Glaucoma primary closed angle,secondary glaucoma, congenital glaucoma
Surgical management of glaucoma pgs
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Transcript of Surgical management of glaucoma pgs
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Surgical Management of Glaucoma
Delivered by:
Cesar A. Perez, Jr. MD, DPBOPrepared by
Philippine Glaucoma SocietyThursday, April 7, 2011
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Outline
• Overview• Trabeculectomy
– Indications, technique & post-operative care
• Laser iridotomy– Indications, technique & post-op care
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TRABECULECTOMY
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Indications for glaucoma surgery
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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical therapy
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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical therapy
• Poor compliance with medical therapy– Relative indication. Maximize compliance 1st
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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical therapy
• Poor compliance with medical therapy– Relative indication. Maximize compliance 1st
• Pupillary block angle closure glaucoma– Laser iridotomy 1st, then give medications if there is residual elevated IOP
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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical therapy
• Poor compliance with medical therapy– Relative indication. Maximize compliance 1st
• Pupillary block angle closure glaucoma– Laser iridotomy 1st, then give medications if there is residual elevated IOP
• Synechial angle closure for @ 360 degrees– May go straight to trabeculectomy
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Indications for glaucoma surgery• Uncontrolled IOP or documented glaucomatous
progression in spite of maximum tolerated medical therapy
• Poor compliance with medical therapy– Relative indication. Maximize compliance 1st
• Pupillary block angle closure glaucoma– Laser iridotomy 1st, then give medications if there is residual elevated IOP
• Synechial angle closure for @ 360 degrees– May go straight to trabeculectomy
• Congenital glaucoma– Definitive treatment is surgery
Thursday, April 7, 2011
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Thursday, April 7, 2011
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POAG
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POAG
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POAG
Medical Tx
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POAG PACG
Medical Tx
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POAG PACG
Medical Tx
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POAG PACG
Medical Tx
LaserIridotomy
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POAG PACG
Medical Tx
LaserIridotomy
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POAG PACGSecondary glaucoma
Medical Tx
LaserIridotomy
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Medical Tx
LaserIridotomy
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Medical Tx
LaserIridotomyTreat primary
cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Medical Tx
LaserIridotomyTreat primary
cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomyTreat primary
cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomyTreat primary
cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
Trabeculectomy + mitomycin-C
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
Trabeculectomy + mitomycin-C
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Trabeculectomy + mitomycin-C
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Trabeculectomy + mitomycin-C
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Trabeculectomy + mitomycin-C
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Consider transcleral cyclophoto-
coagulation if w/ pain
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Consider transcleral cyclophoto-
coagulation if w/ pain
Thursday, April 7, 2011
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POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Consider transcleral cyclophoto-
coagulation if w/ pain
Thursday, April 7, 2011
![Page 40: Surgical management of glaucoma pgs](https://reader033.fdocuments.us/reader033/viewer/2022051412/549367ffb47959744d8b4860/html5/thumbnails/40.jpg)
POAG PACGSecondary glaucoma
Congenital glaucoma
Medical Tx
LaserIridotomy
Refer to GL specialist: •Goniotomy, trabeculotomy, or combined trabeculotomy + trabeculectomy
Treat primary cause, if possible
No superior conjunctival scarring, relatively “quiet eye “; > 2y/o
•Any condition that has a high risk for failure for Trab w/ MMC - scarred superior conjunctivae - active proliferative membrane in the AC (e.g. epithelial ingrowth, NV) - active AC inflammation - multiple failed trabeculectomies
Poor visual Potential
(LP-NLP)
Trabeculectomy + mitomycin-C
Glaucoma drainage device, preferably by a GL specialist
Consider transcleral cyclophoto-
coagulation if w/ painLegend:
Uncontrolled IOP
Thursday, April 7, 2011
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Traction suture
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Traction suture
Peripheral cornea
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Traction suture
Peripheral cornea Superior rectus
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Traction suture
• For good exposure of the surgical site
– Peripheral cornea• Concerns:
– Perforation of the cornea
– Superior rectus• Concerns:
– Greater potential for bleeding– Risk of ptosis post-op
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Conjunctival Peritomy: Fornix based
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Conjunctival Peritomy: Fornix based
• Easier to create
• Easier exposure & dissection of the sclera
• Creates a more posterior diffuse bleb
• May be more prone to leaks if not closed properly
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Conjunctival Peritomy: Limbal based
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Conjunctival Peritomy: Limbal based
• More difficult dissection & exposure
• Better water-tight closure
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Cauterization of episcleral vessels
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Removal of residual episcleral tissues
JA Tumbocon, MD
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Application of Anti-metabolites
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Application of Anti-metabolites• Mitomycin-C 2mg/ vial
– Concentration: 0.25 to 0.5 mg/ml– Duration: 1 to 5 minutes– Concentration & duration is dependent on the
appearance of the conjunctiva & presence of risk factors for failure
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Application of Anti-metabolites• Mitomycin-C 2mg/ vial
– Concentration: 0.25 to 0.5 mg/ml– Duration: 1 to 5 minutes– Concentration & duration is dependent on the
appearance of the conjunctiva & presence of risk factors for failure
• 5-Fluorouracil 250mg/ml– Intra-op: 0.5ml (25mg) to 1ml (50mg) for 5 mins– Post-op: 0.1ml (5mg) subconjunctival injection
daily for 7-14 days (Total dose not to exceed 50mg or 1ml.)
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Application of Anti-metabolites
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Irrigate copiously
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Scleral Flap Dissection
• 1/3 to 1/2 scleral thickness– Thinner flap = more
aqueous flow
• Shapes: – square, rectangular,
trapezoidal, triangular
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Scleral Flap Dissection
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Paracentesis
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Limbal Fistula
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Limbal FistulaDescemet’s punch
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Limbal Fistula Knife & Vannas scissors
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Limbal Fistula Knife & Vannas scissors
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Peripheral Iridectomy
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Peripheral Iridectomy
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Peripheral Iridectomy
• Iris usually prolapses through after creation of the the limbal fistula
• Iridectomy should be wider than the limbal fistula/ internal sclerectomy
• Better too wide than too small
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Scleral Flap closure
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Scleral Flap closure
• 10-0 Nylon suture
• May use 2 to 6 interrupted sutures
• Burry all suture knots
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Scleral Flap closure• No standard number or tightness
of sutures
• Should be able to visualize minimal aqueous flow through the borders of the scleral flap after AC reformation
– Add more sutures if there is excessive aqueous flow
– Loosen or remove sutures if there is no flow
• Better to err on the “tight side”
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Conjunctival Closure Limbal based peritomy
JA Tumbocon, MD
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Conjunctival Closure Fornix based peritomy
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Reform AC, note for elevation of the bleb & check for leaks
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JA Tumbocon, MD
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Trabeculectomy: Post-op care
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Trabeculectomy: Post-op care• Follow-up closely
– Success = 50% surgery + 50% post-op care
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Trabeculectomy: Post-op care• Follow-up closely
– Success = 50% surgery + 50% post-op care• Keep aqueous flowing
– Massage, laser suture lysis &/ or removal of releasable scleral flap sutures
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Trabeculectomy: Post-op care• Follow-up closely
– Success = 50% surgery + 50% post-op care• Keep aqueous flowing
– Massage, laser suture lysis &/ or removal of releasable scleral flap sutures
• Topical steroids (usually for 6-12 weeks)
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Trabeculectomy: Post-op care• Follow-up closely
– Success = 50% surgery + 50% post-op care• Keep aqueous flowing
– Massage, laser suture lysis &/ or removal of releasable scleral flap sutures
• Topical steroids (usually for 6-12 weeks)
• Prophylactic topical antibiotic
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Trabeculectomy: Post-op care• Follow-up closely
– Success = 50% surgery + 50% post-op care• Keep aqueous flowing
– Massage, laser suture lysis &/ or removal of releasable scleral flap sutures
• Topical steroids (usually for 6-12 weeks)
• Prophylactic topical antibiotic• + Cycloplegic agent (e.g. Atropine)
– Stabilizes blood-aqueous barrier– Pulls lens-iris diaphragm posteriorly
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JA Tumbocon, MD
http://www.glaucomatoday.com/art/0305/0305sp.pdf
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Thank you
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Laser I r idotomy
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Laser Iridotomy• Mechanism
– Creates a bypass route for the aqueous to flow from the posterior to the anterior chamber & thus relieve relative or absolute pupillary block
• Lasers– Nd:YAG Laser– Argon Laser– Diode Laser
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Interruption of Pupillary block• Creation of a hole in the outer
half of the iris (iridotomy / iridectomy
– allows fluid from the PC to enter to the AC, bypassing the pupillary block
– equalization of pressure in both chambers
– peripheral iris falls posteriorly
– opens the appositionally closed angle
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Laser Iridotomy
• Indications:
– Relative pupillary block / primary angle closure
– Occludable angles– Occlusio pupillae– Fellow eye of patients w/ unilateral
angle closure (prophylactic L.I.)
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Laser Iridotomy• Other Indications:
– Nanophthalmos/ crowded “middle segment”
– Prevent pseudophakic or aphakic pupillary block
– With the use of post-vitrectomy silicone oil (inferior iridectomy)
– Can be used as initial therapy in:• Phacomorphic glaucoma
• Plateau iris
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Laser IridotomyPre-op evaluation: Gonioscopy
Closed angles Opens on indentation gonioscopy
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Laser Iridotomy
• Pre-laser medications– Brimonidine – Proparacaine– Pilocarpine (optional)
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Abraham lens
Magnifies view & has 4x laser beam minification (increases power concentration)
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Laser Iridotomy site
• Supero-temporal or supero-nasal peripheral iris
• Choose an iris crypt, if available
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Laser Iridotomy site
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Laser Iridotomy
• Nd: Yag (1064nm wavelength)
• Argon
• Frequency doubled CW Nd: YAG (532 nm wavelength / “Green Laser”)
• Diode
“ThermalLasers”
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Nd: YAG Laser Iridotomy
• Suggested Settings: – 2-6 mJ– 1-4 pulses / burst
• Less bursts for phakic eyes
– 2-4 bursts
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Nd: YAG Laser Iridotomy
• Advantages:– Fewer applications needed for
perforation– Less inflammation– Greater tendency to remain
patent
• Disadvantages:– Possibility of bleeding from the
treatment site
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Argon Laser Iridotomy Techniques
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Argon Laser Iridotomy Techniques“Chipping Technique”
• Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs– Short pulse duration: 1000-1500mW, 50 um,
0.02-0.05 secs
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Argon Laser Iridotomy Techniques“Chipping Technique”
• Suggested Settings: – Long pulse duration: 700-1500mW, 50 um, 0.2 secs– Short pulse duration: 1000-1500mW, 50 um,
0.02-0.05 secs
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Argon Laser Iridotomy Techniques“Hump technique”
– Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only• Perforation: 1000mW, 50um, 0.2sec
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Argon Laser Iridotomy Techniques“Hump technique”
– Suggested Settings: • “Hump”: 500mW, 500um, 0.5sec 1 burn only• Perforation: 1000mW, 50um, 0.2sec
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Argon Laser Iridotomy Techniques“Drumhead technique”
– Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns• Perforation: 500mW, 50um, 0.2sec
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Argon Laser Iridotomy Techniques“Drumhead technique”
– Suggested Settings: • Drumhead: 200mW, 200um, 0.2 sec, 4 burns• Perforation: 500mW, 50um, 0.2sec
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Argon Laser Iridotomy
• Advantage:– Less potential for bleeding
• Disadvantage:– Requires more energy and more prone to
closure than Nd:YAG iridotomy
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Combined Argon & Nd: YAG Laser Iridotomy
• Suggested Settings:– Argon: Use “chipping, drumhead or hump” technique
settings to thin out the iris. – Nd:YAG for perforation: 1.5 - 5mJ, 1-2 pulses/burst,
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Combined Argon & Nd: YAG Laser Iridotomy
• Suggested Settings:– Argon: Use “chipping, drumhead or hump” technique
settings to thin out the iris. – Nd:YAG for perforation: 1.5 - 5mJ, 1-2 pulses/burst,
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Laser Iridotomy
• Endpoint
– Rush of pigment bearing aqueous through the iridectomy
– Deepening of the AC
– Presence of a retro-illuminated red reflex (not definite sign of a patent iridotomy)
– Visualization of anterior lens capsule through the iridectomy
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Laser Iridotomy
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Pre-L.I. Post-L.I.
Laser Iridotomy
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Laser Iridotomy
• Immediate post-laser – Check IOP hourly for at least 3 hours
(check for IOP spike)
– Topical steroids x 3-7 days
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Laser Iridotomy
• Potential Complications– IOP elevation– Persistent iritis– Corneal burns– Corectopia– Localized lenticular opacities– Posterior synechiae formation– Iris atrophy– Possibility of retinal burns (argon)– Late iridotomy closure
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Laser Iridotomy
• Post L.I. follow up– Patency of iridotomy– IOP – Gonioscopy: Monitor the irido-corneal angle.
May still close in spite of a patent iridotomy (possibly by other non-pupillary block mechanisms)
Long-term follow up is essential
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Thank you
Thursday, April 7, 2011