This document discusses various surgical procedures for glaucoma management. It provides details on laser trabeculoplasty, incisional surgery such as filtering procedures, laser iridotomy, glaucoma drainage devices, and cyclodestructive procedures. Laser trabeculoplasty involves applying laser energy to the trabecular meshwork to lower intraocular pressure. Filtering surgery involves creating a fistula to allow aqueous humor to drain from the anterior chamber. Laser iridotomy is used to treat pupillary block glaucoma by creating an iridotomy. Glaucoma drainage devices provide an alternative drainage pathway through a tube. Cyclodestructive procedures aim to reduce aqueous production by ablating the ciliary body. The

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