTAGES:
• -More control of AC
• -Less conjuctival manipulation (main
reason)
• -Smallest wound of the 3 techniques
• -Less astigmatism
• -Faster
• DISADVANTAGES:
• -More difficult operation for the
inexperienced surgeon

45. CE IN SPECIFIC SUBSETS OF
GLAUCOMA
• WHO survey in 2002 highlight cataract and glaucoma as the two greatest sources of
visual impairment worldwide, with 17 (47.8%) and 4.4 million (12.3%) persons affected
• Africa, in particular, has the highest prevalence of glaucoma in the adult population
• CE lowers IOP by 2-4mmHg
• CE in specific subsets of patients with glaucoma – primary OAG (POAG), ACG and
pseudoexfoliation (PXE).
• ‘MIGS’+CE better than CE alone

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49. CYCLO-DESTRUCTIVE PROCEDURES: REDUCE AQUEOUS HUMOR
PRODUCTION BY PARTIALLY ELIMINATING THE FUNCTION OF
CILIARY PROCESSES
• Rarely the first choice
• Unpredictable result
• May have pronounced inflammatory response
• May damage adjacent ocular structures
• Valuable adjunct when other procedures have failed

50. CYCLO-DIATHERMY (WEVE, 1933,
MODIFIED BY VOGT)
• 2.5 to 5mm behind corneo-limbal junction
• 1-1.5mm electrode
• Diathermy current of 40-45mA for 10-20 seconds
• 1 or 2 rows for 180 degrees
• With/without a conjunctival flap
• Cell death in CB

51. CYCLO-CRYOTHERAPY BIETTI, 1950)
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53. TRANS-SCLERAL CYCLO-
PHOTOCOAGULATION
• Acts by destruction of ciliary
epithelium and reduced vascular
perfusion
• Also by increased outflow by trans-
scleral filtration and uveo-scleral
outflow
• Trans-pupillary and intra-ocular cyclo-
photo-coagulation
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54. CLASSIFICATION OF GLAUCOMA
SURGERIES
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